Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Learning from errors in radiology to improve patient safety

Objective: To determine the views and practices of trainees and consultant radiologists about error reporting.STUDY Design: Cross-sectional survey.PLACE AND DURATION OF STUDY: Radiology trainees and consultant radiologists in four tertiary care hospitals in Karachi approached in the second quarter of 2011.METHODOLOGY: Participants were enquired as to their grade, sub-specialty interest, whether they kept a record/log of their errors (defined as a mistake that has management implications for the patient), number of errors they made in the last 12 months and the predominant type of error. They were also asked about the details of their department error meetings. All duly completed questionnaires were included in the study while the ones with incomplete information were excluded.Results: A total of 100 radiologists participated in the survey. Of them, 34 were consultants and 66 were trainees. They had a wide range of sub-specialty interest like CT, Ultrasound, etc. Out of the 100 responders, 49 kept a personal record/log of their errors. In response to the recall of approximate errors they made in the last 12 months, 73 (73%) of participants recorded a varied response with 1 - 5 errors mentioned by majority i.e. 47 (64.5%). Most of the radiologists (97%) claimed receiving information about their errors through multiple sources like morbidity/mortality meetings, patients\u27 follow-up, through colleagues and consultants. Perceptual error 66 (66%) were the predominant error type reported. Regular occurrence of error meetings and attending three or more error meetings in the last 12 months was reported by 35% participants. Majority among these described the atmosphere of these error meetings as informative and comfortable (n = 22, 62.8%).CONCLUSION: It is of utmost importance to develop a culture of learning from mistakes by conducting error meetings and improving the process of recording and addressing errors to enhance patient safety

The nurse's liberation : an evolutionary epistemological paradigm for nursing

Rapidly changing technology and complex bureaucracies in health care institutions represent modern society's attempt to deal with human problems. But it may seem to those nurses whose altruistic values led them to choose their profession that such progressions serve only to further complicate health care. The challenge to nurses is to maintain clear vision in their own practice so that health care will continue to improve. This study offers an evolutionary epistemological paradigm in an effort to explain the evolution of theoretical approaches in nursing as society has become more technologically sophisticated. Nurses' social consciousness must grow in sophistication to balance the technology. This study explores the evolution of nursing theory development from pre-humans caring for their young to Florence Nightingale's military traditionalism to humanist views of Dorthea Orem and Martha Rogers to the professional socialization theory of Ada Jacox. The expanded paradigm offers a place for spiritual reality and healing arts adopted from ancient cultures. Hence, the paradigm attempts to reveal the evolutionary balance of practical technology with spiritual and moral reality, supported by the writings of Ken Wilber and Martin Buber

Stafford Beer in memoriam – ‘an argument of change’ three decades on.

Purpose This paper is written in memory of the late Stafford Beer. The paper engages with only one dimension of the whole man: Stafford Beer as the diagnostician and prognostician of the social conditions that he so keenly observed. Design/methodology/approach The paper revisits a talk that Stafford Beer gave, over three decades ago, to administrators of the UK National Health Service (NHS). It uses the content of the talk, entitled “Health and Quiet Breathing”, to diagnose the problems that have been encountered in the development of NHS information management strategies. The paper concludes with some brief personal recollections of Stafford Beer as a friend and as a teacher. Findings The paper finds Stafford Beer’s managerial cybernetics to be a useful tool in understanding many of the problems that have beset NHS information management strategies: lack of operational research, problems in the commodification of information, financial scandal, and bureaucracy. In its examination of these issues, the paper recognises Stafford Beer’s status as a legatee of not only Norbert Wiener, but also of the great philosophers. Value The paper demonstrates how the problem-orientation of Stafford Beer’s managerial cybernetics continues to be fresh and relevant to today’s society and provides a brief portrait of him both as a friend and as a teacher

Evaluation Independence in Organizations

Background: Evaluation independence is a neglected issue in the literature. Yet, it is a critical aspect of evaluation governance in organizations.   Purpose: The article draws on organizational theory, institutional economics and international development evaluation practice to define evaluation independence in organizations, outline principles geared to the design of evaluation processes within organizations and trigger a debate on evaluation independence in the evaluation community.   Intervention: Not applicable.   Research Design: Literature review informed by personal exposure to management of the World Bank Independent Evaluation Group.   Data Collection and Analysis: Not applicable.   Findings: Independent and self-evaluation are complementary and synergistic. Organizational theory demonstrates that a judicious combination of independent and self-evaluation contributes to managerial accountability and double loop learning.   Keywords: independence; accountability; internal evaluation; external evaluation; double loop learnin