Patient safety in primary and emergency care

This thesis explores aspects of risk and safety in health care. Patient safety is about preventing harm to patients. A perspective of resilience is used, which is a proactive approach to making care safer. Resilient organisations recognise the fact that work is done in a complex and adaptive system that can be improved, not only by studying what goes wrong, but even more so by studying what works well. The thesis adds to previous research by studying patient safety in first-contact care, primary health care and the emergency department, resulting in new knowledge that could be used to make care safer. We investigated reported preventable harm and serious safety incidents in primary health care and in emergency departments (Study I). In these contexts, diagnostic error was the most common type. A diagnostic error is when a patient does not receive the correct diagnosis within a reasonable timeframe when there were clear opportunities to establish the correct diagnosis. The consequence is delayed adequate treatment. There is limited knowledge of the panorama of diagnoses that are involved in diagnostic errors. We explored the diagnoses that were most frequent in this material. Cancer was the most common missed diagnosis in primary health care, in particular colorectal cancer, and fractures were the most common missed diagnoses in the emergency departments. Furthermore, little is known about patient-related risk factors for preventable harm. We explored factors associated with an increased risk of reported pre- ventable harm, or serious safety incidents, in primary health care and in the emergency departments (Study II). The most prominent risk was psychiatric disease. This was, to our knowledge, the first study in an out-patient setting, with all types of psychiatric diseases. This thesis also examines what patients and health care professionals per- ceived as the major risks in primary health care and what solutions they would prefer (Study III and IV). Solutions generated from the people in the system are likely to be more accurate and easier to implement than top- down solutions. In Study III, qualitative analysis of free-text answers to structured questionnaires was performed. The results were used to build a survey for Study IV, where specified risks and solutions were rated accord- ing to importance. Regarding risks, the areas that were thought to need most improvement were continuity of care, communication and knowledge. Solutions included: information about what to do when tests were fine, but symptoms remained, so called safety-netting; the use of a nationwide medication record online; and a personal doctor with a restricted number of patients per doctor, to facilitate continuity of care. These studies support future work for safer and more resilient health care. There were suggestions from the level of the general practice up to the national level. Further research should test interventions that proactively support systems in improved accuracy in diagnosis and correct medication, for example, an intervention to improve continuity of care or to practice safety-netting. Proactive interventions like these could probably improve the resilience of the system in question

Powerful knowledge in ethics education

Syftet med denna studie är att undersöka vilken powerful knowledge som åtta intervjuade lärare på mellanstadiet framhåller som avgörande för att eleverna ska utveckla en etisk kompetens. Studien ingår i det pågående forskningsprojektet EthiCoII, som avser svara på hur en framgångsrik etikundervisning i skolan kan se ut. Följande frågeställningar undersöks i studien: Vad säger lärare att elever behöver lära sig för att bli etiskt kompetenta? Kan det innehåll som lärarna lyfter fram tolkas som powerful knowledge? Studien är en kvalitativ intervjustudie och materialet består av åtta transkriberade lärarintervjuer från forskningsprojektet EthiCoII. En tematisk analys av materialet har genomförts. Denna analys resulterade i fyra huvudteman och nio underliggande teman. Dessa teman har sedan analyserats utifrån det teoretiska ramverket etisk mångdimensionell kompetens (Osbeck m.fl., 2018). Resultaten i studien visar att det som lärare framhåller att elever behöver lära sig för bli etiskt kompetenta är att se bortom sig själva, ansvarsfulla handlingar, social kompetens och reflektion. Detta kopplas i analysen till etisk mångdimensionell kompetens, framtagen av Osbeck m.fl. (2018). Studiens diskussion avser binda samman resultaten med powerful knowledge och vill hävda att etisk mångdimensionell kompetens är avgörande för att elever ska utveckla powerful knowledge inom etik

Resolution of the type material of the Asian elephant, Elephas maximus Linnaeus, 1758 (Proboscidea, Elephantidae)

The understanding of Earth’s biodiversity depends critically on the accurate identification and nomenclature of species. Many species were described centuries ago, and in a surprising number of cases their nomenclature or type material remain unclear or inconsistent. A prime example is provided by Elephas maximus, one of the most iconic and well-known mammalian species, described and named by Linnaeus (1758) and today designating the Asian elephant. We used morphological, ancient DNA (aDNA), and high-throughput ancient proteomic analyses to demonstrate that a widely discussed syntype specimen of E. maximus, a complete foetus preserved in ethanol, is actually an African elephant, genus Loxodonta. We further discovered that an additional E. maximus syntype, mentioned in a description by John Ray (1693) cited by Linnaeus, has been preserved as an almost complete skeleton at the Natural History Museum of the University of Florence. Having confirmed its identity as an Asian elephant through both morphological and ancient DNA analyses, we designate this specimen as the lectotype of E. maximus

Pilot study in human healthy volunteers on the use of magnetohydrodynamics in needle-free continuous glucose monitoring

The benefits of continuous glucose monitoring (CGM) in diabetes management are extensively documented. Yet, the broader adoption of CGM systems is limited by their cost and invasiveness. Current CGM devices, requiring implantation or the use of hypodermic needles, fail to offer a convenient solution. We have demonstrated that magnetohydrodynamics (MHD) is effective at extracting dermal interstitial fluid (ISF) containing glucose, without the use of needles. Here we present the first study of ISF sampling with MHD for glucose monitoring in humans. We conducted 10 glucose tolerance tests on 5 healthy volunteers and obtained a significant correlation between the concentration of glucose in ISF samples extracted with MHD and capillary blood glucose samples. Upon calibration and time lag removal, the data indicate a Mean Absolute Relative Difference (MARD) of 12.9% and Precision Absolute Relative Difference of 13.1%. In view of these results, we discuss the potential value and limitations of MHD in needle-free glucose monitoring.Peer reviewe

Sampling of fluid through skin with magnetohydrodynamics for noninvasive glucose monitoring

Out of 463 million people currently with diabetes, 232 million remain undiagnosed. Diabetes is a threat to human health, which could be mitigated via continuous self-monitoring of glucose. In addition to blood, interstitial fluid is considered to be a representative sample for glucose monitoring, which makes it highly attractive for wearable on-body sensing. However, new technologies are needed for efficient and noninvasive sampling of interstitial fluid through the skin. In this report, we introduce the use of Lorentz force and magnetohydrodynamics to noninvasively extract dermal interstitial fluid. Using porcine skin as an ex-vivo model, we demonstrate that the extraction rate of magnetohydrodynamics is superior to that of reverse iontophoresis. This work seeks to provide a safe, effective, and noninvasive sampling method to unlock the potential of wearable sensors in needle-free continuous glucose monitoring devices that can benefit people living with diabetes.Peer reviewe

Interlaboratory Evaluation of Different Extraction and Real-Time PCR Methods for Detection of Coxiella burnetii DNA in Serum

In the Netherlands, there is an ongoing and unparalleled outbreak of Q fever. Rapid and reliable methods to identify patients infected with Coxiella burnetii, the causative agent of Q fever, are urgently needed. We evaluated the performance of different DNA extraction methods and real-time PCR assays that are in use in seven diagnostic or reference laboratories in the Netherlands. A low degree of variation in the sensitivities of most of the developed real-time PCR assays was observed. However, PCR assays amplifying short DNA fragments yielded better results than those producing large DNA fragments. With regard to DNA extraction, the automated MagNA Pure Compact system and the manual QIAamp DNA mini kit consistently yielded better results than either the MagNA Pure LC system and NucliSens EasyMag (both automated) or the High Pure viral nucleic acid kit (manual). The present study shows that multiple combinations of DNA extraction kits and real-time PCR assays offer equivalent solutions to detect C. burnetii DNA in serum samples from patients suspected to have Q fever

Association of Angiotensin II Type 2 Receptor Gene A1818T Polymorphism with Progression of Immunoglobulin A Nephropathy in Korean Patients

We determined the relationship between the progression of immunoglobulin A nephropathy (IgAN) and the A1818T polymorphism in intron 2 of Angiotensin II type 2 receptor (AT2R) gene, which might play protective roles in the pathogenesis of IgAN. Patients with biopsy-proven IgAN were recruited from the registry of the Progressive REnal disease and Medical Informatics and gEnomics Research (PREMIER) which was sponsored by the Korean Society of Nephrology. A1818T polymorphism of AT2R gene was analyzed with PCR-RFLP method and the association with the progression of IgAN, which was defined as over 50% increase in baseline serum creatinine level, was analyzed with survival analysis. Among the 480 patients followed for more than 10 months, the group without T allele had significantly higher rates of progression of IgAN than the group with T allele (11.4% vs. 3.9%, p=0.024), although there were no significant differences in the baseline variables such as initial serum creatinine level, the degree of proteinuria, and blood pressure. In the Cox's proportional hazard model, the hazard ratio of disease progression in the patients with T allele was 0.221 (95% confidence interval for Exp(B): 0.052-0.940, p=0.041) compared to that of without T allele. In conclusion, A1818T polymorphism of AT2R gene was associated with the progression of IgAN