Speaking up for patient safety by hospital-based health care professionals: a literature review

BACKGROUND: Speaking up is important for patient safety, but often, health care professionals hesitate to voice concerns. Understanding the influencing factors can help to improve speaking-up behaviour and team communication. This review focused on health care professionals’ speaking-up behaviour for patient safety and aimed at (1) assessing the effectiveness of speaking up, (2) evaluating the effectiveness of speaking-up training, (3) identifying the factors influencing speaking-up behaviour, and (4) developing a model for speaking-up behaviour. METHODS: Five databases (PubMed, MEDLINE, CINAHL, Web of Science, and the Cochrane Library) were searched for English articles describing health care professionals’ speaking-up behaviour as well as those evaluating the relationship between speaking up and patient safety. Influencing factors were identified and then integrated into a model of voicing behaviour. RESULTS: In total, 26 studies were identified in 27 articles. Some indicated that hesitancy to speak up can be an important contributing factor in communication errors and that training can improve speaking-up behaviour. Many influencing factors were found: (1) the motivation to speak up, such as the perceived risk for patients, and the ambiguity or clarity of the clinical situation; (2) contextual factors, such as hospital administrative support, interdisciplinary policy-making, team work and relationship between other team members, and attitude of leaders/superiors; (3) individual factors, such as job satisfaction, responsibility toward patients, responsibility as professionals, confidence based on experience, communication skills, and educational background; (4) the perceived efficacy of speaking up, such as lack of impact and personal control; (5) the perceived safety of speaking up, such as fear for the responses of others and conflict and concerns over appearing incompetent; and (6) tactics and targets, such as collecting facts, showing positive intent, and selecting the person who has spoken up. CONCLUSIONS: Hesitancy to speak up can be an important contributing factor to communication errors. Our model helps us to understand how health care professionals think about voicing their concerns. Further research is required to investigate the relative importance of different factors

Donor selection for renal transplantation : a study on mixed lymphocyte reactions and kidney allograft survival in unimmunosuppressed dogs

The prime cause of failure of a transplanted kidney is immunological rejection of the graft. Graft rejection will not occur, when the transplanted organ is obtained from a donor which is genetically identical to the recipient (isogenic transplant). Graft rejection can always occur, when donor and recipient are genetically different (allogenic transplant). Unrelated people are always genetically different. Only when donor and recipient are monozygotic twins, complete genetic identity exists. Thus a transplanted organ will be antigenic, when donor and recipient are not monozygotic twins. The immune reaction, evoked by the antigens of such an allograft, consists of two components. In the first place, antibodies will be produced, which are specifically directed against the transplanted antigens (the so called humoral immune response). Secondly, immune reactive cells are generated, which specifically can attack the transplanted organ (the cellular immune response). The mechanism of the destruction of the allograft is complicated and only partly known. Both different types of antibodies and different types of cells are involved. Microscopically, arteritis and a cellular infiltrate can be seen (Busch et al., 1977). Progressive damaging of the glomeruli and tubuli results in a increasing loss of function of the transplanted kidney. Two factors determine the strength of the immune reaction of the recipient against the allograft. These factors are the immune response potential of the recipient and the strength of the antigenic stimulus (Lengerova, 1969). The strength of the antigenic stimulus is dependent on the immunogenetic difference between donor and recipient. Consequently, two methods are available to prevent allograft rejection, namely modification of the immune response and selection of compatible donor-recipient pairs

Incidence of osteonecrosis after renal transplantation

The incidence of osteonecrosis was 24% in 248 patients who had received 262 kidney transplants 1971-1982. However, based only on patients at risk, i.e. alive with functioning transplants, the incidence at 1, 3 and 6 years was found to be 13, 27 and 36%; after six years no new cases were found. the relative increase in body-weight at 180 days was predictive as regards risk for osteonecrosis, while the cumulative dose of steroids was not. This suggests that individual sensitivity to steroids rather than the absolute cumulative dose is involved in the development of osteonecrosis

Transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND-study)

Background: Recent non-randomized studies suggest that extended endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM). If equally effective, EMR might be a more cost-effective approach as this strategy does not require expensive equipment, general anesthesia and hospital admission. Furthermore, EMR appears to be associated with fewer complications. The aim of this study is to compare the cost-effectiveness and cost-utility of TEM and EMR for the resection of large rectal adenomas. Methods/design. Multicenter randomized trial among 15 hospitals in the Netherlands. Patients with a rectal adenoma 3 cm, located between 115 cm ab ano, will be randomized to a TEM- or EMR-treatment strategy. For TEM, patients will be treated under general anesthesia, adenomas will be dissected en-bloc by a full-thickness excision, and patients will be admitted to the hospital. For EMR, no or conscious sedation is used, lesions will be resected through the submucosal plane i

Lysophosphatidic Acid Prevents Renal Ischemia-Reperfusion Injury by Inhibition of Apoptosis and Complement Activation

Renal ischemia-reperfusion (I/R) injury is an important cause of acute renal failure as observed after renal transplantation, major surgery, trauma, and septic as well as hemorrhagic shock. We previously showed that the inhibition of apoptosis is protective against renal I/R injury, indicating that apoptotic cell-death is an important feature of I/R injury. Lysophosphatidic acid (LPA) is an endogenous phospholipid growth factor with anti-apoptotic properties. This tempted us to investigate the effects of exogenous LPA in a murine model of renal I/R injury. LPA administered at the time of reperfusion dose dependently inhibited renal apoptosis as evaluated by the presence of internucleosomal DNA cleavage. I/R-induced renal apoptosis was only present in tubular epithelial cells with evident disruption of brush border as assessed by immunohistochemistry for active caspase-7 and filamentous actin, respectively. LPA treatment specifically prevented tubular epithelial cell apoptosis but also reduced the I/R-induced loss of brush-border integrity. Besides, LPA showed strong anti-inflammatory effects, inhibiting the renal expression of tumor necrosis factor-α and abrogating the influx of neutrophils. Next, LPA dose dependently inhibited activation of the complement system. Moreover, treatment with LPA abrogated the loss of renal function in the course of renal I/R. This study is the first to show that administration of the phospholipid LPA prevents I/R injury, abrogating apoptosis and inflammation. Moreover, exogenous LPA is capable of preventing organ failure because of an ischemic insult and thus may provide new means to treat clinical conditions associated with I/R injury in the kidney and potentially also in other organs

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

BACKGROUND: Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography. METHODS: A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography. RESULTS: Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (+/-SD) manometric findings: mean resting pressure 41.3 (+/-20), 43.8 (+/-20) and 61.6 (+/-23) Hg (p <0.001); incremental squeeze pressure 20.6 (+/-20), 38.4 (+/-31) and 62.4 (+/-34) Hg (p <0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography. CONCLUSIONS: Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonograph