Deborah C. Saltman

Patient safety events reported in general practice: a taxonomy

Objective: To develop a taxonomy describing patient safety events in general practice from reports submitted by a random representative sample of general practitioners (GPs), and to determine proportions of reported event types. Design: 433 reports received by the Threats to Australian Patient Safety (TAPS) study were analysed by three investigating GPs, classifying event types contained. Agreement between investigators was recorded as the taxonomy developed. Setting and participants: 84 volunteers from a random sample of 320 GPs, previously shown to be representative of 4666 GPs in New South Wales, Australia. Main outcome measures: Taxonomy, agreement of investigators coding, proportions of error types. Results: A three-level taxonomy resulted. At the first level, errors relating to the processes of healthcare (type 1; n = 365 (69.5%)) were more common than those relating to deficiencies in the knowledge and skills of health professionals (type 2; n = 160 (30.5%)). At the second level, five type 1 themes were identified: healthcare systems (n = 112 (21.3%)); investigations (n = 65 (12.4%)); medications (n = 107 (20.4%)); other treatments (n = 13 (2.5%)); and communication (n = 68 (12.9%)). Two type 2 themes were identified: diagnosis (n = 62 (11.8%)) and management (n = 98 (18.7%)). The third level comprised 35 descriptors of the themes. Good inter-coder agreement was demonstrated with an overall κ score of 0.66. A least two out of three investigators independently agreed on event classification in 92% of cases. Conclusions: The proposed taxonomy for reported events in general practice provides a comprehensible tool for clinicians describing threats to patient safety, and could be built into reporting systems to remove difficulties arising from coder interpretation of events.

Understanding avoidant leadership in health care: findings from a secondary analysis of two qualitative studies

AIM To illuminate ways that avoidant leadership can be enacted in contemporary clinical settings. BACKGROUND Avoidance is identified in relation to laissez-faire leadership and passive avoidant leadership. However, the nature and characteristics of avoidance and how it can be enacted in a clinical environment are not detailed. METHODS This paper applied secondary analysis to data from two qualitative studies. RESULTS We have identified three forms of avoidant leader response: placating avoidance, where leaders affirmed concerns but abstained from action; equivocal avoidance, where leaders were ambivalent in their response; and hostile avoidance, where the failure of leaders to address concerns escalated hostility towards the complainant. CONCLUSIONS Through secondary analysis of two existing sets of data, we have shed new light on avoidant leaderships and how it can be enacted in contemporary clinical settings. Further work needs to be undertaken to better understand this leadership style. IMPLICATIONS FOR NURSING MANAGEMENT We recommend that organizations ensure that all nurse leaders are aware of how best to respond to concerns of wrongdoing and that mechanisms are created to ensure timely feedback is provided about the actions taken.

Case reports at the vanguard of 21st century medicine.

As doctors, working with our patients, we have the opportunity to make new discoveries every day about human existence, health and disease. Research in medicine often starts with observations made during patient encounters.

Aggregating case reports: a way for the future of evidence‐based health care?

The role of case reports in increasing our understanding of health care is growing. To date, case reports have mainly been used as a singular entity: to describe individual cases or cases managed by an individual practitioner. The feature of these reports has also been quite singular: usually to either identify a unique symptom, presentation, or adverse event. At Clinical Case Reports, we also have an interest in emphasizing best practice in addressing frequently occurring clinical events, and particularly drawing attention to the clinical use of published systematic reviews or clinical guidelines [1]. Case reports have a unique value and represent an enormous potential reservoir of knowledge that is largely untapped at the present time. Case reports provide a detailed and contextualized account of an event or illness trajectory that captures events including the presentation, diagnostic dilemma, diagnosis, initial treatment and treatment over time, and rationale for and response to any changes to treatment. Case reports capture the detailed nuance of the trajectory of an illness, that can include a single presentation event or an event with multiple and repeated presentations. Furthermore, the existence of comorbid conditions and how they interplay with the presenting problem (or evolution of a problem) can be teased out and made visible in ways that others can learn from. The initial encounter or reason for presentation may not have been as neat as a single presenting problem. As text, case reports are constructed in retrospect and so the detailed events of an illness or event can be reconstructed. Consequently comprehensive, well-constructed case reports can have significant heuristic potential for novice to expert clinicians and educators. Analysis of reports can also take account of treatment delivery patterns, relative efficacy, and any relationship to best practice or where they exist, evidence-based guidelines for care. These reports can also serve as a catalyst for generation of new evidence to support new or novel approaches to clinical care. However, despite the fact that case reports usually contain a detailed description of the sequencing and ongoing care of patients in the real world, very little attention has been paid to the way this information can be used. Case reports represent a potential rich source of primary data. They provide important and detailed information about individuals, which is often lost or labeled confounding in larger studies [1,2]. It is the very detail available in case reports that can provide crucial insight into the illness trajectory and allow the common patterns arising over the course of an illness or condition, as well as unusual events and occurrences to become visible. Significant epidemiological and clinical data, including patient responses to treatment, adverse events, and details of the eventual outcome are available in published case reports. With the current renaissance in case reports resulting in increasing numbers of case reports journals and more and more case reports making it into the literature, the possibility of using case reports in a more aggregated fashion is becoming a reality. Tentative beginnings in the arena of aggregation have occurred in the description of unusual treatment combinations or responses. For example, in 2004 Treon et al. [3] reported an unusual response to sildenafil in Waldenstroms macroglobulinemia. Although aggregated case reports do not replace well-designed meta-analyses nor provide a statistically significant cross-sectional view of medicine, they can enhance our knowledge of certain areas of clinical medicine and health care practice – especially where complexity is a key feature. Examples of these areas include those chronic and complex problems where cure is not the endpoint (such as the long term management of diabetes or hypertension), diagnosis and management of diseases which can significantly worsen within short intervals (such as many cancers), and the rise of personalized medicine and companion diagnostics (such as companion diagnostic testing) [4]. While case reports have long been a part of the medical and wider health literature, many of the traditional databases do not include all case reports, particularly those that are not peer reviewed. This makes systematic searching for cases difficult and aggregating them even more difficult. Some journals and publishers are beginning to develop case reports databases. However, without some consistent methodology with which to analyze this rich and important data source, the databases may not be of practical use. This is where the CARE Guidelines for Case Reports and the associated checklist (http://www.care-statement.org/care-checklist) are invaluable in helping to ensure thorough and consistent reporting of information, which potentially makes aggregation of case reports easier. As we have highlighted, the detail of the case makes them particularly rich and potentially amenable to aggregation. But the questions of how to aggregate them in ways that are meaningful remain. There is a clear role for aggregated case reports to increase our understanding of the trajectories of care in individual patients as well as overall trends in patient care in complex and rare conditions. Robust methodology and consistent reporting is required to underpin this process and optimize the value of this rich data source.

In pursuit of certainty: can the systematic review process deliver?

BackgroundThere has been increasing emphasis on evidence-based approaches to improve patient outcomes through rigorous, standardised and well-validated approaches. Clinical guidelines drive this process and are largely developed based on the findings of systematic reviews (SRs). This paper presents a discussion of the SR process in providing decisive information to shape and guide clinical practice, using a purpose-built review database: the Cochrane reviews; and focussing on a highly prevalent medical condition: hypertension.MethodsWe searched the Cochrane database and identified 25 relevant SRs incorporating 443 clinical trials. Reviews with the terms ‘blood pressure’ or ‘hypertension’ in the title were included. Once selected for inclusion, the abstracts were assessed independently by two authors for their capacity to inform and influence clinical decision-making. The inclusions were independently audited by a third author.ResultsOf the 25 SRs that formed the sample, 12 provided conclusive findings to inform a particular treatment pathway. The evidence-based approaches offer the promise of assisting clinical decision-making through clarity, but in the case of management of blood pressure, half of the SRs in our sample highlight gaps in evidence and methodological limitations. Thirteen reviews were inconclusive, and eight, including four of the 12 conclusive SRs, noted the lack of adequate reporting of potential adverse effects or incidence of harm.ConclusionsThese findings emphasise the importance of distillation, interpretation and synthesis of information to assist clinicians. This study questions the utility of evidence-based approaches as a uni-dimensional approach to improving clinical care and underscores the importance of standardised approaches to include adverse events, incidence of harm, patient’s needs and preferences and clinician’s expertise and discretion.

Running effective meetings: a primer for doctors

This paper uses a series of exercises and practical examples to assist individuals and groups of doctors in training to gain skills in a critical area of management: conducting and participating in effective meetings. Through this paper, readers will be shown how to recognise and manage situations as they occur in meetings to work towards appropriate outcomes. By understanding the elements of conducting a meeting from preparation through to follow up, doctors will be able to conduct and participate more effectively in meetings that arise in their workplaces.

Transportability of tertiary qualifications and CPD: a continuing challenge for the global health workforce.

BackgroundIn workforces that are traditionally mobile and have long lead times for new supply, such as health, effective global indicators of tertiary education are increasingly essential. Difficulties with transportability of qualifications and cross-accreditation are now recognised as key barriers to meeting the rapidly shifting international demands for health care providers. The plethora of mixed education and service arrangements poses challenges for employers and regulators, let alone patients; in determining equivalence of training and competency between individuals, institutions and geographical locations.DiscussionThis paper outlines the shortfall of the current indicators in assisting the process of global certification and competency recognition in the health care workforce. Using Organisation for Economic Cooperation and Development (OECD) data we highlight how International standardisation in the tertiary education sector is problematic for the global health workforce. Through a series of case studies, we then describe a model which enables institutions to compare themselves internally and with others internationally using bespoke or prioritised parameters rather than standards.SummaryThe mobility of the global health workforce means that transportability of qualifications is an increasing area of concern. Valid qualifications based on workplace learning and assessment requires at least some variables to be benchmarked in order to judge performance.

Building research capacity in Australian departments of general practice and rural health: a document review of annual reports

Aim: To describe the scope and nature of research capacity building activity within academic departments of general practice and rural health in Australia. Method: Document review of Annual Reports for the years 2000 and 2003 of 17 university departments of general practice and rural health, funded through the Research Capacity Building Initiative (RCBI) of the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy. Results: The review indicated that from 2000 to 2003, departments increased their activities in all areas of research capacity building activities. Mentoring and/or supervision other than higher degree students increased from 14 in 2000 to 266 in 2003. Twenty-two research networks involving over 1377 participants were operating in 2003. All departments were involved in collaborations either as part of grant applications, research projects or educational activities. Over 3630 people participated in 189 educational activities in 2003 compared to over 624 people attending 103 activities in 2000. Compared to

Corrections in an electronic environment

10.98 million in 2000, departments had obtained more than

Preparing Health Professionals for Community-Based Practice: Some Issues for Consideration

15.6 million for research projects in 2003. While there were more peer reviewed papers published in 2000 (n � 178) compared to 2003 (n � 130), these 17 departments gave 187 conference presen-tations. Conclusions:This review shows that the RCBI has contributed towards a considerable increase in research activities in these university departments of general practice and rural health. This has provided a major boost to primary health care research in Australia. These activities would have been unlikely to occur without the support and assistance of the PHCRED Strategy. Clearly, the full impact of the RCBI will take some time to evolve.