A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Phylogenetic signal in phonotactics

Phylogenetic methods have broad potential in linguistics beyond tree inference. Here, we show how a phylogenetic approach opens the possibility of gaining historical insights from entirely new kinds of linguistic data – in this instance, statistical phonotactics. We extract phonotactic data from 112 Pama-Nyungan vocabularies and apply tests for phylogenetic signal, quantifying the degree to which the data reflect phylogenetic history. We test three datasets: (1) binary variables recording the presence or absence of biphones (two-segment sequences) in a lexicon (2) frequencies of transitions between segments, and (3) frequencies of transitions between natural sound classes. Australian languages have been characterized as having a high degree of phonotactic homogeneity. Nevertheless, we detect phylogenetic signal in all datasets. Phylogenetic signal is greater in finer-grained frequency data than in binary data, and greatest in natural-class-based data. These results demonstrate the viability of employing a new source of readily extractable data in historical and comparative linguistics.1. Introduction 1.1 Motivations 1.2 Phonotactics as a source of historical signal 2. Phylogenetic signal 3. Materials 3.1 Language sample 3.2 Wordlists 3.3 Reference phylogeny 4. Phylogenetic signal in binary phonotactic data 4.1 Results for binary phonotactic data 4.2 Robustness checks 5. Phylogenetic signal in continuous phonotactic data 5.1 Robustness checks 5.2 Forward transitions versus backward transitions 5.3 Normalization of character values 6. Phylogenetic signal in natural-class-based characters 6.1 Natural-class-based characters versus biphones 7. Discussion 7.1 Overall robustness 7.2 Limitations 8. Conclusio

Randomised controlled trial of specialist nurse intervention in heart failure

<p>Objectives. To determine whether specialist nurse intervention improves outcome in patients with chronic heart failure.</p> <p>Design. Randomised controlled trial.</p> <p>Setting. Acute medical admissions unit in a teaching hospital.</p> <p>Participants. 165 patients admitted with heart failure due to left ventricular systolic dysfunction. The intervention started before discharge and continued thereafter with home visits for up to 1 year.</p> <p>Main outcome measures. Time to first event analysis of death from all causes or readmission to hospital with worsening heart failure.</p> <p>Results. 31 patients (37%) in the intervention group died or were readmitted with heart failure compared with 45 (53%) in the usual care group (hazard ratio=0.61, 95% confidence interval 0.33 to 0.96).Compared with usual care, patients in the intervention group had fewer readmissions for any reason (86 v 114, P=0.018), fewer admissions for heart failure (19 v 45, P<0.001) and spent fewer days in hospital for heart failure (mean 3.43 v 7.46 days, P=0.0051).</p> <p>Conclusions. Specially trained nurses can improve the outcome of patients admitted to hospital with heart failure.</p&gt

TWO NEW PLOCENE SPECIES OF CYCLOSTEPHANOS (BACILLARIOPHYCEAE) WITH COMMENTS ON THE CLASSIFICATION OF THE FRESHWATER THALASSIOSIRACEAE 1

Two new species of the diatom genus Cyclostephanos Round are described from Pliocene fossil deposits in western North America. Cyclostephanos undatus is distinguished from other Cyclostephanos species by its tangentially undulate valve face; Cyclostephanos fenestratus is distinguished by its extremely shallow alveoli. This paper records previously unreported morphological detail of Cyclostephanos and speculates that structure of the punctum, labiate process and strutted process may enhance diagnosis of the freshwater genera of the Thalassiosiraceae Lebour emend. Hasle. Cyclostephanos undatus is similar to several Cyclotella species, but its external costae are raised and its alveolar morphology is similar to that of Cyclostephanos dubius (Fricke) Round. Cyclostephanos fenestratus is similar in external view to Stephanodiscus Ehrenb. However, the two species described here have flat cribra covering the mantle puncta and the labiate processes appear to lack external tubes, whereas Stephanodiscus species have domed mantle cribra and external tubes.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65645/1/j.1529-8817.1986.tb04154.x.pd

Spatial and temporal variations in the occurrence of low flow events in the UK

International audienceInformation on the magnitude and variability of low river flows at the river reach scale is central to most aspects of water resource and water quality management. Within the UK, river stretches with permanent gauging stations represent less than one percent of the total number of river stretches mapped at a scale of 1:50,000 and fewer that 20% of gauged catchments can be regarded as having natural flow regimes. This has led to the development of simple, multivariate models for predicting average annual natural flow duration statistics through relationships with catchment characteristics. One assumption within these models is that low flows occur at the same time at all points within a catchment, irrespective of the hydrogeological nature and climatic condition of the catchment. This paper discusses the implications of spatial variations in the timing of low flow events for this type of model. Differences in the timing of the mean day of occurrence of the annual Q95 flow in UK catchments can be identified with low flows occurring earlier in the year within impermeable dry catchments and later in the year for wet permeable catchments. However, any differences in the mean day of occurrence between different catchments are generally masked by the magnitude of the inter-year variability in the day of occurrence. From analysis of linear combinations of flow statistics from nearest-neighbour gauged catchments, the paper demonstrates that the assumption of temporal coherence of low flows will generally result in an under-estimate of Q95; these underestimates are more significant for pairs of impermeable catchments than for combinations of permeable catchments and impermeable-permeable catchments

A New Species of Muscicapa Flycatcher from Sulawesi, Indonesia

The Indonesian island of Sulawesi, a globally important hotspot of avian endemism, has been relatively poorly studied ornithologically, to the extent that several new bird species from the region have been described to science only recently, and others have been observed and photographed, but never before collected or named to science. One of these is a new species of Muscicapa flycatcher that has been observed on several occasions since 1997. We collected two specimens in Central Sulawesi in 2012, and based on a combination of morphological, vocal and genetic characters, we describe the new species herein, more than 15 years after the first observations. The new species is superficially similar to the highly migratory, boreal-breeding Gray-streaked Flycatcher Muscicapa griseisticta, which winters in Sulawesi; however, the new species differs strongly from M. griseisticta in several morphological characters, song, and mtDNA. Based on mtDNA, the new species is only distantly related to M. griseisticta, instead being a member of the M. dauurica clade. The new species is evidently widely distributed in lowland and submontane forest throughout Sulawesi. This wide distribution coupled with the species' apparent tolerance of disturbed habitats suggests it is not currently threatened with extinction.This project was funded by the National Geographic Society (NGS CRE 8919-11; granted to PCR), the Loke Wan Tho Memorial Foundation (granted to DLY), and an EIPR scholarship at the University of Adelaide (granted to JBCH). Labwork for this project was co-funded by a National University of Singapore Faculty of Science start-up grant to FER (WBS R-154-000-570-133). We thank RISTEK for issuing the national research permits (for 2011, 0215/SIP/FRP/VI/2011; for 2012, 183/SIP/FRP/SM/VI/2012) and Lore Lindu National Park for permit letters. The Research Centre for Biology-LIPI supported DMP and DDP in their field research and provided facilities for laboratory analysis. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

Relativity principles in 1+1 dimensions and differential aging reversal

We study the behavior of clocks in 1+1 spacetime assuming the relativity principle, the principle of constancy of the speed of light and the clock hypothesis. These requirements are satisfied by a class of Finslerian theories parametrized by a real coefficient $\beta$, special relativity being recovered for $\beta=0$. The effect of differential aging is studied for the different values of $\beta$. Below the critical values $|\beta| =1/c$ the differential aging has the usual direction - after a round trip the accelerated observer returns younger than the twin at rest in the inertial frame - while above the critical values the differential aging changes sign. The non-relativistic case is treated by introducing a formal analogy with thermodynamics.Comment: 12 pages, no figures. Previous title "Parity violating terms in clocks' behavior and differential aging reversal". v2: shortened introduction, some sections removed, pointed out the relation with Finsler metrics. Submitted to Found. Phys. Let

A new cell primo-culture method for freshwater benthic diatom communities

A new cell primo-culture method was developed for the benthic diatom community isolated from biofilm sampled in rivers. The approach comprised three steps: (1) scraping biofilm from river pebbles, (2) diatom isolation from biofilm, and (3) diatom community culture. With a view to designing a method able to stimulate the growth of diatoms, to limit the development of other microorganisms, and to maintain in culture a community similar to the original natural one, different factors were tested in step 3: cell culture medium (Chu No 10 vs Freshwater “WC” medium modified), cell culture vessel, and time of culture. The results showed that using Chu No 10 medium in an Erlenmeyer flask for cell culture was the optimal method, producing enough biomass for ecotoxicological tests as well as minimising development of other microorganisms. After 96 h of culture, communities differed from the original communities sampled in the two rivers studied. Species tolerant of eutrophic or saprobic conditions were favoured during culture. This method of diatom community culture affords the opportunity to assess, in vitro, the effects of different chemicals or effluents (water samples andindustrial effluents) on diatom communities, as well as on diatom cells, from a wide range of perspectives

Perioperative passport: empowering people with diabetes along their surgical journey

© 2017 Diabetes UK Aim: To determine whether a handheld ‘perioperative passport’ could improve the experience of perioperative care for people with diabetes and overcome some of the communication issues commonly identified in inpatient extracts. Methods: Individuals with diabetes undergoing elective surgery requiring at least an overnight stay were identified via a customized information technology system. Those allocated to the passport group were given the perioperative passport before their hospital admission. A 26-item questionnaire was completed after surgery by 50 participants in the passport group (mean age 69 years) and by 35 participants with diabetes who followed the usual surgical pathway (mean age 70 years). In addition, the former group had a structured interview about their experience of the passport. Results: The prevalence of those who reported having received prior information about their expected diabetes care was 35% in the control group vs 92% in the passport group (