Contemporary Topics in Patient Safety

As healthcare systems continue to evolve, it is clear that providing safe, high-quality care to patients is an extremely complex process. Ranging from multi-disciplinary teams to bedside care, virtually every aspect of the patient-care experience provides us with an opportunity for doing things better, from improving efficiency, safety, and overall outcomes to reducing costs and promoting team synergy. This book, the fifth in our patient safety series collection, consists of chapters that help explore key concepts related to both the safety and quality of care. In a departure from the vignette-driven format of our earlier books, this installment gravitates toward discussing frameworks, theoretical considerations, team-centric approaches, and a variety of other concepts that are critical to both our understanding and the implementation of safer and better-performing health systems. We also feel that the knowledge presented herein increasingly applies across the world, especially as global health systems evolve and mature over time. It is our goal to improve the recognition of potential opportunities that will highlight various aspects of the delivery of healthcare and thus contribute to better patient experiences, with safety at the forefront. Topics covered in this volume, as well as the previous volumes, highlight the critical importance of identifying and addressing opportunities for improvement, not as one-time events, but rather as continuous, hardwired institutional processes

Fitness for purpose of South African anaesthesiologists.

Doctoral Degree. University of KwaZulu-Natal, Durban.Anaesthesiologists, like all medical specialists, should be able to function independently and appropriately to provide the service beneficial to those whom they serve. However, difficulties have been experienced with the transition from trainee to specialist, posing potential adverse effects to the patient and the practitioner. To avoid these negative occurrences, it is necessary to ensure that graduates are well prepared for their specialist roles and are fit for purpose (FFP). The practice of a medical specialist incorporates various clinical and non-clinical roles; such roles include medical expertise, scholarship, communication, collaboration, management and leadership, professionalism, and health advocacy. Graduates have reported feeling better prepared for some of these roles and less prepared for others, with deficiencies noted particularly in those that are predominantly non-technical in nature. In anaesthesiology, there is a paucity of evidence in the literature with respect to fitness for purpose (FnFP), and there has been no assessment of whether anaesthesiologists internationally or in the South African context are FFP. The aim of this step-wise study was to develop and define the concept of FnFP and explore its nature in the South African anaesthesiology context. The first step provides a literature review of FnFP, and proposes how FnFP relates to current terminologies. Step two attempts to define FnFP in the South African anaesthesiology context, culminating in a list of defining competences useful as a tool to conceptualise, and possibly to gauge FnFP henceforth. Once FnFP has been defined for South African anaesthesiology, the next step is to establish whether local (South African) graduates are considered FFP using the derived criteria. This is undertaken by exploring opinions of FnFP by teachers, examiners and graduates. The final step in this thesis assesses the temporal nature of graduate self-assessment of FnFP. This study explores and highlights contemporary terminologies in postgraduate medical education and proposes refinements that suggest consideration, and inclusion, of the concept of FnFP as a means to enhance graduate readiness for practice. Fitness for purpose in the South African anaesthesiology context is explored with the aim to ultimately address and minimise graduate deficiencies in specialist practice. This work contributes to new knowledge in the field by conceptualising and defining FnFP for local anaesthesiology, and, through the proposal of a useful list of criteria, with an accompanying graphic, defines and illustrates the concept of the FFP anaesthesiologist. It also proposes an educational tool that can be used to dynamically monitor the progress of trainees during the learning process, which may assist in addressing and remediating deficiencies timeously. Similarly, after highlighting where deficiencies in local graduates are perceived to lie, this work proposes how these may be addressed and should be explored in future research to enhance the preparedness of graduates in anaesthesiology

Design, validation and implementation of a virtual reality high fidelity laparoscopic appendicectomy curriculum

INTRODUCTION: The treatment for acute appendicitis is laparoscopic appendicectomy (LA), usually performed by trainees who face significant challenges to training. Simulation curricula are being increasingly utilised and optimised to accelerate learning and improve skill retention in a safe environment. The aim of this study is to produce and implement a virtual reality (VR) curriculum for laparoscopic appendicectomy (LA) on the high-fidelity LAP Mentor VR simulator. METHODOLOGY: Performance data of randomised experts and novices were compared to assess the construct validity of the LAP Mentor basic skills (BS) and LA modules. Face validity of the simulator and module was assessed by questionnaire. These results informed the construction of a VR LA curriculum on an evidence-based theoretical framework. The curriculum was implemented and evaluated by analysis of participant diaries. RESULTS: Thirty-five novices and 25 experienced surgeons performed either BS, five LA procedural tasks or the LA full procedure. Both modules demonstrated construct validity. The LA module was deemed moderately realistic and useful for developing laparoscopic psychomotor skills. Seven novice trainees completed the new LA curriculum (three others dropped out). Analysis of participants diaries revealed the presence of frustration, the benefits of feedback sessions and the advantages and pitfalls of open access. DISCUSSION: Evaluations of the implementation of similar curricula are rare and participant diaries led to critical insights. The curriculum was difficult and sometimes frustrating, mitigated by rewarding experiences and coaching. The latter facilitated deliberate practice. Scheduling issues were mitigated by open access. Limitations of the curricula include the invariability in the presentation of appendicitis, and the reason for dropouts are not known. CONCLUSION: Several BS and all LA tasks are construct-valid. A new VR LA curriculum was implemented and analysis of participant diaries yielded critical insights into real-world implementation. Future study should investigate its effect on real-world performance and patient outcomes

A review of the effectiveness of lower limb orthoses used in cerebral palsy

To produce this review, a systematic literature search was conducted for relevant articles published in the period between the date of the previous ISPO consensus conference report on cerebral palsy (1994) and April 2008. The search terms were 'cerebral and pals* (palsy, palsies), 'hemiplegia', 'diplegia', 'orthos*' (orthoses, orthosis) orthot* (orthotic, orthotics), brace or AFO

Education in laparoscopic surgery:All eyes towards in vivo training

Tegenwoordig worden steeds meer buikoperaties d.m.v. laparoscopische (knoopsgat) chirurgie uitgevoerd. Omdat deze manier van chirurgie zo anders is dan conventionele chirurgie staat tegenwoordig de manier van selectie, training en beoordeling van artsen in opleiding tot chirurg ter discussie in de wetenschap. Uit dit proefschrift blijkt dat neuropsychologische testen voor ruimtelijk inzicht en psychomotorische vaardigheden een voorspellende waarde hebben in de laparoscopische chirurgie. Beoordeling van applicaties voor de opleiding chirurgie zouden daarom gebaat zijn bij een neuropsychologische test van deze vaardigheden. De training van chirurgen kan mogelijk worden verbeterd door het gebruik van het Pareto-principe, een principe dat veel gebruikt wordt in de bedrijfseconomie en verondersteld dat 20% van de verschillende oorzaken verantwoordelijk is voor 80% van de gevolgen. Ook op de operatiekamer blijkt namelijk 20% van de laparoscopische vaardigheden verantwoordelijk te zijn voor 80% van de verbale correcties gegeven door supervisoren. Ten behoeve van trainingsefficiëntie lijkt het dus verstandig om traininginstrumenten (VR simulator taken, boeken, cursussen, etc.) te ontwikkelen die juist deze 20% aanpakken. In het huidige trainingsysteem wordt een algemeen beoordelingsformulier gebruikt voor het geven van feedback, de OSATS. Alhoewel dit een duidelijke vooruitgang is t.o.v. de meer subjectieve beoordelingen van vroeger kan het formulier niet gebruikt worden voor procedure specifieke feedback. Uit dit proefschrift blijkt dat het beoordelen van de mate van fysieke en verbale ondersteuning die een arts in opleiding tot chirurg nodig heeft van zijn supervisor een goed beeld geeft van zijn/haar niveau tijdens een laparoscopische operatie en tevens kan worden gebruikt voor het geven van procedure specifieke feedback

Surgical education: development of curricula to optimise training and evaluate competency

This PhD by Published Work (Route 2) thesis is comprised of a collection of significant papers I have published with co-authors between the years of 2010 and 2017. These published works are supported by supplemental papers, abstracts, and conference proceedings and comprise a body of work that has sought to understand how surgical education is carried out in surgical residency programs, with particular interest in learning about how surgical educators teach, how surgical trainees perceive the teaching they receive, the creation, use, and evaluation of new tools for surgical education, and the development of new surgical training curricula in an era of competency-based medical education. My research began out of a need to evaluate the problem of a lack of formal guidelines and direction to aid surgical educators in the development, delivery, and evaluation of competency-based residency education programs throughout Canada. Without formal guidelines driving curricula development, surgical trainees could potentially be graduating at different levels of proficiency, which is problematic. In addition to existing standardised testing procedures, other surgical education researchers and I believe that residents must also be evaluated via ongoing thorough assessments of their level of competency when performing in the high stakes environment of the operating room. The Royal College of Physicians and Surgeons of Canada (RCPSC) is well-known for their Canadian Medical Education Directives for Specialists (CanMEDS) physician competency framework, which has been adopted by medical and surgical training programs worldwide. In its most recent CanMEDS iteration (2015), the RCPSC has released a new initiative called Competence by Design (CBD), which will affect all Canadian residency programs. The primary goal of this initiative is to completely remove the time element of residency training and focus on residents’ progression through their respective programs solely based on the passing of pre-defined competency “milestones”. This will cause a paradigm shift whereby the traditional apprenticeship model long-used in surgical teaching may eventually cease to exist. With this thesis, I have included papers that have focused on surgical education within competency-based frameworks and means by which to optimise curricula for surgical training. My research began with the exploratory work around how surgical educators teach and how trainees perceive they are taught, and is followed by a description of simulation and the development of new tools for surgical simulation and training. I then describe the development of new curricula that are focused on competency-based initiatives and can be used to begin the development of residency curricula for CBD. This research is timely, as many accrediting bodies worldwide are currently in the process of adopting and developing competency-based curricula at different training levels. The research presented in this thesis significantly contributes to the existing body of surgical education research, and future work, some of which is described, will focus on expanding the reach of our research initiatives via collaborative efforts with other surgical residency programs within Canada and also abroad