Strengthening the contribution of quality improvement research to evidence based health care.
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Community Health Services↗
Biomedical subjects
G R Baker
Publications and source records attributed to G R Baker.
Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.
This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as "relational coordination" to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.
Anesthesiology↗
Localization: conventional and CT simulation.
Recent developments in imaging and computer power have led to the ability to acquire large three dimensional data sets for target localization and complex treatment planning for radiation therapy. Conventional simulation implies the use of a machine capable of the same mechanical movements as treatment units. Images obtained from these machines are essentially two dimensional with the facility to acquire a limited number of axial slices to provide patient contours and tissue density information. The recent implementation of cone beam imaging on simulators has transformed them into three dimensional imaging devices able to produce the data required for complex treatment planning. The introduction of computed axial tomography (CT) in the 1970s was a step-change in imaging and its potential use in radiotherapy was quickly realised. However, it remained a predominantly diagnostic tool until modifications were introduced to meet the needs of radiotherapy and software was developed to perform the simulation function. The comparability of conventional and virtual simulation has been the subject of a number of studies at different disease sites. The development of different cross sectional imaging modalities such as MRI and positron emission tomography has provided additional information that can be incorporated into the simulation software by image fusion and has been shown to aid in the delineation of tumours. Challenges still remain, particularly in localizing moving structures. Fast multislice scanning protocols freeze patient and organ motion in time and space, which may lead to inaccuracy in both target delineation and the choice of margins in three dimensions. Breath holding and gated respiration techniques have been demonstrated to produce four-dimensional data sets that can be used to reduce margins or to minimize dose to normal tissue or organs at risk. Image guided radiotherapy is being developed to address the interfraction movement of both target volumes and critical normal structures. Whichever method of localization and simulation is adopted, the role of quality control is important for the overall accuracy of the patient's treatment and must be adapted to reflect the networked nature of the process.
Artifacts↗
Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.
BACKGROUND: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. METHODS: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. RESULTS: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1-6 minutes (mean 3.5) and most commonly took place in the OR before the patient's arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members' preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. CONCLUSIONS: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.
Communication↗
Communication failures in the operating room: an observational classification of recurrent types and effects.
BACKGROUND: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. METHODS: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. RESULTS: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. CONCLUSION: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.
Anesthesia Department, Hospital↗
Paramagnetic cobalt(II) as an NMR probe of dendrimer structure: mobility and cooperativity of dendritic arms.
Cobalt(II) has been utilized as an external paramagnetic (1)H NMR probe for the study of the structure of dendrimers that possess specifically located metal recognition sites. The hyperfine-shifted (1)H NMR signals of the Co(II) complexes of several 2,6-diamidopyridine-containing dendrimers have been fully assigned by means of 1D and 2D NMR techniques, including NOE difference, EXSY, COSY, and TOCSY. Temperature-dependent T(1) values of the hyperfine-shifted signals were used to conclude that the Co(II)-dendrimer complexes are in the "liquidlike" regime, indicative of a shell-like structure instead of a "dense-core" structure. The presence of sizable cavities within the dendrimers was observed including a loosely packed conformation for the 2,6-diamidopyridino moiety to bind to potential guest molecules. Cooperativity among the dendritic arms in metal binding is also observed, whereby two dendritic arms bind to the metal center at the same time. In the case of dendrimers with the metal binding site located near the surface of the molecule, such binding cooperativity is still observed despite the large degree of freedom of the metal-binding moiety. Cooperativity among the dendritic arms can thus be considered an intrinsic property, which has to be taken into consideration in future design of functional dendrimers for the purpose of specific recognition and catalysis. The hydrodynamic radii of these dendrimers have been determined by means of nuclear Overhouser effect at low temperature. The study offers a method for the study of the dynamics of dendrimers in solution under different conditions and upon ligand binding and recognition. The study also provides a tool for monitoring systematic variation of the metal binding site in different dendrimer frameworks for specific applications, such as catalysis and molecular recognition.
Journal Article↗
Benign idiopathic haemorrhagic retinopathy.
PURPOSE: To describe a new condition characterised by an unusual unilateral idiopathic haemorrhagic retinopathy. METHODS: A review is presented of patient histories from 5 patients with acute-onset unilateral idiopathic haemorrhagic retinopathy, including results of ophthalmological, haematological and fluorescein angiographic examinations. RESULTS: All patients had an extensive deep blot haemorrhagic retinopathy without significant vascular signs or abnormal optic discs. In 4 cases the haemorrhage was sufficiently severe to break through into the vitreous. Fluorescein angiography demonstrated normal arteriovenous flow, without capillary non-perfusion, vessel or disc leakage. Disc swelling, macular oedema and cotton wool spots were not seen at any stage in these patients. All patients recovered the visual acuity in the affected eye by 4 months. Systemic examination in all cases was unremarkable. CONCLUSION: This distinct and rare form of retinopathy is important to define since it has a good prognosis without treatment.
Acute Disease↗
Making patients safer! Reducing error in Canadian healthcare.
Media reports of adverse events experienced by patients raise questions about whether these are isolated exceptions or part of a larger problem. There is no reliable Canadian data on medical error; but there is little reason to expect that the situation differs markedly from Australia or the United States which have rigorously studied the problem. Research in Australia has concluded that as many as 16% of hospital patients are injured as a result of their treatment. The Australian study and more recent research in the United States have created widespread concern that an epidemic of error exists in healthcare. Fortunately, experts in healthcare and other industries, have pointed toward a number of solutions that will reduce these errors. Three key strategies need to be pursued First, better information about the numbers and types of errors that occur is needed to help pinpoint change efforts. Non-punitive reporting policies must be put in place, to assist in altering the traditional culture of blame that has discouraged error reporting. Second, a set of strategies have to focus on developing more effective systems, including physician-order entry and medication administration systems which have been shown to have a dramatic impact in reducing errors. These systems are expensive, but their importance in reducing injury - and greatly reducing the costs of additional care that come from such injuries - make them an essential part of the answer. Finally, healthcare organizations need to work to create more effective cultures oriented toward preventing errors and intercepting errors that inevitably occur. These cultures will require a new emphasis on teamwork, a continual focus on redesigning care systems, particularly in high risk areas such as operating rooms, intensive care units and emergency rooms. These are not easy tasks and will require investments in new equipment and new skills. These steps are essential if we are to maintain public confidence in healthcare.
Australia↗
Healthcare managers in the complex world of healthcare.
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Delivery of Health Care↗
Domains and core competencies for effective evidence-based practice--quality improvement.
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Competency-Based Education↗
Creating a balanced scorecard for a hospital system.
In 1999, hospitals in Ontario, Canada, collaborated with a university-based research team to develop a report on the relative performance of individual hospitals in Canada's most populated province. The researchers used the balanced-scorecard framework advocated by Kaplan and Norton. Indicators of performance were developed in four areas: clinical utilization and outcomes, patient satisfaction, system integration and change, and financial performance and condition. The process of selecting, calculating, and validating meaningful indicators of financial performance and condition is outlined. Lessons learned along the way are provided. These lessons may prove valuable to other finance researchers and practitioners who are engaged in performance measurement endeavors.
Benchmarking↗
Application of acoustic emission to the monitoring and end point determination of a high shear granulation process.
The application of a novel monitoring technique, based on the use of acoustic emissions, is reported for a model high shear granulation process. It has been demonstrated that this technique is capable of monitoring changes in physical properties of powder material during granulation (particle size, flow properties and compression properties). The technique is non-invasive, sensitive and relatively inexpensive.
Acoustics↗
Comparison of oil recovered from tea tree leaf by ethanol extraction and steam distillation.
Two methods for the determination of oil and oil major components from tea tree (Melaleuca alternifolia) leaf are quantitatively compared. A microwave assisted ethanol extraction and a 2-h hydrodistillation technique were used on both dry and fresh leaf from a low and a high oil concentration tree. There was no significant difference between dry and fresh leaf. The distillation technique recovered 88% and 82% of the extractable oil for the low and high concentration material, respectively. For both samples this distilled oil was composed of lower absolute amounts of sesquiterpenoids and marginally lower amounts of monoterpenoids. Extending the distillation to 6 h increased the sesquiterpenoid recovery but this resulted in a reduction in both the absolute and relative amounts of the oxygenated monoterpenoids, terpinen-4-ol and 1,8-cineole.
Chromatography, Gas↗
The behavioural outcomes of quality improvement teams: the role of team success and team identification.
This study investigates the relationship between hospital quality improvement (QI) team success and changes in empowerment, 'organizational commitment, organizational citizenship behaviour' (OCB) and job behaviour related to QI. Data were collected from administrative staff, healthcare professionals and support staff from four community hospitals. The study involved a field investigation with two data collection points. Structured questionnaires and interviews with hospital management were used to collect data on the study variables. High scores were observed for organizational commitment, OCB and job behaviour related to QI when individuals identified with teams that were successful. Low scores were observed when individuals identified with teams that were unsuccessful. Empowerment was positively related to job behaviour associated with QI. It is concluded that participation on QI teams can lead to organizational learning, resulting in the inculcation of positive 'extra-role' and 'in-role' job behaviour.
Health Services Research↗
Pathophysiology of thrombocytopenia and anemia in mice lacking transcription factor NF-E2.
Expression of the p45 subunit of transcription factor NF-E2 is restricted to selected blood cell lineages, including megakaryocytes and developing erythrocytes. Mice lacking p45 NF-E2 show profound thrombocytopenia, resulting from a late arrest in megakaryocyte differentiation, and a number of red blood cell defects, including anisocytosis and hypochromia. Here we report results of studies aimed to explore the pathophysiology of these abnormalities. Mice lacking NF-E2 produce very few platelet-like particles that display highly disorganized ultrastructure and respond poorly to platelet agonists, features consistent with the usually lethal hemorrhage in these animals. Thrombocytopenia was evident during fetal life and was not corrected by splenectomy in adults. Surprisingly, fetal NF-E2-deficient megakaryocyte progenitors showed reduced proliferation potential in vitro. Thus, NF-E2 is required for regulated megakaryocyte growth as well as for differentiation into platelets. All the erythroid abnormalities were reproduced in lethally irradiated wild-type recipients of hematopoietic cells derived from NF-E2-null fetuses. Whole blood from mice lacking p45 NF-E2 showed numerous small red blood cell fragments; however, survival of intact erythrocytes in vivo was indistinguishable from control mice. Considered together, these observations indicate a requirement for NF-E2 in generating normal erythrocytes. Despite impressive splenomegaly at baseline, mice lacking p45 NF-E2 survived splenectomy, which resulted in increased reticulocyte numbers. This reveals considerable erythroid reserve within extra-splenic sites of hematopoiesis and suggests a role for the spleen in clearing abnormal erythrocytes. Our findings address distinct aspects of the requirements for NF-E2 in blood cell homeostasis and establish its roles in proper differentiation of megakaryocytes and erythrocytes.
Anemia↗
Transient thrombocytopenia produced by administration of macrophage colony-stimulating factor: investigations of the mechanism.
Administration of macrophage colony-stimulating factor (M-CSF) to mice (2 to 8 mg/kg/d x 5d) produced dose-dependent thrombocytopenia, which reached its nadir on days 4 to 5, followed by rapid recovery. Surprisingly, when administration of M-CSF was prolonged, the thrombocytopenia completely resolved, despite continued treatment. Splenectomy did not prevent the thrombocytopenia. Readministration of M-CSF after various intervals continued to produce the thrombocytopenic effect, even after 35 days. Measurements of Meg-CFC and megakaryocyte ploidy during the periods of M-CSF treatment and recovery of normal platelet levels showed no evidence of bone marrow suppression. Platelet survival was markedly decreased after 5 days of M-CSF (at the platelet count nadir) and after 9 days of continued M-CSF treatment, when the platelet count had returned to normal. Platelets from M-CSF-treated donors demonstrated normal survival when transfused into normal recipients. We concluded that thrombocytopenia produced by M-CSF was not due to suppression of thrombopoiesis, but to increased activity of the monocyte/macrophage system, which caused shortened platelet survival, and that subsequently, increased platelet production compensated for ongoing platelet destruction and resulted in normal platelet levels.
Adaptation, Physiological↗
Collaborating for improvement in health professions education.
Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.
Competency-Based Education↗
A review of organizational performance assessment in health care.
As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.
Canada↗