Responsible management of motor vehicle drivers with dementia.

When Bridget Driscoll, a 44-year-old mother of two died after being struck by a motor vehicle, considered to be the first motor vehicle fatality in UK and possibly the world, the coroner stated 'I trust this sort of nonsense will never happen again'.1 Sadly, the coroner, medical practitioners and general public would be deeply and repeatedly disappointed. It was 1896. Motor vehicles were a curiosity. Drivers did not undergo any form of testing, be it medical fitness, driving ability or otherwise, and there were no licensing regulatory agencies. By 2010, road injury was the ninth most common cause of death globally (1.3 million deaths per annum) and dementia the fourth most common in high income countries.2 By 2030 the number of all licensed UK drivers who are 65 years or older will increase by almost 50% to almost one in every four drivers.3 If the juxtaposition of driving with dementia in an ageing population is not already a contentious social, political and medical issue, it certainly will become so.

Validity of the indicator 'death in low-mortality diagnosis-related groups' for measuring patient safety and healthcare quality in hospitals.

The indicator 'death in low-mortality diagnosis-related groups (DRG)' is a patient safety indicator (PSI) that can be derived from routinely collected administrative data sources. It is included in a group of PSI that have been proposed to compare and monitor standards of hospital care in Australia. To summarize the attributes of this indicator as a measure of quality and safety in healthcare and examine issues regarding the development process, definitions and use of the indicator in practice. A structured literature search was conducted using the Ovid Medline database to identify peer-reviewed published literature which used 'death in low-mortality DRG' as a quality/safety indicator. Key quality websites were also searched. The studies were critically appraised using a standardized method. A total of 12 articles was identified which met our search criteria. Most were of low methodological quality because of their retrospective study designs. Only three studies provided evidence that the quality of care gap is higher in 'deaths in low-mortality DRG' than in other cases. Most of the studies reviewed show that there are several limitations of the indicator for assessing patient safety and quality of care. The few studies that have assessed associations with other measures of hospital quality have shown only weak and inconsistent associations. Higher quality, prospective, analytic studies are required before 'death in low-mortality DRG' is used as an indicator of quality and safety in healthcare. Based on current evidence, the most appropriate use is as a screening tool for institutions to quickly and easily identify a manageable number of medical records to investigate in more detail.

Resilience in healthcare and clinical handover.

BACKGROUND: Understanding and applying human factors in healthcare provides significant opportunities for improving patient safety. A key human factors concept is "resilience," which investigates how individuals, teams and organisations monitor, adapt to and act on failures in high-risk situations. Although it is a new concept to healthcare, it is well accepted in other high-risk industries. Resilience moves the focus away from "What went wrong?" to "Why does it go right?", that is, it moves from simplistic reactions to error making toward valuing a proactive focus on error recovery. Resilience is a better match for healthcare settings than the principles for high reliability because it more effectively addresses the unique complexities of healthcare. OBJECTIVE: This article introduces the concept of resilience and how it applies to healthcare using clinical handover as an exemplar. Clinical handover and the risks it presents to patient safety are used to illustrate the key principles of resilience to healthcare professionals. The overall aim of this paper is to motivate research which focuses on understanding how frontline staff "fix" mistakes. Researching resilience in healthcare needs to focus on developing measurement, improvement and prediction tools. CONCLUSION: Resilience can benefit patient safety efforts because it represents a change in emphasis from a traditional, reactive focus on errors to seeing humans as a defence against failure. Translating this concept into practice requires identifying and testing mechanisms for measuring and building resilience within complex healthcare processes.

Improving measurement in clinical handover.

BACKGROUND: Poor clinical handover creates discontinuities in care leading to patient harm. However, the field of handover research continues to lack standardised definitions and reliable measurement tools to identify factors that would lead to harm reduction and improved safety strategies. OBJECTIVE: This paper introduces a conceptual framework to underpin a research agenda around the important patient safety topic of clinical handover. METHODS: Five frameworks with potential application to clinical handover were identified in a consultation process with clinicians, researchers and policy makers. RESULTS: The framework consists of three key handover elements-information, responsibility and/or accountability and system-in relation to three key measurement elements-policy, practice and evaluation. Using this framework an analysis of current "gaps" in the measurement of handover was completed. CONCLUSION: The paper argues that measurement will identify gaps in knowledge about handover practice and promote rigor in the design and evaluation of interventions to reduce patient harm.

World without borders: integrating clinical perspectives into the coronial jurisdiction in Victoria, Australia.

A professional world without borders would allow for more appropriate collaboration between the Coroner's office and the healthcare sector in their endeavours to improve patient safety. In Victoria (Australia), the Clinical Liaison Service draws on the distinct experiences and expertise of medical, nursing and research personnel to evaluate clinical evidence for the investigation of healthcare deaths reported to the State Coroner's Office. This approach allows for greater intersectoral collaboration between the Coroner's office and healthcare sector than a traditional English-style coronial system that relies on the expertise of coroners, forensic pathologists and police officers to investigate unexpected deaths. Encouraging collaboration between these two sectors may have averted or at least mitigated the atrocities caused by Harold Shipman or the events at Bristol's Royal Infirmary. This paper describes the work processes employed by the Clinical Liaison Service (CLS) to investigate healthcare deaths in a coronial setting. To describe how this work has fostered the advancement of patient care.

Experience with practice guidelines for medico-legal death investigations: the case of falls-related deaths in hospital.

Western philosophical and political thought has focussed on the significance of individual relativism. The legal system's approach to the investigation and regulation of medical practice is generally ad hoc and based on case law. In contrast, medical knowledge and understanding is progressively shifting towards a system of taxonomies and norms. Clinical guidelines and evidence-based medical practice are now commonplace in clinical practice. Due to the polarity of professional frameworks underpinning medicine and law, there has been an on-going struggle for the successful use of medical law that benefits both the quality of medical practice as well as its practitioners. This paper discusses the principles in developing and implementing a standard investigation tool for the coronial sector using the Falls Investigation Standard as an example, which has been in use for 12 months in the state of Victoria, Australia. It is hoped that using a standardised tool can balance the often conflicting tensions between medical and legal sectors by enabling an in-depth review of each issue while also strengthening the health system's capacity for self-regulation.

Phenomenon of quality and health-care: snowball or an avalanche?

The quality-of-care in health as a phenomenon is developing through small incremental steps. Some suggest this approach is too slow and more rapid change is warranted. It is possible to achieve more rapid change by reaching a 'tipping point' or a critical level. To reach a critical level requires (i) identifying key people, (ii) having an idea that sticks, and (iii) having the right context. Examples from selected aspects of quality in health-care including the use of report cards, recognition and remedial action for adverse events, the substantial reviews of health systems for quality-of-care suggest the critical level has been achieved. However, when the three rules for reaching the 'tipping point' are examined closely, it would seem that much more work is required to transform quality in health-care from a snowball into an avalanche.

Prioritising quality.

The deluge of new initiatives, proposals and recommendations for solving the problems required to improve patient safety and quality of health care continues unabated. Implementing the proposed solutions for improving patient safety and quality of care requires setting priorities for action throughout the different levels of the health-care system. Currently, we face the dilemma of having to set priorities from the plentiful themes that are intuitively sensible and well accepted. There is an increasing number of examples of using systematic processes which contain explicit and transparent criteria for priority setting in patient safety and quality initiatives. These should be more widely adopted and become a key requirement for all future proposals for improving patient safety and quality of health care.

A system for systems is required for quality health systems.

Improving quality of health-care requires a systematic approach at many different levels within a health system. The levels range from the interactions between individual patient-health provider to the international stage. The provision of care within and between each level needs to be systematically organised if the quality of our health-care is to improve. There is a need to develop a systematic approach to the multiple systems within health care. An organisational structure similar to the Cochrane Collaboration may provide the mechanism to better coordinate all our efforts to improve health-care quality.

The extraction of quality-of-care clinical indicators from State health department administrative databases.

OBJECTIVE: To assess whether three proposed quality-of-care indicators (unplanned readmissions, hospital-acquired bacteraemia, and postoperative wound infection) can be accurately identified from State health department databases. DESIGN: Algorithms were applied to State health department databases to maximise the identification of individuals potentially positive for each indicator. Records of these patients were then examined to determine the percentage of cases that met the precise indicator definitions. SETTING: 10 public, acute-care hospitals from Victoria, South Australia and New South Wales. Data from the 1994-95 and 1995-96 financial years were collected. PARTICIPANTS: Individuals 18 years of age or older who were identified from State health department administrative databases as potentially meeting the indicator criteria. MAIN OUTCOME MEASURES: The proportion of screened cases that met the precise indicator definitions, and the elements of the indicator definitions which could not be extracted from the administrative databases. RESULTS: The proportions of cases confirmed by medical record review to be positive for the indicator events were 76.3% for unplanned readmissions within 28 days, 20% for hospital-acquired bacteraemia, 43.5% for wound infections after clean surgery, and 34.8% for wound infections after contaminated surgery. The clinical elements of each indicator definition were not easily extracted from the administrative databases. CONCLUSIONS: The three proposed clinical indicators could not be extracted from current State health department databases without an extensive process of secondary medical record review. If administrative databases are to be used for assessing quality of care, more systematic recording of data is needed.