Diabetes medication patient safety incident reports to the National Reporting and Learning Service: the care home setting.

AIMS: To analyse adverse drug events in older people with diabetes in the care home setting via incident reports obtained from the National Reporting and Learning Service. METHODS: A Freedom of Information request was made to the National Reporting and Learning Service via the National Patient Safety Agency. Within the National Reporting and Learning Service, reports on diabetes within the category of 'medication' using the location limiter of 'hospice or nursing home or residential home' were searched. We requested information about the number and nature of adverse drug event reports that had been received in relation to diabetes. The data were subdivided into reports (1) relating to insulin therapy and (2) oral glucose-lowering agents. RESULTS: Data were collected between 1 January 2005 and 31 December 2009. There were 684 reports related to insulin and 84 incidents related to oral glucose-lowering agents. The most common error category with both types of drug therapy was wrong or unclear dose: 173 reports for insulin, including one death, and 20 reports for oral therapy. CONCLUSIONS: Residents with diabetes in care homes are potentially at risk of harm from adverse drug events pertaining to insulin and oral glucose-lowering agents. Because of under-reporting, our data most likely represent only a fraction of events.

Building a safety culture.

This is the first article in a series of seven based on the Seven Steps to Patient Safety (National Patient Safety Agency (NPSA) 2004a). It is aimed at enhancing nurses' and midwives' knowledge about patient safety, including strategies and tools that are available to improve the quality of health care. This article outlines the patient safety agenda and emphasises the importance of creating an open and fair culture in the NHS.

The concept of care in male nurse work: an ontological hermeneutic study in acute hospitals.

AIMS: The aims of the study were to facilitate reflection upon an aspect of practice chosen by the participants, to explore and analyse these experiences and compare them with current literature on the concept of care in nursing practice. BACKGROUND: The concept of care is commonly used in the attempt to define what is unique about the role of the nurse, and both nursing and the concept of care are frequently associated with womanhood. Little research has been undertaken in relation to male nurse experiences and views on the concept. METHODS: The study used ontological hermeneutics to explore the concept of care in male nurse work in the acute general hospital setting. Eight male voluntary subjects from acute general hospital areas participated in the study and were asked to complete a summary of an experience from their practice that they felt exemplified care. Data for the study included the participants choice of practice experience, their subsequent reflections, the interview itself, the field journal and relevant literature and research. RESULTS: Six of the participants selected positive experiences in which they felt that their performance was satisfactory even though the events chosen for reflection were difficult and/or sad. The remaining two participants chose to reflect further on the difficulties they had within the experience. A conceptual model was constructed showing that the meeting of needs, effective communication and information giving were central to these nurses' explanations of care within their practice. All but two of the participants broadened their gaze to include the significant others of the patient. CONCLUSIONS: The reflections of these participants emphasize the emotional load of practice and a sensitivity on their part to the male stereotype of being able to cope with such pressures. It is suggested therefore that those providing and managing clinical supervision take into account the possible reluctance of male nurses to seek such support. Issues of gender should be emphasized in nurse education, as these nurses were sensitive to the impact of gender on their practice, both with patient/clients and their significant others, and with colleagues.

Anticipating the decline of the large general hospital.

Changing attitudes to healthcare provision look set to prompt a move away from treating patients in large general hospitals. Hospitals would then be left to deal with acute problems, while local provision would cater for patients requiring care.

Beyond the rhetoric of problem-based learning: emancipatory limits and links with andragogy.

Problem-based learning (PBL), sometimes referred to as enquiry-based learning, is an approach to education that has gained increasing usage within health care in recent years. Its origins very much lie within medical education. The bulk of literature on PBL is optimistic about its potential, especially in relation to nurse education. It is argued here that the benefits of PBL are that it moves toward student-centred education and process-oriented methods that have been taking place for at least 16 years. There are clear links with andragogy although this is not always acknowledged, but the potential move away from emancipatory education inherent in PBL if used without reflection, is inconsistent with andragogy. This article takes a more critical view of the concept and argues that there are significant limits which need to be considered carefully. Apart from the possible move away from the emancipatory aims of education, there is commonly an implicit support of the medical model within PBL which is inappropriate at a time when the limits of medicine are becoming increasingly clear. It is concluded that further debate and research on the approach is necessary, but that as a facilitative strategy PBL does hold some promise. However, it would be inappropriate to use it as a curriculum model if only because it lacks the diversity required of a postmodern curriculum and would not respond effectively to differing student learning styles.

Defining and assessing competence: the distraction of outcomes and the importance of educational process.

The concept of competence is in common usage in various areas of education and training at present, and it is evident from these different usages that it has a variety of meanings. These meanings are explored, with particular attention being paid to the increasing influence of the National Vocational Qualification (NVQ) initiative and the rise of vocational education. It is concluded that the utilization of competence within these fields offers little to nurse/midwifery education (with the exception of a refocusing on the concept of skills) because it is exactly that: education, and is therefore different in some significant aspects from training and vocational approaches. It is suggested that a holistic conceptualization of competence is the most appropriate for nurse/midwifery education: one that empowers students and practitioners, facilitating critical thinking, rather than emphasizing, as the NVQ initiative does, outcomes over the importance of educational process and the use of a variety of forms of knowledge in practice. It is acknowledged that there is probably a skills deficit in some areas of nursing/midwifery education, although definition of this term 'skills' remains problematic, and that this should be addressed through the increased use of skills laboratories.

The iatrogenic epidemic.

Medicine can often cause unnecessary harm to people while trying to treat them, but this phenomenon, known as iatrogenesis, is rarely debated. The author of this article argues that nurses have a responsibility to consider the concept of iatrogenesis and its effects on the health of their patients.

In defence of andragogy. Part 2: An educational process consistent with modern nursing's aims.

In 1987 the English National Board (1987) made it clear that it supported a move towards an andragogical approach to nurse education. Recently such moves have been questioned as has the validity of andragogy (Darbyshire 1993). In response to such challenges this paper extends some of the arguments made in the article 'In defence of andragogy' (Milligan 1995). It is argued that andragogy provides a framework within which care and other crucial aspects of the nurse-patient/client relationship can be mirrored and thereby facilitated in future practitioners. In the socialization processes inherent in nurse education, care is surely difficult to teach or facilitate unless the philosophy and methods are consistent with such ends. Furthermore, it is frequently argued that as educationalists we need to be consistent in our approach to students with that which we hope to see in their future practice (Bevis & Murray 1990). Andragogy offers a medium through which this can be facilitated. It is essentially a humanistic educational process that values the individual. The power relationship between the educator and student is much more horizontal than is found in the historically common hierarchical educational relationship. An educational process based upon andragogy therefore mirrors important parts of the nurse-patient/client relationship. It offers a theory of education consistent with the aims of modern day nursing practice. We should seek to improve our understanding of andragogy and no longer conceptualize it as one end of a false dichotomy with pedagogy.

The use of criteria-based grading profiles in formative and summative assessment.

This article outlines the development and use of criteria based grading profiles for formative and summative assessment. The profiles were developed in 1991 in an attempt to improve assessment validity, inter-marker and inter-course reliability and student feedback within the Faculty of Health Care and Social Studies. Important underlying aspects of assessment theory are examined and it is argued that assessment should be conceptualised as an ethical activity requiring clarification for students of expectations through specification of criteria. It is concluded that the profiles have proved useful in guiding both lecturers and students in the completion and marking of assessed work and that further study and debate needs to take place in relation to the effectiveness and potential disadvantages of such profiles.

In defence of andragogy.

This paper supports the continued use of the term andragogy in Project 2000 nurse education programmes. It is argued that the theory of andragogy, and its supporting philosophy, methods, and research, are consistent with both the means and ends of contemporary nurse education. Some of the recent pressure felt in relation to use of alternative terms, such as critical pedagogy, are linked to wider socio-political influences and it is argued that it is essentially a sign of the times that andragogy has now come under threat. The call, from some, for a return to pedagogy is also seen as an attempt to reassert an increased degree of control over the student by those educationalists. This article is also a response to the article by Philip Darbyshire (1993) which questions the viability and relevance of the term andragogy.

Collagenous colitis in setting of nonsteroidal antiinflammatory drugs and antibiotics.

Collagenous colitis is a clinicopathologic syndrome characterized by chronic watery diarrhea and a mucosal inflammatory process with increased subepithelial collagen band on colonic biopsy. This disorder occurs primarily in females, and the etiology is unknown. We report the atypical presentation of collagenous colitis in two older-aged men following prolonged use of nonsteroidal antiinflammatory agents and short-term use of antibiotics. Although one patient had colonic pseudomembranes, neither patient had microbiological evidence of C. difficile toxin or infection. A variety of medications were initially given to these patients without resolution of diarrhea. Only after the diagnosis of collagenous colitis was made and antiinflammatory drugs directed at the colitis given did the diarrhea abate. These cases illustrate an unusual presentation of collagenous colitis with possible implications for pathogenesis.

Bleeding following endoscopic sphincterotomy: angiographic management by transcatheter embolization.

Transcatheter embolization is a well-established and effective method for the control of bleeding from the upper gastrointestinal tract and often represents the preferred alternative to more invasive surgical management. The applications of this technique for the management of bleeding following endoscopic sphincterotomy have not been reported previously. Of five patients referred for arteriography with life-threatening postsphincterotomy bleeding, active bleeding from branches of the gastroduodenal artery was demonstrated in four. Embolization of this vessel with Gelfoam controlled the bleeding in all three patients in whom it was attempted. Arterial stenosis and spasm precluded such treatment in one patient. The fifth patient was not bleeding at the time of arteriography. There were no complications from these procedures. Our experience shows that postsphincterotomy bleeding can be safely and effectively controlled by transcatheter embolization, thereby avoiding surgery which is associated with significant morbidity and mortality in this setting.

Enlargement of the pancreatic head in patients with pancreas divisum.

Pancreas divisum (PD) is a congenital anomaly present in 6-10% of the population. Computed tomography (CT) examinations in eight of 15 patients (53%) with endoscopic retrograde pancreatography (ERCP)-proven PD were interpreted as showing enlargement of the pancreatic head. Two of these had carcinoma, three had pancreatitis limited to the ventral pancreas, and three were normal. Criteria to distinguish nonpathologic enlargement of the pancreatic head due to PD alone from pathologic causes may include homogeneous parenchyma and an absence of other abnormal signs on CT. Because PD may simulate a pancreatic head mass, the radiologist should be familiar with this variant, and ERCP should precede biopsy unless other evidence of malignancy is present.

Complications of endoscopic retrograde sphincterotomy: computed tomographic evaluation.

Although the reported complication rate of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is low, patients often experience abdominal pain postprocedure. When pain persists, or fever and leukocytosis develop, a procedure-related complication should be suspected. The authors reviewed a series of 36 patients referred to computed tomography (CT) for evaluation of possible complications following ERCP with sphincterotomy. Initial CT scans were obtained within 24 h in 19 patients, and during the second to seventh day in the remainder. Complications detected by CT included acute pancreatitis (23), duodenal perforation (11), retroperitoneal dissection of air (4), pneumoperitoneum (4), and development of retroperitoneal abscess (4). Eight patients had normal CT scans except for air and contrast material in the biliary tree. The severity and extent of injury were readily assessed by CT, and response to therapy effectively monitored by serial CT examinations. Thirty-one cases (31 of 36) were successfully managed conservatively with antibiotics, intravenous hydration, and restriction of oral intake. Four patients required surgical intervention for drainage of a retroperitoneal abscess (3) or a pseudocyst (1). A fifth patient required intensive care resuscitation for septic shock. We conclude that CT is the study of choice for evaluating the patient with suspected complication following ERCP and sphincterotomy.

Pancreatitis or duodenal perforation after peri-Vaterian therapeutic endoscopic procedures: diagnosis, differentiation, and management.

The diagnosis, differentiation, and management of severe pancreaticoduodenal complications occurring after therapeutic endoscopic sphincterotomy and related procedures on the ampulla of Vater were reviewed for 254 patients. Five patients had duodenal (peri-Vaterian) perforation and six patients had clinically significant pancreatitis. Most patients were not suspected of having a significant complication the night of the procedure despite abdominal pain. Computer tomography proved to be the most accurate test for establishing the existence of a significant complication. A periduodenal collection of fluid (abscess) without significant pancreatic enlargement was the predominant complication in patients with duodenal perforation. In patients who had pancreatitis after peri-Vaterian procedures, generalized pancreatic enlargement and peripancreatic edema were most prominent. Four of the five patients with duodenal perforation required surgical drainage; all recovered. In contrast, four of the six patients with pancreatitis had medical therapy. One patient with pancreatitis died after multiple pancreatitic debridements were done. A second patient with pancreatitis who underwent exploration eventually recovered. Pancreaticoduodenal complications after therapeutic endoscopic sphincterotomy and related procedures are difficult to diagnose early; they should be suspected early and approached aggressively to limit morbidity and death.

Sclerosing cholangitis. Anatomical distribution of obstructive lesions.

The cholangiograms of 36 patients with sclerosing cholangitis were reviewed. The mean age of the patient group was 43 years, and the mean disease duration was 4.5 years. Seventeen of the patients had associated inflammatory bowel disease. The mean serum bilirubin was 6.8 mg/dl, the mean SGOT was 105 IU/L, the mean SGPT was 108 IU/L, and the mean serum alkaline phosphatase was 534 IU/L. The cholangiograms demonstrated involvement of the extrahepatic bile ducts in 33 patients, involvement of the hepatic duct bifurcation in 33 patients, and involvement of the intrahepatic bile ducts in 35 patients. The cholangiograms were graded as to the areas of the most severe obstructive involvement. In 24 patients the area of most severe involvement was the hepatic duct bifurcation. In eight additional patients the hepatic duct bifurcation, along with the extrahepatic ducts and/or the intrahepatic ducts, were felt to be the areas most severely affected. This predilection for severe obstructive disease at the hepatic duct bifurcation in sclerosing cholangitis held for both patients with and without inflammatory bowel disease. Thus, most patients with sclerosing cholangitis have cholangiographic evidence of diffuse extrahepatic and intrahepatic biliary tract disease, with the hepatic duct bifurcation being the area generally most severely affected.

Pathogenesis of colonic polyps in multiple juvenile polyposis: report of a case associated with gastric polyps and carcinoma of the rectum.

The pathogenesis of juvenile polyps of the colon was studied in a patient with multiple juvenile polyposis who underwent proctocolectomy for rectal carcinoma and antrectomy for associated polyps of the stomach. Numerous polyps up to 3 cm in diameter were present predominantly in the cecum and rectum, and in addition there was an adenocarcinoma in the rectum. Microscopically there were five categories of lesions: 1) Hyperplastic epithelial foci and small hyperplastic polyps; 2) Typical Juvenile polyps; 3) Juvenile polyps with focal adenomatous epithelium; 4) Adenomas; and 5) and adenocarcinoma. The five categories could represent a pathogenetic sequence, beginning with epithelial hyperplasia, leading to small hyperplastic polyps which become inflamed and enlarge, forming juvenile polyps. Focal adenomatous areas which develop in some juvenile polyps might give rise to adenomas and in turn lead to carcinoma. Although juvenile polyps are generally not considered to be premalignant lesions, this case demonstrates that neoplastic changes may occur in juvenile polyps in certain individuals, and raises the possibility that these may on occasion give rise to carcinoma.

Treatment of antibiotic-associated pseudomembranous colitis with cholestyramine resin.

Pseudomembranous colitis (PMC) is an infrequent but serious complication of oral and intravenous antibiotic therapy. Twelve patients with antibiotic-associated PMC, documented by sigmoidoscopy and rectal biopsy, were treated with cholestyramine resin. The mean time from the institution of therapy to cessation of diarrhea was 2.1 days. The response interval bore no relationship to the time symptoms were present prior to therapy. Complete resolution of sigmoidoscopic and histologic evidence of PMC usually accompanied or followed cessation of diarrhea. Obstipation was reported in 5 of 12 patients as a side effect of cholestyramine treatment. Therapy should be continued for up to five days after cessation of diarrhea to prevent recurrence of active PMC. Cholestyramine resin is shown to be an effective treatment for antibiotic-associated PMC.