Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

Objective The aim of this systematic review was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. Design A mixed-methods systematic review of the literature was conducted. Data sources Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. Eligibility criteria Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. Results 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. Conclusions This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients

Displays and claims of understanding in conversation by people with aphasia

Background: There is scope for additional research into the specific linguistic and sequential structures used in speech and language therapist (SLT)-led therapeutic conversations with people with aphasia (PWA). Whilst there is some evidence that SLTs use different conversational strategies than the partners of PWA, research to date has focussed mainly on measuring the effects of conversation-based therapies—not on analysing therapeutic conversations taking place between SLTs and PWA. Aims: This paper presents an analysis of the use of oh-prefacing by some PWA during therapeutic supported conversations with SLTs. Methods & Procedures: Normally occurring therapeutic conversations between SLTs and PWA after stroke were qualitatively analysed using Conversation Analysis. Interactions with five PWA were video-recorded, involving three different specialist stroke SLTs. Outcomes & Results: The analysis revealed a difference in the way some PWA use turns that display understanding (e.g., oh right) versus those that continue the conversation, merely claiming understanding (e.g., right). This use of oh-prefacing is similar to that described in the literature on typical conversations. In our data, SLTs are shown to treat oh-prefaced turns differently from non-oh-prefaced turns, by pursuing the topic in the latter, and progressing on to a new topic in the former. Conclusions: At least some PWA use oh-prefacing in the same way as non-language-impaired adults to display understanding of information versus merely claiming to understand. The SLTs in our data are shown to treat non-oh-prefaced turns as mere claims of understanding by providing the PWA with additional information, using supported conversation techniques, and pursuing additional same-topic talk, whereas oh-prefaced turns are treated as displays of understanding by being confirmed, and leading to changes of topic. This study is a first step in providing SLTs with a clearer understanding of the ways in which they are assessing the understanding of PWA, which may in turn help them better support non-therapy staff

Effects of a demand-led evidence briefing service on the uptake and use of research evidence by commissioners of health services:A controlled before-and-after study

Background: The Health and Social Care Act 2012 has mandated research use as a core consideration of health service commissioning arrangements. We evaluated whether or not access to a demand-led evidence briefing service improved use of research evidence by commissioners compared with less intensive and less targeted alternatives. Design: Controlled before-and-after study. Setting: Clinical Commissioning Groups (CCGs) in the north of England. Main outcome measures: Change at 12 months from baseline of a CCG’s ability to acquire, assess, adapt and apply research evidence to support decision-making. Secondary outcomes measured individual clinical leads’ and managers’ intentions to use research evidence in decision-making. Methods: Nine CCGs received one of three interventions: (1) access to an evidence briefing service; (2) contact plus an unsolicited push of non-tailored evidence; or (3) an unsolicited push of non-tailored evidence. Data for the primary outcome measure were collected at baseline and 12 months post intervention, using a survey instrument devised to assess an organisation’s ability to acquire, assess, adapt and apply research evidence to support decision-making. In addition, documentary and observational evidence of the use of the outputs of the service was sought and interviews with CCG participants were undertaken. Results: Most of the requests were conceptual; they were not directly linked to discrete decisions or actions but intended to provide knowledge about possible options for future actions. Symbolic use to justify existing decisions and actions were less frequent and included a decision to close a walk-in centre and to lend weight to a major initiative to promote self-care already under way. The opportunity to impact directly on decision-making processes was limited to work to establish disinvestment policies. In terms of impact overall, the evidence briefing service was not associated with increases in CCGs’ capacity to acquire, assess, adapt and apply research evidence to support decision-making, individual intentions to use research findings or perceptions of CCGs’ relationships with researchers. Regardless of the intervention received, at baseline participating CCGs indicated that it felt it was inconsistent in its research-seeking behaviours and its capacity to acquire research remained so at follow-up. The informal nature of decision-making processes meant that there was little or no traceability of the use of evidence. Limitations: Low baseline and follow-up response rates (of 68% and 44%, respectively) and missing data limit the reliability of these findings. Conclusions: Access to a demand-led evidence briefing service did not improve the uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. Commissioners appear to be well intentioned but ad hoc users of research. Future work: Further research is required on the effects of interventions and strategies to build individual and organisational capacity to use research. Resource-intensive approaches to providing evidence may best be employed to support instrumental decision-making. Comparative evaluation of the impact of less intensive but targeted strategies on the uptake and use of research by commissioners is warranted. Funding: National Institute for Health Research Health Services and Delivery Research programme

Treating patients as persons : a capabilities approach to support delivery of person-centered care

Peer reviewedPublisher PD

Structure of Tagatose-1,6-bisphosphate Aldolase. Insight into chiral discrimination, mechanism, and specificity of class II aldolases

Tagatose-1,6-bisphosphate aldolase (TBPA) is a tetrameric class II aldolase that catalyzes the reversible condensation of dihydroxyacetone phosphate with glyceraldehyde 3-phosphate to produce tagatose 1,6-bisphosphate. The high resolution (1.45 Å) crystal structure of the Escherichia coli enzyme, encoded by the agaY gene, complexed with phosphoglycolohydroxamate (PGH) has been determined. Two subunits comprise the asymmetric unit, and a crystallographic 2-fold axis generates the functional tetramer. A complex network of hydrogen bonds position side chains in the active site that is occupied by two cations. An unusual Na(+) binding site is created using a interaction with Tyr(183) in addition to five oxygen ligands. The catalytic Zn(2+) is five-coordinate using three histidine nitrogens and two PGH oxygens. Comparisons of TBPA with the related fructose-1,6-bisphosphate aldolase (FBPA) identifies common features with implications for the mechanism. Because the major product of the condensation catalyzed by the enzymes differs in the chirality at a single position, models of FBPA and TBPA with their cognate bisphosphate products provide insight into chiral discrimination by these aldolases. The TBPA active site is more open on one side than FBPA, and this contributes to a less specific enzyme. The availability of more space and a wider range of aldehyde partners used by TBPA together with the highly specific nature of FBPA suggest that TBPA might be a preferred enzyme to modify for use in biotransformation chemistry

A randomised controlled trial of patient led training in medical education: protocol

<p>Abstract</p> <p>Background</p> <p>Estimates suggest that approximately 1 in 10 patients admitted to hospital experience an adverse event resulting in harm. Methods to improve patient safety have concentrated on developing safer systems of care and promoting changes in professional behaviour. There is a growing international interest in the development of interventions that promote the role of patients preventing error, but limited evidence of effectiveness of such interventions. The present study aims to undertake a randomised controlled trial of patient-led teaching of junior doctors about patient safety.</p> <p>Methods/Design</p> <p>A randomised cluster controlled trial will be conducted. The intervention will be incorporated into the mandatory training of junior doctors training programme on patient safety. The study will be conducted in the Yorkshire and Humber region in the North of England. Patients who have experienced a safety incident in the NHS will be recruited. Patients will be identified through National Patient Safety Champions and local Trust contacts. Patients will receive training and be supported to talk to small groups of trainees about their experiences. The primary aim of the patient-led teaching module is to increase the awareness of patient safety issues amongst doctors, allow reflection on their own attitudes towards safety and promote an optimal culture among the doctors to improve safety in practice. A mixture of qualitative and quantitative methods will be used to evaluate the impact of the intervention, using the Attitudes to Patient Safety Questionnaire (APSQ) as our primary quantitative outcome, as well as focus groups and semi-structured interviews.</p> <p>Discussion</p> <p>The research team face a number of challenges in developing the intervention, including integrating a new method of teaching into an existing curriculum, facilitating effective patient involvement and identifying suitable outcome measures.</p> <p>Trial Registration</p> <p>Current controlled Trials: <a href="http://www.controlled-trials.com/ISRCTN94241579">ISRCTN94241579</a></p

Inactivation of Pmel Alters Melanosome Shape But Has Only a Subtle Effect on Visible Pigmentation

PMEL is an amyloidogenic protein that appears to be exclusively expressed in pigment cells and forms intralumenal fibrils within early stage melanosomes upon which eumelanins deposit in later stages. PMEL is well conserved among vertebrates, and allelic variants in several species are associated with reduced levels of eumelanin in epidermal tissues. However, in most of these cases it is not clear whether the allelic variants reflect gain-of-function or loss-of-function, and no complete PMEL loss-of-function has been reported in a mammal. Here, we have created a mouse line in which the Pmel gene has been inactivated (Pmel−/−). These mice are fully viable, fertile, and display no obvious developmental defects. Melanosomes within Pmel−/− melanocytes are spherical in contrast to the oblong shape present in wild-type animals. This feature was documented in primary cultures of skin-derived melanocytes as well as in retinal pigment epithelium cells and in uveal melanocytes. Inactivation of Pmel has only a mild effect on the coat color phenotype in four different genetic backgrounds, with the clearest effect in mice also carrying the brown/Tyrp1 mutation. This phenotype, which is similar to that observed with the spontaneous silver mutation in mice, strongly suggests that other previously described alleles in vertebrates with more striking effects on pigmentation are dominant-negative mutations. Despite a mild effect on visible pigmentation, inactivation of Pmel led to a substantial reduction in eumelanin content in hair, which demonstrates that PMEL has a critical role for maintaining efficient epidermal pigmentation

Cost-effectiveness of cryotherapy versus salicylic acid for the treatment of plantar warts: economic evaluation alongside a randomised controlled trial (EVerT trial)

Background Plantar warts (verrucae) are extremely common. Although many will spontaneously disappear without treatment, treatment may be sought for a variety of reasons such as discomfort. There are a number of different treatments for cutaneous warts, with salicylic acid and cryotherapy using liquid nitrogen being two of the most common forms of treatment. To date, no full economic evaluation of either salicylic acid or cryotherapy has been conducted based on the use of primary data in a pragmatic setting. This paper describes the cost-effectiveness analysis which was conducted alongside a pragmatic multicentre, randomised trial evaluating the clinical effectiveness of cryotherapy versus 50% salicylic acid of the treatment of plantar warts. Methods A cost-effectiveness analysis was undertaken alongside a pragmatic multicentre, randomised controlled trial assessing the clinical effectiveness of 50% salicylic acid and cryotherapy using liquid nitrogen at 12 weeks after randomisation of patients. Cost-effectiveness outcomes were expressed as the additional cost required to completely cure the plantar warts of one additional patient. A NHS perspective was taken for the analysis. Results Cryotherapy costs on average £101.17 (bias corrected and accelerated (BCA) 95% CI: 85.09-117.26) more per participant over the 12 week time-frame, while there is no additional benefit, in terms of proportion of patients healed compared with salicylic acid. Conclusions Cryotherapy is more costly and no more effective than salicylic acid

Rapid tests and urine sampling techniques for the diagnosis of urinary tract infection (UTI) in children under five years: a systematic review

Background: Urinary tract infection (UTI) is one of the most common sources of infection in children under five. Prompt diagnosis and treatment is important to reduce the risk of renal scarring. Rapid, cost-effective, methods of UTI diagnosis are required as an alternative to culture. Methods: We conducted a systematic review to determine the diagnostic accuracy of rapid tests for detecting UTI in children under five years of age. Results: The evidence supports the use of dipstick positive for both leukocyte esterase and nitrite (pooled LR+ = 28.2, 95% CI: 17.3, 46.0) or microscopy positive for both pyuria and bacteriuria (pooled LR+ = 37.0, 95% CI: 11.0, 125.9) to rule in UTI. Similarly dipstick negative for both LE and nitrite (Pooled LR- = 0.20, 95% CI: 0.16, 0.26) or microscopy negative for both pyuria and bacteriuria (Pooled LR- = 0.11, 95% CI: 0.05, 0.23) can be used to rule out UTI. A test for glucose showed promise in potty-trained children. However, all studies were over 30 years old. Further evaluation of this test may be useful. Conclusion: Dipstick negative for both LE and nitrite or microscopic analysis negative for both pyuria and bacteriuria of a clean voided urine, bag, or nappy/pad specimen may reasonably be used to rule out UTI. These patients can then reasonably be excluded from further investigation, without the need for confirmatory culture. Similarly, combinations of positive tests could be used to rule in UTI, and trigger further investigation