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Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare.

Serious events within healthcare occur daily exposing the failure of the system to safeguard patient and providers. The complex nature of healthcare contributes to myriad ambiguities affecting quality nursing care and patient outcomes. Leaders in healthcare organizations are looking outside the industry for ways to improve care because of the slow rates of improvement in patient safety and insufficient application of evidenced-based research in practice. Military and aviation industry strategies are recognized by clinicians in high-risk care settings such as the operating room, emergency departments, and intensive care units as having great potential to create safe and effective systems of care. Complexity science forms the basis for high reliability teams to recognize even the most minor variances in expected outcomes and take strong action to prevent serious error from occurring. Cultural and system barriers to achieving high reliability performance within healthcare and implications for team training are discussed.

Communication↗

[Julien-Francois Jeannel (1814-1896). A "Prothee", or a singular military pharmacist officer].

Military pharmacist officer since 1838, Julien Jeannel studied medicine too (1838 Class). During the algerian campaign (1840), surrounded inside Medea, he slaughtered the whole part of sick animals to cook up bubbles next changed into stock cubes (Never patented!). Nominated in Toulouse and further in Bordeaux, he wrote many books about worker's medicine, anaesthesia, suicide, syphilis, prostitution as well as a french Codex the Army used until 1918. In 1858, he set up the A.G.M.F. (French General Practitioner's Association). He enlarged the purpose of cultural gardens and promoted reforestation,. Imperial Guard Field-officer during the 1870-71 War, he was among the Metz besieged; there, he contrived a gadget: small hydrogen balloons carrying letters - a king of "air mail"! After retiring, he founded with Ferau and Papillion the Lille Free Medical University. Then he ended his life at Villefranche sur Mer, devoted to botany and natural sciences; he published "Les Fables de La Fontaine" meant for young people.

France↗

Ivan Pavlov on communist dogmatism and the autonomy of science in the Soviet Union in the early 1920s. 1923.

On 25 September, 1923, two days before his 74th birthday, Ivan Petrovich Pavlov stood before a class of medical students assembled in the auditorium of his Alma Mater, the Military Medical Academy in Leningrad. Pavlov, the recipient of the Nobel prize in medicine in 1904 for his work in physiology, was about to address his first class of the new academic year, and, as was his custom, he had prepared his first lecture on a general theme. This was an especially significant address, however, for in it Pavlov reviewed the impressions he had gathered during his travels in Western Europe and the United States in the summer of 1923, and he criticised the prevailing ideology of Soviet communism by attacking the ideas of Nikolai Ivanovich Bukharin, then the leading expositor of Bolshevik Marxism. An English translation of the lecture is printed below.

Communism↗

Concordance rates for benign prostatic disease among twins suggest hereditary influence.

OBJECTIVES: The etiology of benign prostatic hyperplasia (BPH) is unknown. Evidence for a hereditary trait would provide new avenues for investigation. METHODS: We compared the concordance for benign prostate disease in monozygotic (MZ) and dizygotic (DZ) twins who served in the United States military in World War II and have been followed by the Medical Follow-up Agency, Institute of Medicine of the National Academy of Sciences. Questionnaires completed in 1985 by 10,000 twins were reviewed for evidence of prostatic disease. Key words indicating benign prostatic disease (prostate, prostatectomy, BPH, TURP, and prostatism) were identified in 533 (5.3%) of the questionnaires. RESULTS: The average age was 64 +/- 3 years (range 56 to 68 in 1985). After eliminating men with known prostate cancer, there were 256 twin pairs that were informative for benign prostatic disease: both twins were concordant in 25 instances and discordant in 231, with only one twin mentioning benign prostatic disease. The pairwise concordance for MZ twins was 14.7% (19 of 129) and for DZ pairs it was 4.5% (5 of 112). The relative risk for benign prostatic disease for MZ twins was thus 3.3 (p = 0.008). The probandwise concordance rates, which express the probability of BPH in a cotwin of an affected twin, were 25.7% for MZ twins and only 8.5% for DZ twins. A covariance analysis estimated that 49% of the observed variance between twins could be attributed to genetic effects. CONCLUSIONS: These data provide preliminary evidence for the heritability of benign prostatic disease.

Aged↗

Heterotopic ossification in the residual limbs of traumatic and combat-related amputees.

Reports on the occurrence and treatment of heterotopic ossification in amputees are rare. Heterotopic ossification in the residual limbs of amputees may cause pain and skin breakdown and complicate or prevent optimal prosthetic fitting and utilization. Basic science research has shed light on the cellular and molecular basis for this disease process, but many questions remain unanswered. The recent experience of the military amputee centers with traumatic and combat-related amputations has demonstrated a surprisingly high prevalence of heterotopic ossification in residual limbs. Primary prophylactic regimens, such as nonsteroidal anti-inflammatory drugs and local irradiation, which have proved to be effective in preventing and limiting heterotopic ossification in other patient populations, have not been studied in amputees and generally are not feasible in the setting of acute traumatic amputation. When nonsurgical measures such as activity and repeated prosthetic modifications fail to provide relief, surgical excision has provided good early clinical results, with low rates of recurrence and acceptable complication rates in military amputees.

Amputation Stumps↗

Familial factors in early deaths: twins followed 30 years to ages 51-61 in 1978.

Subjects in the National Academy of Sciences-National Research Council Twin Registry of 31,848 male twin veterans were followed for mortality from 1 January 1946, or from the date of entry into military service if that was later, to 31 December 1978. During this time 3,573 deaths occurred among them, 837 due to trauma and 2,712 due to disease. Mortality from all causes for the entire follow-up period was 10.2% among 11,350 monozygotic (MZ) twins and 11.4% among 14,450 dizygotic (DZ) twins. Mortality of veterans is known to be favorable compared to U.S. males. Among U.S. males of the same ages as the two respective twin zygosity groups, a mortality of 13.9% would have been expected during this time period. Observed mortality from trauma was 2.3% for MZ twins and 2.5% for DZ twins, with 3.0% expected in either group. Observed mortality from all disease was 7.9% for MZ twins and 8.8% for DZ twins, with 10.9% expected in either group. For total mortality, the case twin concordance rates, based on individual deaths, were 28.2% among MZ twins and 17.7% among DZ twins. For trauma, respectively by zygosity, these concordance rates were 6.9% and 3.9%. In this sample, familial factors appear to be of little consequence in trauma deaths. For all disease the concordance rates were 30.1% and 17.4%. Estimating heritability of liability to death from disease, as proposed by Edwards (1969), provides values of h2 = r = 0.51 for MZ twins, h2 = 2r = 0.48 for DZ twins, and h2 = 2(rMZ-rDZ) = 0.54 using data for the two zygosity groups combined.

Adult↗

Henry M. Jackson Foundation for the advancement of military medicine: a brief history.

The Henry M. Jackson Foundation for the Advancement of Military Medicine (HMJFAMM) was created by Congress in 1983. This not-for-profit organization championed by Senator Henry M. Jackson was brought into being to serve as a partner with the Uniformed Services University of the Health Sciences to facilitate the latter's mission execution. In the foundation's 17-year history, which is discussed, it has served multiple functions. A major role has been to manage militarily relevant research. Currently, there are more than 500 research projects, and the HMJFAMM ranks in the top 10% of institutions receiving grants from the National Institutes of Health. More than 500 education funds support more than 200 education programs annually. Each year, hundreds of military physicians and research scientists are assisted in attending outside professional meetings. The Marion B. Sulzberger Chair, a stimulus that gave rise to the foundation, is among almost 50 endowments that now exist under foundation management. This not-for-profit institution currently employs more than 1,100 individuals.

Education, Medical↗

Modeling an integrative physical examination program for the Departments of Defense and Veterans Affairs.

Current policies governing the Departments of Defense and Veterans Affairs physical examination programs are out of step with current evidence-based medical practice. Replacing periodic and other routine physical examination types with annual preventive health assessments would afford our service members additional health benefit at reduced cost. Additionally, the Departments of Defense and Veterans Affairs repeat the physical examination process at separation and have been unable to reconcile their respective disability evaluation systems to reduce duplication and waste. A clear, coherent, and coordinated strategy to improve the relevance and utility of our physical examination programs is long overdue. This article discusses existing physical examination programs and proposes a model for a new integrative physical examination program based on need, science, and common sense.

Delivery of Health Care, Integrated↗

[The introduction of the western psychiatry into Korea: from the mid seventeenth century to 1911, the time of Japanese forced annexation of Korea].

The object of this study is to investigate the routes of the introduction of the western psychiatric knowledges and practices in Korea. The historical documents including newspapers and governmental bulletins as well as articles and books on the history of the Korean medicine were examined and the results are as follows: The western knowledge about the brain anatomy and physiology were introduced from China by the enlightened Confucian and Taoistic scholars of Korea in the mid seventeenth century through the Chinese translations of the western science and medicine. Due to the lack of support for the scholars and even persecution by the ruling power to those who had great interests in the western thoughts including sciences, the western medical knowledges could not be actualized in practice. Thus, the active practices of western medicine were started in the late 19th century in Korea through the two routes; one, via Japanese military physicians and the other one, via the western missionary physicians. The psychiatry was lectured by Japanese psychiatrist in 1910 at the medical school of Tai-Han Unwon, the Korean governmental clinic and 1913 at the Severance medical school of Tai-Han Uiwon, the Korean governmental clinic and in 1913 at the Severance medical school by the Australian psychiatrist, McLaren. As the independent department with the psychiatric ward, the first Dept. of Psychiatry was established in 1913 at the colonial governmental clinic, Chosun Chondokbu-Uiwon, the former Tai-Han Ui-won. Medicine as well as psychiatry was introduced into Korea under the political atmosphere of one sided admiration for the western science. The attempts to combine the western medicine with the traditional Korean medicine could not be tolerated by both missionary physicians and the colonial regime.

Colonialism↗

Military service and migration in nineteenth-century France: some evidence from Loir-et-Cher.

"Military service in France during the nineteenth century removed many young men from their own localities for long periods. The widely accepted claim that few conscripts returned home after completing their period of service is based on little evidence. The paper examines the conscription classes of 1856 and 1891 in two cantons in the departement of Loir-et-Cher. In those cases, there was not a significant relationship between conscription and migration, nor between literacy and migration. Instead, migration of youths in their twenties was linked partly to prior experiences of migration but principally to their occupations."

Adolescent↗

The life, achievements and legacy of a great Canadian investigator: Professor Boris Petrovich Babkin (1877-1950).

The present paper reviews the life and achievements of Professor Boris Petrovich Babkin (MD DSc LLD). History is only worth writing about if it teaches us about the future; therefore, this historical review concludes by describing what today's and future gastrointestinal physiologists could learn from Dr Babkin's life. Dr Babkin was born in Russia in 1877. He graduated with an MD degree from the Military Medical Academy in St Petersburg, Russia, in 1904. Not being attracted to clinical practice, and after some hesitation concerning whether he would continue in history or basic science of medicine, he entered the laboratory of Professor Ivan Petrovich Pavlov. Although he maintained an interest in history, in Pavlov's exciting environment he became fully committed to physiology of the gastrointestinal system. He advanced quickly in Russia and was Professor of Physiology at the University of Odessa. In 1922, he was critical of the Bolshevik revolution, and after a short imprisonment, he was ordered to leave Russia. He was invited with his family by Professor EH Starling (the discoverer of secretin) to his department at University College, London, England. Two years later, he was offered a professorship in Canada at Dalhousie University, Halifax, Nova Scotia. After contributing there for four years, he joined McGill University, Montreal, Quebec, in 1928 as Research Professor. He remained there for the rest of his career. Between 1940 and 1941, he chaired the Department, and following retirement, he remained as Research Professor. At the invitation of the world-famous neurosurgeon, Wilder Penfield, Dr Babkin continued as Research Fellow in the Department of Neurosurgery until his death in 1950 at age 73. His major achievements were related to establishing the concept of brain-gut-brain interaction and the influence of this on motility, as well as on interface of multiple different cells, nerves and hormones on secretory function. He had a major role in the rediscovery of gastrin. He established a famous school of gastrointestinal physiologists at McGill University. He supported his trainees and helped them establish their careers. He received many honors: a DSc in London, England, and an LLD from Dalhousie University. Most importantly, he was the recipient of the Friedenwald Medal of the American Gastroenterological Association for lifelong contributions to the field. Dr Babkin taught us his philosophical aspect of approaching physiology, his devotion to his disciples and his overall kindness. Most importantly, he has proven that one can achieve international recognition by publishing mainly in Canadian journals. He is an example to follow.

Achievement↗