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.

Adverse drug reactions amongst adult patients admitted in Lagos State University Teaching Hospital Lagos, Nigeria.

BACKGROUND: Adverse drug reaction (ADR) is a global drug therapy problem. It has been rated as one of the top leading causes of morbidity and mortality. In Nigeria, not much is known about ADRs especially with the existing weak post marketing surveillance for monitoring drug use, and its effect on the population. OBJECTIVES: The study is aimed at determining the incidence of ADRs, presentations of ADRs, classes of drugs that frequently cause ADRs and predictors of ADRs in adult medical in-patients in LASUTH. METHOD: A retrospective study of six hundred and twenty four (624) case notes of all patients admitted to the medical wards in LASUTH between January 1, 2009 and December 31, 2009 was carried out. Information obtained included age, gender, and adverse drug reaction and drug details. The results obtained were analyzed using SPSS version 16 statistical software. Level of significance was set at p ≤ 0.05. RESULTS: A total of 624 case notes consisting of 358 males and 266 females were assessed. The number of patients who experienced adverse drug reactions was 67 (n = 624, 10.7%). The incidence rate of ADRs in LASUTH from the study was 10.7 per 100 patients' population. Most of the ADRs observed were type A reactions (97.8%). Mostly implicated classes of drugs were antidiabetics (26.7%) and NSAIDs (29.3%). CONCLUSION: The incidence rate of ADRs was 10.7%. ADRs which are predictable and preventable occur in hospitalized patients, such may be prevented or minimized by implementing measures to target specific drugs that are commonly suspected.

Dental anxiety levels in British servicemen and women.

OBJECTIVES: The objectives of the study were to determine: 1, the level of dental anxiety in British Service personnel; 2 whether there was a difference in dental anxiety levels across the three Services; and, 3, the relationship between number of operational tours and level of dental anxiety. BASIC RESEARCH DESIGN: Cross sectional questionnaire survey of individuals attending 3 Armed Services dental treatment centres in the UK. The questionnaires were completed between February 2008 and April 2009. PARTICIPANTS: 50 patients each from the Royal Navy, Army and Royal Air Force, selected consecutively from those attending the centres for treatment. There was a 100% response rate. MAIN MEASURES: Dental fear as assessed by the Dental Fear Survey (DFS) and scores on a scale of fear of dental injections. RESULTS: 27% of the Armed Services experienced severe dental anxiety: a level similar to that found in the general population. There was no difference in the level of dental anxiety or fear of dental injections across the three Armed Services. There was no relationship between number of operational tours undertaken and level of dental anxiety. CONCLUSIONS: Dental anxiety is found amongst members of the British Armed Services at levels similar to that in the general population. This represents a challenge for service provision, particularly in operational settings.

Summary of: compliance with pre-operative instructions for procedures with conscious sedation: a complete audit cycle.

INTRODUCTION: A wide variety of procedures in all surgical departments are performed under conscious sedation with midazolam. Patients are required to adhere to a list of pre-operative instructions but poor compliance has been noted anecdotally in our department and in the literature. This can lead to delayed and cancelled appointments. AIM: We aimed to audit the compliance of patients in following preoperative sedation instructions in the oral and maxillofacial department of a large tertiary teaching hospital with a view to improving compliance. All patients undergoing conscious sedation for day case procedures in a five month period were audited. We implemented changes based on findings and a literature review, followed by a second eight month period of audit. RESULTS: Twenty-nine and 30 patients participated in each cycle respectively. In the first cycle over 55% of patients were non-compliant. The most common reasons were not bringing a competent adult escort at the start of the appointment (17% of total) and having consumed alcohol in the 24 hours pre-operatively (17%). Based on this, the patient information leaflet was revised. Patients received copies when being listed and then with their posted appointment letter, as well as being verbally reminded before attending. Second cycle results revealed a 22% increase in compliance rates across all instructions with all patients bringing competent escorts along. CONCLUSIONS: Efficacy within the NHS is often achieved with simple and practical improvement to clinical and administrative practice. By achieving a reduction in non-compliance rates, the department was able to reduce appointment delays and waiting lists, ultimately to the patients' benefit.

Acceptability of behaviour therapy for dental phobia.

OBJECTIVE: To determine how people with dental phobia rate the acceptability of behavioural therapy. METHODS: One hundred and twenty individuals with dental phobia participated in a three-factor experimental vignette-based design. The three factors examined were dental treatment history, nature of intervention (intravenous sedation or behavioural therapy) and treatment outcome. There were eight different vignettes representing all combinations of the three experimental variables, and 15 participants completed each vignette. RESULTS: Treatment outcome had a strong effect on rated acceptability (F = 115.76, P < 0.001). There was a weaker effect of treatment type (F = 5.49, P < 0.05) with behavioural therapy rated as more acceptable than intravenous sedation. Previous history of intravenous sedation was associated with a decreased perception that it is possible to overcome dental fear. CONCLUSIONS: The perceptions of individuals with dental phobia of the acceptability of behavioural approaches to management are influenced by the perceived outcome of the treatment.

What happens after referral for sedation?

OBJECTIVE: To follow up 100 referrals to the sedation clinic, examining dental anxiety and background of patients, and to assess how many patients attended for treatment planning, initial treatment and how many completed treatment, and describe the characteristics of each. For those who attended for initial treatment, to investigate which type of sedation they received and the level of clinician they saw. DESIGN: Descriptive, cross-sectional survey and review of case notes. SUBJECTS AND METHODS: Subjects were 100 consecutive new patients to the Department of Sedation and Special Care Dentistry at Guy's and St Thomas NHS Foundation Trust. The notes were analysed by an experienced member of staff (CAB) and data entered into an Excel spreadsheet and an SPSS data file created. These data were merged with a dataset containing their responses to the initial questionnaire and medical history for analysis. RESULTS: Of the 100 patients initially referred, 72 attended the treatment planning session, 66 of the 72 (92%) attended for initial dental treatment, and 33 of 66 (50%) completed treatment. Dental Fear Survey (DFS) scores were related to attendance at the initial treatment visit but not to completion of treatment. Only 33 of 100 referred patients completed treatment. CONCLUSIONS: Attendance for treatment planning and initial treatment was high. Attendance is related to fear and mental health. Overall completion of treatment from referral was 33%.

Intranasal/intravenous sedation for the dental care of adults with severe disabilities: a multicentre prospective audit.

OBJECTIVE: This study was designed to provide an evaluation of the combined intranasal/intravenous midazolam sedation technique. It involved adults with severe disabilities which prevented them from being able to co-operate with dental treatment and intravenous cannulation for sedation. METHOD: Following a previous retrospective audit, additional treatment centres were enrolled and a standardised form used to collect prospective data about the effectiveness of the technique in facilitating cannulation, dental examination and treatment. Data was also collected on safety and patient acceptability. RESULTS: In a total of 316 sedation episodes in primary and secondary care settings, cannulation was achieved in 96.2% (304). Dental examination and treatment was able to be carried out without major interference from the patient in 78.8% (241) episodes. Adverse sedation events occurred in 6.0% (19), the most frequent being desaturation which was easily managed. There were no incidents with serious sequelae. Favourable acceptability ratings were given by carers regarding advantages of ease of administration and speed of onset of the intranasal dose, plus reduction in the stress associated with cannulation and treatment. CONCLUSIONS: This study provides further evidence to support the effectiveness, safety and acceptability of this technique. The authors suggest this provides sufficient basis to justify its use by suitably trained dental practitioners in primary care as part of the spectrum of anxiety and behaviour management for this group.

Internal recycle to improve denitrification in a step feed anoxic/aerobic activated sludge system.

During periods of low load (weekends and holidays) the Mangere wastewater treatment plant effluent has breached the summer consent conditions for total nitrogen. The purpose of this research was to determine if an internal recycle would improve nitrogen removal in the anoxic/aerobic activated sludge reactors sufficient to meet the summer resource consent standard. The recycle returned nitrate rich mixed liquor from the downstream aerobic zone back to the initial anoxic zone, thus potentially improving denitrification. A full scale trial showed that installation of the internal recycle on each RC would have satisfied the resource consent for total nitrogen in most cases over the three summer resource consent periods since the upgrade. However, further modifications of the internal recycle would be required to ensure that consent conditions were satisfied at all times and to improve the consistency of the results.

Obesity and dentistry: a growing problem.

Obesity has increased at an alarming rate in recent years. It is now a worldwide public health problem. The World Health Organisation (WHO) classifies obesity as a chronic disease. Affected individuals are at increased risk of hypertension, heart disease and other illnesses. There are also important social implications.Within dentistry and particularly in the provision of conscious sedation, obesity can be a potential complicating factor. For example, the position of anatomical landmarks may be less obvious if surrounded by fatty tissue. Very obese patients may be housebound or have difficulty accessing dental surgeries. Dental chairs may not be of an appropriate design to accommodate some obese patients. However, little information or advice on this topic is available in the literature.This article reviews obesity from a dental perspective. Challenges in providing dental care for obese patients are identified and practical recommendations made for their management.

Who is referred for sedation for dentistry and why?

OBJECTIVE: To assess referrals to sedation, examining dental anxiety and background of patients, and compare these characteristics to those referred to a restorative dentistry clinic. DESIGN: Descriptive, cross sectional survey. SUBJECTS AND METHODS: Subjects were 100 consecutive new patients in sedation and special care and 50 new patients in restorative dentistry at Guy's and St Thomas NHS Foundation Trust. A questionnaire included demographics, self-reported oral health and dental attendance, and dental fear. Information from the patients records was taken: ASA classification, previous sedation or general anaesthesia, alcohol and tobacco use, and medications. RESULTS: The best predictors of referral were dental anxiety level and an irregular attendance. The most important fears were seeing, hearing and feeling the vibrations of the dental drill, and the perception of an accelerated heart rate. Other factors such as general, mental and dental health and alcohol use were related to referral but less important. CONCLUSIONS: Referral is consistent with the goal of the sedation clinic to see anxious patients. Referring general practitioners are able to identify these patients.

Conscious sedation training received by specialist registrars in restorative dentistry in the UK: a survey.

OBJECTIVE: To investigate conscious sedation training received by Specialist Registrars in Restorative Dentistry (SpRs) during their training programme. DESIGN: Postal questionnaire survey in the UK. Setting SpRs and recently certificated Consultants in Restorative Dentistry (CRDs). METHOD: A questionnaire was sent to 81 current SpRs in Restorative Dentistry and CRDs who had been awarded a Certificate of Completion of Specialist Training within the previous three years. One follow-up letter was sent to non-responders. RESULTS: The completed questionnaire was returned by 67 (83%) SpRs and CRDs. Analysis revealed that 44 (69%) respondents had received conscious sedation training during their specialist training programme and that 50 (78%) respondents carried out restorative dental treatment under sedation during their programme. Thirteen (20%) respondents had not received conscious sedation training in their programmes but eight (13%) SpRs indicated that sedation training was planned. Training experiences differed throughout the UK: 29 (66%) respondents gained experience in inhalational and single agent intravenous sedation techniques under the supervision of an experienced colleague. Fourteen (32%) respondents who performed sedation had not been on a resuscitation course in the previous year. These included nine (21%) current SpRs. Sixteen (53%) current SpRs intended to offer restorative dental treatment under sedation after specialist training. Fifty-nine (92%) respondents thought that all SpRs in Restorative Dentistry should receive sedation training and 42 (71%) thought that a structured core course would be the most appropriate format. CONCLUSIONS: Although the majority of SpRs and recently certificated CRDs considered that all SpRs should receive training in conscious sedation via a core course during the restorative dentistry training programme, a small number had not received or planned to undertake such training. Conscious sedation training experiences differed throughout the UK and SpRs treated a wide range of deserving patient categories under sedation. It is encouraging that many SpRs hope to continue employing sedation techniques after their restorative dentistry training has finished. The results of this survey should inform all those involved with restorative dentistry training programmes.

Effectiveness in controlling haemorrhage after dental scaling in people with haemophilia by using tranexamic acid mouthwash.

AIMS: To compare the effectiveness of tranexamic acid mouthwash (TAMW) in controlling gingival haemorrhage after dental scaling with that of using factor replacement therapy (FRT) prior to dental scaling in people with haemophilia. DESIGN: Double-blind cross-over randomised control trial. SETTING: Dedicated hospital dental practice for patients with inherited bleeding disorders. METHOD: Sixteen patients with haemophilia who required dental scaling participated in this pilot study. The experimental treatment regime (ETR) involved transfusing each patient with saline before scaling both quadrants on one side of the mouth followed by oral rinsing with TAMW four times daily for up to eight days. The control regime (CR) involved giving each patient FRT before scaling the opposite side of the mouth followed by use of a placebo TAMW. Each patient underwent both treatments in a random-ised sequence. Both the operator and the patients were unaware of which were the ETR and CR episodes. On both occasions the patient kept a log book of the rinsing regime and any post-operative bleeding. Additionally, a structured post-treatment telephone interview was conducted to assess the effectiveness and the patient acceptability of the ETR. RESULTS: Thirteen patients completed the study. No statistically significant difference was found in gingival bleeding and mouthwashing frequencies between the ETR and the CR (p > 0.05). Five patients reported no gingival bleeding with either the ETR or the CR. No patient, using either regime, required extra FRT due to gingival haemorrhage. All subjects found the ETR acceptable and easy and reported feeling safe in using TAMW alone to control gingival bleeding after dental scaling. CONCLUSION: TAMW use after dental scaling was as effective as using FRT beforehand in controlling gingival haemorrhage for people with haemophilia.

A theory-based method for the evaluation of individual quality of life: the SEIQoL.

Few reports about methods of evaluating quality of life (QoL) among the thousands published since medical interest in the subject slowly began nearly 40 years ago are based upon theory. This paper, prepared in response to a request to furnish an exception (Meadows KA. Introduction to an Advanced Seminar: Assessing Health-Related Quality of Life. What can the Cognitive Sciences Contribute? Hull University, October 9, 2000) describes the origins of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL). This derives its cognitive aspects from theoretical studies of perception by Egon Brunswik, their extension to Social Judgment Theory (SJT) by Kenneth Hammond and the application of these ideas to QoL by the present authors and their colleagues.

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.

Increased risk for developmental disabilities in children who have major birth defects: a population-based study.

OBJECTIVE: We sought to quantify the strength of associations between each of four specific developmental disabilities (DDs) and specific types of major birth defects. METHODS: We linked data from 2 independent surveillance systems, the Metropolitan Atlanta Congenital Defects Program and the Metropolitan Atlanta Developmental Disabilities Surveillance Program. Children with major birth defects (n = 9142; born 1981-1991 in metro Atlanta) and 3- to 10-year-old children who were born between 1981 and 1991 in metro Atlanta and identified between 1991 and 1994 as having mental retardation, cerebral palsy, hearing impairment, or vision impairment (n = 3685) were studied. Prevalence ratio (PR), which is the prevalence of a DD in children with 1 or more major birth defects divided by the prevalence of the same DD in children without major birth defects, was measured. RESULTS: Among the 9142 children who were born with a major birth defect, 657 (7.2%) had a serious DD compared with 0.9% in children with no major birth defect, yielding a PR of 8.3 (95% confidence interval: 7.6-9.0). In general, the more severe the DD, the higher was the PR. Birth defects that originated in the nervous system and chromosomal defects resulted in the highest PRs for a subsequent DD. For all other categories of birth defects, PRs were lowest when all major birth defects present were confined to a single category (ie, isolated defects). PRs for any DD increased monotonically with the number of coded birth defects per child or the number of different birth defect categories per child, regardless of the severity of the defect or whether defects of the nervous system, chromosomal defects, or "other syndromes" were counted. CONCLUSIONS: These data highlight the possible early prenatal origins of some DDs and suggest that both the number of coded birth defects present and the number of anatomic systems involved are strongly related to functional outcomes.

Nurses' motivation to wash their hands: a standardized measurement approach.

Handwashing is a simple procedure that is critical to prevention and control of infections, yet many health care workers (HCWs) do not practice hand hygiene according to recommended guidelines. The Handwashing Assessment Inventory (HAI) is a self-report instrument that is designed to measure the motivational schema of HCWs for handwashing.

Contribution of sickle cell disease to the occurrence of developmental disabilities: a population-based study.

PURPOSE: Population-based surveillance of children aged 3-10 years from metropolitan Atlanta was used to determine if stroke-related neurological damage in children with sickle cell disease (SCD) is associated with developmental disabilities (DD). METHODS: School and medical records were reviewed annually to identify eligible children. Observed-to-expected ratios, P values, and population attributable fractions were calculated. RESULTS: Children with SCD had increased risk for DD (O/E = 3.2, P < 0.0001), particularly mental retardation (O/E = 2.7, P = 0.0005) and cerebral palsy (O/E = 10.8, P < 0.0001). This risk was confined to DD associated with stroke (O/E = 130, P < 0.0001; for DD without stroke: O/E = 1.3, P = 0.23). CONCLUSIONS: Children with SCD have increased risk for DD associated with stroke; thus, aggressive interventions are needed to prevent stroke in these children.

Tocolytic magnesium sulfate exposure and risk of cerebral palsy among children with birth weights less than 1,750 grams.

The authors examined the relation between intrapartum magnesium sulfate exposure and risk of cerebral palsy in a case-control study of low birth weight children designed to control for confounding by the clinical indications for magnesium in pregnancy. Case children (n = 97) included all singleton children with cerebral palsy who were born in 1985-1989 in Atlanta, Georgia with a birth weight less than 1,750 g and whose mothers had not had a hypertension-related disease during pregnancy. Control children (n = 110) were randomly selected from the infant survivors using identical selection criteria. Data on magnesium sulfate exposure, labor and delivery, and infant characteristics were abstracted from hospital records. The authors found no association between exposure to magnesium sulfate and cerebral palsy risk (odds ratio = 0.9; 95% confidence interval: 0.3, 2.6) either in all children or in subgroups with varying likelihoods for exposure to magnesium. However, the association did vary by birth weight, with a protective effect being seen in children born weighing less than 1,500 g and an elevated risk in children with birth weights of 1,500 g or more; all confidence intervals included 1.0 except for the combined <1,500 g group. Several ongoing randomized clinical trials of magnesium and cerebral palsy may shed more definitive light on this relation.

A sedation technique for implant and periodontal surgery.

OBJECTIVE: Evaluation of a sedation technique which involved titrating intravenous midazolam to an 'ideal' sedation end point, followed by a continuous infusion of propofol. This technique might be a satisfactory alternative to general anaesthesia for implant surgery in anxious patients or when procedures exceed 60-min duration. MATERIAL AND METHODS: 20 patients were treated on 23 occasions. A 2-mg bolus of midazolam was injected intravenously followed after 90 s by 1 mg increments until the patient was adequately sedated. 30 min after this induction with midazolam, a propofol infusion was started at a rate which varied between 0-300 mg/h (0-30 ml/h). The actual infusion rate was adjusted in order to maintain the optimum sedation level which had been achieved using midazolam. The quality of sedation was assessed using Ellis and Sedation scores. RESULTS: Midazolam dosage varied between 5 and 14 mg. The initial propofol infusion rate was 200 mg/h (20 ml/h) for 21 of the 23 implant surgery treatments. CONCLUSION: The sedation technique described takes advantage of the differing pharmacokinetic properties of midazolam and propofol. Initial sedation was achieved using midazolam, this was then maintained using a variable propofol infusion. The shorter distribution and elimination half-lifes of the latter drug made matching the level of sedation to the patient's needs easier and also provided good short-term recovery.