Online patient safety education programme for junior doctors: is it worthwhile?

BACKGROUND: Increasing demand exists for blended approaches to the development of professionalism. Trainees of the Royal College of Physicians of Ireland participated in an online patient safety programme. AIMS: Study aims were: (1) to determine whether the programme improved junior doctors' knowledge, attitudes and skills relating to error reporting, open communication and care for the second victim and (2) to establish whether the methodology facilitated participants' learning. METHODS: 208 junior doctors who completed the programme completed a pre-online questionnaire. Measures were "patient safety knowledge and attitudes", "medical safety climate" and "experience of learning". Sixty-two completed the post-questionnaire, representing a 30 % matched response rate. RESULTS: Participating in the programme resulted in immediate (p < 0.01) improvement in skills such as knowing when and how to complete incident forms and disclosing errors to patients, in self-rated knowledge (p < 0.01) and attitudes towards error reporting (p < 0.01). Sixty-three per cent disagreed that doctors routinely report medical errors and 42 % disagreed that doctors routinely share information about medical errors and what caused them. Participants rated interactive features as the most positive elements of the programme. CONCLUSIONS: An online training programme on medical error improved self-rated knowledge, attitudes and skills in junior doctors and was deemed an effective learning tool. Perceptions of work issues such as a poor culture of error reporting among doctors may prevent improved attitudes being realised in practice. Online patient safety education has a role in practice-based initiatives aimed at developing professionalism and improving safety.

Quality-of-life measurement in advanced cancer: assessing the individual.

PURPOSE: Despite the increasing importance of assessing quality of life (QoL) in patients with advanced cancer, relatively little is known about individual patient's perceptions of the issues contributing to their QoL. The Schedule for the Evaluation of Individual Quality of Life (SEIQoL) and the shorter SEIQoL-Direct Weighting (SEIQoL-DW) assess individualized QoL using a semistructured interview technique. Here we report findings from the first administration of the SEIQoL and SEIQoL-DW to patients with advanced incurable cancer. PATIENTS AND METHODS: QoL was assessed on a single occasion using the SEIQoL and SEIQoL-DW in 80 patients with advanced incurable cancer. RESULTS: All patients were able to complete the SEIQoL-DW, and 78% completed the SEIQoL. Of a possible score of 100, the median QoL global score was as follows: SEIQoL, 61 (range, 24 to 94); SEIQoL-DW, 60.5 (range, 6 to 95). Psychometric data for SEIQoL indicated very high levels of internal consistency (median r =.90) and internal validity (median R(2) = 0.88). Patients' judgments of their QoL were unique to the individual. Family concerns were almost universally rated as more important than health, the difference being significant when measured using the SEIQoL-DW (P =.002). CONCLUSION: Patients with advanced incurable cancer were very good judges of their QoL, and many patients rated their QoL as good. Judgments were highly individual, with very high levels of consistency and validity. The primacy given to health in many QoL questionnaires may be questioned in this population. The implications of these findings are discussed with regard to clinical assessment and advance directives.

A double-blind evaluation of captopril in elderly hypertensives.

To establish the role of angiotensin converting enzyme inhibitors in the management of hypertension in the elderly, 16 patients were treated with captopril in a randomized double-blind placebo-controlled cross-over study. Clinic blood pressure, ambulatory blood pressure, renal function and mental performance, with emphasis on mood and psychological well-being, were assessed. Twelve patients, aged 73 (+/- 4.4) years, completed the study. The doses of captopril used were 50 mg (11 patients) and 25 mg (one patient) twice daily for 4 weeks. Mean (+/- s.e.m.) clinic sitting blood pressure during captopril therapy was significantly lower than during administration of placebo (172 +/- 4.5/83 +/- 25 versus 188 +/- 4.4/89 +/- 3.4 mmHg; P less than 0.001/P less than 0.05). Mean ambulatory blood pressure was also significantly lower on captopril treatment than during administration of placebo (166 +/- 5.3/87 +/- 1.6 versus 179 +/- 5.1/94 +/- 2.4 mmHg; P less than 0.02/P less than 0.02) and this effect was sustained over the dosing interval. Renal blood flow and mental performance were unaltered by treatment. Gastrointestinal discomfort occurred in two patients, one of whom was withdrawn and cough developed in one patient. We conclude that captopril is effective as monotherapy in lowering blood pressure in the elderly.

Benzodiazepine--induced event amnesia following a stressful surgical procedure.

In a randomised, double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted third molar teeth received either midazolam 15 mg orally followed at 35 min by intravenous saline or oral placebo followed by intravenous diazepam 10 mg (Diazemuls). Episodic (event) memory was assessed by showing patients photographs of dental and neutral objects both before and after sedation and by testing subsequent recognition at 1 week. Recall of actual surgical events was assessed by questionnaire. Both treatments induced significant amnesia for visual stimuli and for surgical events. However, the degree of amnesia was more profound for artificial stimuli and no relationship was found between the extent of amnesia for the two types of event. Drilling of bone was found to provoke the greatest cardiovascular stress response and a significant relationship was found between the degree of cardiovascular activation and subsequent memory for drilling. It is concluded that the extent of benzodiazepine-induced event-amnesia may be modified by cognitive factors and especially by the extent to which the event is cognitively encoded and elaborated.

Understanding adherence to hand hygiene recommendations: the theory of planned behavior.

BACKGROUND: Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene. PURPOSE: The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB). METHOD: A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model. RESULTS: Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations. CONCLUSIONS: The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors.

Quality of life issues in palliative medicine.

The assessment of patient's quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition, and ability to fulfil occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to patients with progressive conditions, particularly in the later phases of the disease. Despite the fact that current definitions of palliative medicine include quality of life as a central concern, relatively little research has been conducted on the impact of palliative care on patient quality of life. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that the unique individual perspective of the patient on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care delivery in progressive diseases.

The antihypertensive efficacy of verapamil in the elderly evaluated by ambulatory blood pressure measurement.

To assess the efficacy, tolerability and pharmacokinetics of verapamil in the elderly, ten patients with blood pressure greater than 160/90 mmHg were studied in a randomized double-blind placebo-controlled cross-over trial. Nine patients aged 75 (+/- 4.9) years completed the study. After titration, doses of verapamil varying from 40 to 120 mg (40 mg in four, 80 mg in one and 120 mg in four patients) twice daily for six weeks were taken. Mean (+/- SEM) clinic lying blood pressure was reduced on verapamil from 187 +/- 6.8/100 +/- 4.1 to 167 +/- 4.6/86 +/- 3.1 mmHg, [P less than 0.001). Mean ambulatory blood pressure was reduced from 174 +/- 1.4/95 +/- 1.0 to 169 +/- 1.3/90 +/- 0.8 mmHg, (P less than 0.01). Lying heart rate was significantly reduced but glomerular filtration rate, renal blood flow and mental function, were not altered by treatment. The mean plasma half-life of verapamil was 6.9 +/- 1.1 hours. Side effects were minimal. We conclude that verapamil is an effective blood pressure lowering agent in the elderly.

Continuous subcutaneous infusion of morphine vs. hydromorphone: a controlled trial.

Seventy-four patients were included in a double-blind, randomized, controlled trial comparing the analgesic efficacy and adverse effects of hydromorphone and morphine delivered by continuous subcutaneous infusion. Patients completed the Memorial Pain Assessment Card and a checklist of opioid-related adverse effects immediately before commencing subcutaneous infusion and 24, 48, and 72 hours later. An assessment tool was developed for the 60 patients who were too ill to complete their own questionnaire. The tool demonstrated excellent inter-rater reliability. Thirty-four percent of patients in the hydromorphone group and 27% of those in the morphine group died before completion of the study (P = 0.66). The hydromorphone group required more analgesia for breakthrough pain in the first 24 hours of the study (P = 0.03) and had a greater improvement in the behavior of frowning on movement and the comfort visual analogue scale (P = 0.08) over the course of the study. Adverse effects were rare and similar in both groups. This study found hydromorphone to be at least as effective as morphine when delivered by continuous subcutaneous infusion.

General practitioner and public health nurse views of nutritional risk factors in the elderly.

A number of risk factors for malnutrition in the elderly have been identified, but their relative importance has yet to be established. General practitioners and public health nurses were interviewed to elicit the relative weights placed on 6 major risk factors when assessing nutritional risk in the elderly (living alone, recent bereavement, denture problems, mobility problems, psychiatric morbidity and multiple medication use). Participants rated risk for 35 hypothetical cases, described by their status on the 6 risk factors. Multiple regression models of these judgments revealed a consistently high weight for psychiatric morbidity compared to the other factors. Little group variation in diagnostic policies was observed between general practitioners and public health nurses or by case gender. These policies may reflect the perception that psychiatric problems pervade many areas of life functioning related to nutritional intake and are therefore more likely to cause malnutrition than other, more specific risk factors.

A new short form individual quality of life measure (SEIQoL-DW): application in a cohort of individuals with HIV/AIDS.

Quality of life is an increasingly important outcome measure in medicine and health care. Many measures of quality of life present patients with predetermined lists of questions that may or may not be relevant to the individual patient. This paper describes a brief measure, the SEIQoL-DW, which is derived from the schedule for evaluation of individual quality of life (SEIQoL). The measure allows respondents to nominate the areas of life which are most important, rate their level of functioning or satisfaction with each, and indicate the relative importance of each to their overall quality of life. Given its practicality and brevity, the measure should prove particularly useful in clinical situations where patient generated data on quality of life is important. This article describes the first clinical application of the measure, assessing the quality of life of a cohort of patients with HIV/AIDS managed in general practice.

Communication skills training in undergraduate medicine.

Good communication with patients is now recognised as the cornerstone in effective medical practice. Medical students do not automatically acquire the art of good communication through clinical training. A new course to promote the development of communication skills at undergraduate level is described. The course was provided at the juncture between pre-clinical and clinical training. Course evaluation illustrated the value of the course as perceived by students themselves and highlighted the areas of greatest need for students in communication skills training.

Communication skills training in undergraduate medicine: attitudes and attitude change.

The importance of communication skills training in undergraduate medical education is now widely accepted. However little is known about student attitudes towards their own communication skills and whether their attitudes changes as a result of participating in communication skills courses. The aim of the present study was to identify these attitudes prior to commencing such a course and to further evaluate changes in these attitudes on completion of the course. Results demonstrated an improvement in perceived confidence regarding a number of specific communication skills. The study provides further evidence of the value of such courses in undergraduate medical training.

Benzodiazepine-induced amnesia and anaesthetic practice: a review.

Anaesthetic practice is the only clinical context in which amnesia is a valued property of benzodiazepine drugs, since decreased recall considerably enhances patient tolerance and acceptance or surgical and diagnostic procedures. Research on the amnesic effects of diazepam, midazolam, lorazepam and flunitrazepam, administered via oral, i.v. or i.m. routes to patients undergoing surgical or diagnostic procedures is reviewed. The degree of anterograde amnesia is a function of the drug, the route of administration and the population of patients being assessed. Retrograde amnesia has not been conclusively demonstrated. Amnesia is more profound for cutaneous-tactile and auditory than for visual stimuli, but actual surgical events, or emotionally laden material, are more likely to be recalled than artificial stimuli. Evidence that the benzodiazepines prevent affective and cognitive processing under general anaesthesia and decrease traumatic postoperative recall of intra-operative events is reviewed. The explanatory value of modern theories of memory for research on benzodiazepine-induced amnesia, and the research potential of the surgical setting are outlined. The development of non-sedative anxiolytics and specific benzodiazepine antagonists provides the tools for assessing the contribution of sedative and anxiolytic properties of drugs to their amnesic effects.

Assessment of quality of life in surgery.

The concept of patients' quality of life is assuming increasing importance in modern medicine and surgery. Interventions are increasingly being assessed in terms of their impact on such areas of functioning as mobility, mood, cognitive function, ability to fulfil occupational and social roles, and general life satisfaction. This paper discusses the theoretical underpinnings of the quality-of-life paradigm and its practical relevance for modern surgery.

Measuring the quality of later life.

This paper examines quality of life as a scientific construct with a wide range of applications. The assessment of patients' quality of life is assuming increasing importance in medicine and health care. Illnesses, diseases and their treatments can have significant impacts on such areas of functioning as mobility, mood, life satisfaction, sexuality, cognition and ability to fulfil occupational, social and family roles. The emerging quality of life construct may be viewed as a paradigm shift in outcome measurement since it shifts the focus of attention from symptoms to functioning. This holistic approach more clearly establishes the patient as the centre of attention and subsumes many of the traditional measures of outcome. Quality of life assessment is particularly relevant to ageing populations both for healthy elderly and for those who develop chronic diseases where maintenance of quality of life rather than cure may be the primary goal of treatment. This paper introduces the concept of quality of life and describes the significant difficulties in definition, measurement and interpretation that must be addressed before such measures can be used as reliable and valid indicators of disease impact and treatment outcomes. It is argued that approaches to quality of life assessment in the elderly should incorporate advances in knowledge about the psychological adaptation to ageing. Consequently, the unique perspective of the individual on his or her own quality of life must be incorporated into outcome assessments aimed at improving the quality of health care. Incorporating measures of subjective outcome such as quality of life into policy decisions on resource allocation in health care will prove one of the major challenges for health services over the next decade.

Sedation in outpatient oral surgery. Comparison of temazepam by mouth and diazepam i.v.

In a randomized double-blind, parallel groups study, 39 patients undergoing surgical removal of impacted third molar teeth received either temazepam 40 mg by mouth (as soft gelatin capsules) followed at 35 min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of significant anxiolytic activity and psychomotor depression was seen following temazepam, while the pattern and duration of postoperative sedation measured with standard psychometric tests, were similar for both treatments. Ratings by the surgeon and by the patients indicated that sedation following the two treatments was comparable. No significant cardiovascular complications were found with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as temazepam provide safe, effective alternatives to i.v. diazepam for sedation in outpatients undergoing minor surgical procedures.

Controlled comparison of a new sublingual lormetazepam formulation and i.v. diazepam in outpatient minor oral surgery.

In a randomized, double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either sublingual lormetazepam 2.5 mg (n = 20) in a new cellulose wafer formulation followed at 35 min by i.v. saline; or sublingual placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of sedation was seen after sublingual lormetazepam, while the course and duration of postoperative sedation, measured using standard psychometric tests, was similar following both treatments. Surgeons' ratings indicated that sublingual lormetazepam was comparable to i.v. diazepam but patients' ratings indicated greater satisfaction with and preference for i.v. diazepam. Significant anterograde amnesia was found following both treatments. Both treatments were tolerated well, with no significant cardiovascular complications. These results indicate that sublingual lormetazepam may have a role in anaesthesia as a premedicant and for conscious sedation.

Comparison of midazolam by mouth and diazepam i.v. in outpatient oral surgery.

In a randomized double-blind, parallel groups study, 40 patients undergoing surgical removal of impacted 3rd molar teeth received either midazolam 15 mg orally followed at 35 min by i.v. saline, or oral placebo followed at 35 min by i.v. diazepam 10 mg (Diazemuls). Rapid onset of sedation was seen after midazolam, while the pattern and duration of postoperative sedation, as measured by standard psychometric tests, indicated slower recovery after midazolam than after diazepam. Ratings by the surgeon indicated superior anxiolysis following midazolam and significantly more patients expressed a preference for oral midazolam sedation. Significant, comparable anterograde amnesia was seen with both treatments. No significant cardiovascular complications occurred with either treatment. The findings indicate that rapidly acting oral benzodiazepines such as midazolam provide safe, effect alternatives to i.v. diazepam for conscious sedation in outpatients undergoing minor surgical procedures.