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.

Quality improvement capacity: a survey of hospital quality managers.

Background Skilled managers are an important component of quality improvement (QI) infrastructure, but there has been little evaluation of QI infrastructure, which is needed to guide enhancement of this capacity. Methods Quality managers at 97 acute care hospitals in Ontario, Canada, were surveyed by mail to describe how their roles were integrated with QI performance objectives. Binary and scaled responses were analysed quantitatively, and open-ended responses were analysed thematically. Results The response rate was 79.4%. Many QI managers were new to their role and had no support staff despite responsibility for multiple portfolios. Respondents thought that QI objectives should be less reactive to hospital executives or boards, adverse events or demands from government and accreditation bodies, and recommended that dedicated QI managers proactively apply explicit strategic plans and engage executives and clinicians. Findings were consistent regardless of rank, staffing or hospital type. Those with master's training and greater experience were more involved in strategic planning, data analysis and communication. Conclusions QI is not well resourced in most acute care hospitals in Ontario. To develop QI capacity, investment and QI training may be required. Research should empirically establish objective performance measures of QI capacity to guide investment and evaluation.

Measures of patient safety in developing and emerging countries: a review of the literature.

CONTEXT: The World Alliance for Patient Safety was formed to accelerate worldwide research progress towards measurably improving patient safety. Although rates of adverse events have been studied in industrialised countries, little is known about the rates of adverse events in developing and emerging countries. PURPOSE: To review the literature on patient safety issues in developing and emerging countries, to identify patient safety measures presently used in these countries and to propose a method of measurably improving patient safety measurement in these countries. METHODS: Using the Medline database for 1998 to 2007, we identified and reviewed 23 English-language articles that examined patient safety measurement in developing and emerging countries. Results Our review included 12 studies that prospectively measured patient safety and 11 studies that retrospectively measured safety. Two studies used measures of structure and the remaining used process measures, outcome measures or both. Whereas a few studies used surveys or direct observation, most studies used chart audits to measure patient safety. Most studies addressed safety at a single facility. CONCLUSIONS: Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.

Localization: conventional and CT simulation.

Recent developments in imaging and computer power have led to the ability to acquire large three dimensional data sets for target localization and complex treatment planning for radiation therapy. Conventional simulation implies the use of a machine capable of the same mechanical movements as treatment units. Images obtained from these machines are essentially two dimensional with the facility to acquire a limited number of axial slices to provide patient contours and tissue density information. The recent implementation of cone beam imaging on simulators has transformed them into three dimensional imaging devices able to produce the data required for complex treatment planning. The introduction of computed axial tomography (CT) in the 1970s was a step-change in imaging and its potential use in radiotherapy was quickly realised. However, it remained a predominantly diagnostic tool until modifications were introduced to meet the needs of radiotherapy and software was developed to perform the simulation function. The comparability of conventional and virtual simulation has been the subject of a number of studies at different disease sites. The development of different cross sectional imaging modalities such as MRI and positron emission tomography has provided additional information that can be incorporated into the simulation software by image fusion and has been shown to aid in the delineation of tumours. Challenges still remain, particularly in localizing moving structures. Fast multislice scanning protocols freeze patient and organ motion in time and space, which may lead to inaccuracy in both target delineation and the choice of margins in three dimensions. Breath holding and gated respiration techniques have been demonstrated to produce four-dimensional data sets that can be used to reduce margins or to minimize dose to normal tissue or organs at risk. Image guided radiotherapy is being developed to address the interfraction movement of both target volumes and critical normal structures. Whichever method of localization and simulation is adopted, the role of quality control is important for the overall accuracy of the patient's treatment and must be adapted to reflect the networked nature of the process.

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of "vulnerable system syndrome", Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as "relational coordination" to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

BACKGROUND: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members' willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. METHODS: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. RESULTS: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1-6 minutes (mean 3.5) and most commonly took place in the OR before the patient's arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members' preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. CONCLUSIONS: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

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.

Paramagnetic cobalt(II) as an NMR probe of dendrimer structure: mobility and cooperativity of dendritic arms.

Cobalt(II) has been utilized as an external paramagnetic (1)H NMR probe for the study of the structure of dendrimers that possess specifically located metal recognition sites. The hyperfine-shifted (1)H NMR signals of the Co(II) complexes of several 2,6-diamidopyridine-containing dendrimers have been fully assigned by means of 1D and 2D NMR techniques, including NOE difference, EXSY, COSY, and TOCSY. Temperature-dependent T(1) values of the hyperfine-shifted signals were used to conclude that the Co(II)-dendrimer complexes are in the "liquidlike" regime, indicative of a shell-like structure instead of a "dense-core" structure. The presence of sizable cavities within the dendrimers was observed including a loosely packed conformation for the 2,6-diamidopyridino moiety to bind to potential guest molecules. Cooperativity among the dendritic arms in metal binding is also observed, whereby two dendritic arms bind to the metal center at the same time. In the case of dendrimers with the metal binding site located near the surface of the molecule, such binding cooperativity is still observed despite the large degree of freedom of the metal-binding moiety. Cooperativity among the dendritic arms can thus be considered an intrinsic property, which has to be taken into consideration in future design of functional dendrimers for the purpose of specific recognition and catalysis. The hydrodynamic radii of these dendrimers have been determined by means of nuclear Overhouser effect at low temperature. The study offers a method for the study of the dynamics of dendrimers in solution under different conditions and upon ligand binding and recognition. The study also provides a tool for monitoring systematic variation of the metal binding site in different dendrimer frameworks for specific applications, such as catalysis and molecular recognition.

Benign idiopathic haemorrhagic retinopathy.

PURPOSE: To describe a new condition characterised by an unusual unilateral idiopathic haemorrhagic retinopathy. METHODS: A review is presented of patient histories from 5 patients with acute-onset unilateral idiopathic haemorrhagic retinopathy, including results of ophthalmological, haematological and fluorescein angiographic examinations. RESULTS: All patients had an extensive deep blot haemorrhagic retinopathy without significant vascular signs or abnormal optic discs. In 4 cases the haemorrhage was sufficiently severe to break through into the vitreous. Fluorescein angiography demonstrated normal arteriovenous flow, without capillary non-perfusion, vessel or disc leakage. Disc swelling, macular oedema and cotton wool spots were not seen at any stage in these patients. All patients recovered the visual acuity in the affected eye by 4 months. Systemic examination in all cases was unremarkable. CONCLUSION: This distinct and rare form of retinopathy is important to define since it has a good prognosis without treatment.

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.

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.

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.

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.

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.