Identification and Adjudication of Adverse Events Following Rectal Cancer Surgery: Observational Case Series in a Region of Ontario, Canada.

BACKGROUND: For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality. METHODS: In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events. RESULTS: Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality. CONCLUSIONS: Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.

Mandatory reporting legislation in Canada: improving systems for patient safety?

Patient safety is a complex systems issue. In this study, we used a scoping review of peer-reviewed literature and a case study of provincial and territorial legislation in Canada to explore the influence of mandatory reporting legislation on patient safety outcomes in hospital settings. We drew from a conceptual model that examines the components of mandatory reporting legislation that must be in place as a part of a systems governance approach to patient safety and used this model to frame our results. Our results suggest that mandatory reporting legislation across Canada is generally designed to gather information about - rather than respond to and prevent - patient safety incidents. Overall, we found limited evidence of impact of mandatory reporting legislation on patient safety outcomes. Although legislation is one lever among many to improve patient safety outcomes, there are nonetheless several considerations for patient safety legislation to assist in broader system improvement efforts in Canada and elsewhere. Legislative frameworks may be enhanced by strengthening learning systems, accountability mechanisms and patient safety culture.

Review of lateral orbital wall ossifying fibroma.

Significant histological overlap exists between fibro-osseous lesions and diagnosis is made on a clinicopathological basis. Ossifying fibroma is a benign fibro-osseous neoplasm of the jaw and craniofacial complex that has generated a degree of controversy regarding diagnosis and classification, especially with respect to the psammomatoid variant. Orbital lesions mainly arise from the paranasal sinuses affecting the medial or inferior orbital wall. Lateral orbital wall ossifying fibroma is, therefore, a rare condition with only a single previous case report. We present a second case of lateral orbital wall ossifying fibroma and a review of the associated literature.

The effects of vitamin A on insulin release and glucose oxidation in isolated rat islets.

We tested the effects of vitamin A, a membrane surface-active agent, on glucose (16.7 mM)-induced biphasic insulin release from collagenase-isolated rat islets. Also, efforts were made to correlate the effects of vitamin A with glucose oxidation. Vitamin A (10(-4) M) inhibited first- and second phase insulin release; 10(-5) M vitamin A inhibited second phase release only and to a lesser extent than that observed with 10(-4) M vitamin A; and 10(-6) M vitamin A had no effect. Vitamin A (10(-7) M) stimulated biphasic insulin release. Exposure to high glucose (27.8 mM) overcame the effects of 10(-4) M vitamin A on first phase release, but not on second phase release of insulin. Exposure to 10(-5) M hydrocortisone opposed the effects of 10(-4) M vitamin A on both phases of insulin release. Vitamin A (10(-4) and 10(-5) M) inhibited glucose oxidation by islets, as measured by the production of 14CO2 from [14C]glucose. The effects of vitamin A on insulin release were dissociated in part from those effects on glucose oxidation, in that hydrocortisone opposed the effect of vitamin A on insulin release but not on glucose oxidation. The effects of vitamin A on insulin secretion can best be explained by the interaction of vitamin A at multiple sites affecting the membrane and intracellular glucose oxidation.

Communication failures in the operating room: an observational classification of recurrent types and effects.

BACKGROUND: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. METHODS: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. RESULTS: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion" (45.7% of instances) where timing was poor; "content" (35.7%) where information was missing or inaccurate, "purpose" (24.0%) where issues were not resolved, and "audience" (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. CONCLUSION: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.

Comparison of oil recovered from tea tree leaf by ethanol extraction and steam distillation.

Two methods for the determination of oil and oil major components from tea tree (Melaleuca alternifolia) leaf are quantitatively compared. A microwave assisted ethanol extraction and a 2-h hydrodistillation technique were used on both dry and fresh leaf from a low and a high oil concentration tree. There was no significant difference between dry and fresh leaf. The distillation technique recovered 88% and 82% of the extractable oil for the low and high concentration material, respectively. For both samples this distilled oil was composed of lower absolute amounts of sesquiterpenoids and marginally lower amounts of monoterpenoids. Extending the distillation to 6 h increased the sesquiterpenoid recovery but this resulted in a reduction in both the absolute and relative amounts of the oxygenated monoterpenoids, terpinen-4-ol and 1,8-cineole.

Application of acoustic emission to the monitoring and end point determination of a high shear granulation process.

The application of a novel monitoring technique, based on the use of acoustic emissions, is reported for a model high shear granulation process. It has been demonstrated that this technique is capable of monitoring changes in physical properties of powder material during granulation (particle size, flow properties and compression properties). The technique is non-invasive, sensitive and relatively inexpensive.

Applying quality improvement to Canadian health care: can organizational skills address strategic challenges?

Most health care organizations in Canada employ quality improvement methods and tools to secure internal efficiencies rather than to achieve broader strategic aims or improve key clinical processes. If quality improvement efforts are to have much impact on the quality of Canadian health care, health care leaders must increase their advocacy of quality improvement methods and demonstrate that these can be used to achieve health care reform.

Using patient feedback for quality improvement.

This article describes the results of a study designed to understand h how health care organizations use patient feedback. The article examines the organizational factors and the barriers that influence patient feedback use and concludes with propositions that can serve to guide future action and research in this area.

Collaborating for improvement in health professions education.

Continual improvement efforts have been slower in health professions education than in health care delivery. This article identifies the lessons learned by teams working in an Interdisciplinary Professional Education Collaborative in overcoming barriers to carrying out continual improvement efforts in these educational organizations.

Continually improving the health and value of health care for a population of patients: the panel management process.

Today's primary care provider faces the challenge of caring for individual patients as well as caring for populations of patients. This article offers a model--the panel management process--for understanding and managing these activities and relationships. The model integrates some of the lessons learned during the past decade as we have worked to gain an understanding of the continual improvement of health care after we have understood that care as a process and system.

Making patients safer! Reducing error in Canadian healthcare.

Media reports of adverse events experienced by patients raise questions about whether these are isolated exceptions or part of a larger problem. There is no reliable Canadian data on medical error; but there is little reason to expect that the situation differs markedly from Australia or the United States which have rigorously studied the problem. Research in Australia has concluded that as many as 16% of hospital patients are injured as a result of their treatment. The Australian study and more recent research in the United States have created widespread concern that an epidemic of error exists in healthcare. Fortunately, experts in healthcare and other industries, have pointed toward a number of solutions that will reduce these errors. Three key strategies need to be pursued First, better information about the numbers and types of errors that occur is needed to help pinpoint change efforts. Non-punitive reporting policies must be put in place, to assist in altering the traditional culture of blame that has discouraged error reporting. Second, a set of strategies have to focus on developing more effective systems, including physician-order entry and medication administration systems which have been shown to have a dramatic impact in reducing errors. These systems are expensive, but their importance in reducing injury - and greatly reducing the costs of additional care that come from such injuries - make them an essential part of the answer. Finally, healthcare organizations need to work to create more effective cultures oriented toward preventing errors and intercepting errors that inevitably occur. These cultures will require a new emphasis on teamwork, a continual focus on redesigning care systems, particularly in high risk areas such as operating rooms, intensive care units and emergency rooms. These are not easy tasks and will require investments in new equipment and new skills. These steps are essential if we are to maintain public confidence in healthcare.

Creating a balanced scorecard for a hospital system.

In 1999, hospitals in Ontario, Canada, collaborated with a university-based research team to develop a report on the relative performance of individual hospitals in Canada's most populated province. The researchers used the balanced-scorecard framework advocated by Kaplan and Norton. Indicators of performance were developed in four areas: clinical utilization and outcomes, patient satisfaction, system integration and change, and financial performance and condition. The process of selecting, calculating, and validating meaningful indicators of financial performance and condition is outlined. Lessons learned along the way are provided. These lessons may prove valuable to other finance researchers and practitioners who are engaged in performance measurement endeavors.

Downsizing, reengineering, and restructuring: long-term implications for healthcare organizations.

This article provides a framework for analyzing how downsizing and reengineering have affected healthcare organizations. These approaches are reviewed, and key tools that have been used, such as across-the-board cuts, reorganizing, and redesigning, are described. Examples are drawn from healthcare as well as other business sectors. The consequences of cost reduction strategies for an organizations's performance in terms of costs, quality of services, and satisfaction of consumers and employees are explored. The case is made that an organization's context--that is, its culture, level of trust, and leadership--is an important factor that influences the effect of cost-cutting strategies. Characteristics of organizations where downsizing has a better chance of succeeding also are described.

The behavioural outcomes of quality improvement teams: the role of team success and team identification.

This study investigates the relationship between hospital quality improvement (QI) team success and changes in empowerment, 'organizational commitment, organizational citizenship behaviour' (OCB) and job behaviour related to QI. Data were collected from administrative staff, healthcare professionals and support staff from four community hospitals. The study involved a field investigation with two data collection points. Structured questionnaires and interviews with hospital management were used to collect data on the study variables. High scores were observed for organizational commitment, OCB and job behaviour related to QI when individuals identified with teams that were successful. Low scores were observed when individuals identified with teams that were unsuccessful. Empowerment was positively related to job behaviour associated with QI. It is concluded that participation on QI teams can lead to organizational learning, resulting in the inculcation of positive 'extra-role' and 'in-role' job behaviour.

A review of organizational performance assessment in health care.

As health care organizations look for ways to ensure cost-effective, high quality service delivery while still meeting patient needs, organizational performance assessment (OPA) is useful in focusing improvement efforts. In addition, organizational performance assessment is essential for ongoing management decision-making, operational effectiveness and strategy formulation. In this paper, the roles and impact of OPA models in use in health care are reviewed, and areas of potential abuse, such as myopia, tunnel vision and gaming, are identified. The review shows that most existing OPA models were developed primarily as sources of information for purchasers or consumers, or to enable providers to identify areas for improvement. However, there was little conclusive evidence evaluating their impact. This review of existing OPA models enabled the establishment of principles for the development, implementation and prevention of abuse of OPA specific to health care. The OPA models currently in use in health care may provide managers with false confidence in their ability to monitor organizational performance. To further enhance the field of OPA, areas for future research are identified.

A conceptual framework for the analysis of health care organizations' performance.

Organizational performance remains an elusive concept despite its importance to health care organizations' (HCOs') management and analysis. This paper uses Parsons' social system action theory to develop a comprehensive theoretically grounded framework by which to overcome the current fragmented approach to HCO performance management. The Parsonian perspective focuses on four fundamental functions that an HCO needs to ensure its survival. Organizational performance is determined by the dynamic equilibrium resulting from the continual interaction of, and interchange among, these four functions. The alignment interchanges allow the creation of bridges between traditional models of organizational performance that are usually used as independent and competing models. The attraction of the Parsonian model lies in its capacity to: (1) embody the various dominant models of organizational performance; (2) present a strong integrative framework in which the complementarity of various HCO performance perspectives are well integrated while their specificity is still well preserved; and (3) enrich the performance concept by making visible several dimensions of HCO performance that are usually neglected. A secondary objective of this paper is to lay the foundation for an integrative process of arbitration among competing indicators and perspectives which is absolutely necessary to make operational the Parsonian model of HCO performance. In this matter, we make reference to the theory of communicative action elaborated by Habermas. It offers, we think, a challenging and refreshing perspective on how to manage HCO performance evaluation processes.

A balanced scorecard for Canadian hospitals.

Managing a health care organization on the basis of one set of information alone (e.g., financial information) does not give a full view of the impact of changes on the organization. A balanced scorecard approach can provide management with a comprehensive framework that turns an organization's strategic objectives into a coherent set of performance measures. This approach has been used extensively in industry, but seldom in health care organizations. By developing a scorecard approach, these organizations could obtain feedback providing a balanced view of organizational performance, letting them see if improvements in one area may have been achieved at the expense of another. It also demands that managers translate their general mission statement on customer service into specific measures that reflect the factors that really matter to customers.

Selecting clinical outcome indicators for monitoring quality of care.

Clinical outcome indicators are used to identify opportunities for improvement in patient care processes. This paper focuses on issues specific to the selection of clinical outcome indicators for use in assessing performance within and between hospitals. The issues and examples are based on the experiences of a university research team that worked in collaboration with a group of teaching hospitals to develop and monitor clinical outcome indicators. Four sets of issues are discussed: the intended use, and end users of indicator information; aspects of indicator validity; data quality; and dissemination and use of indicator information. Recommendations are made that apply to individual hospitals, groups of hospitals and health care systems.

Regulation and hospital strategic planning in Canada.

Constraints on resources push hospitals into strategic planning. Although this process is accelerating in the United States, Canadian hospitals need to approach planning according to the provincial structure. This study included a literature and policy review as well as interviews of key stakeholders. Decisions toward centralized planning versus hospital-initiated development were found to depend on the availability of planning and policy staff, and the views of the elected representatives. Implications for Canadian health care planners were offered.