Contributory factors to patient safety incidents in primary care: protocol for a systematic review

BACKGROUND: Organisations need to systematically identify contributory factors (or causes) which impact on patient safety in order to effectively learn from error. Investigations of error have tended to focus on taking a reactive approach to learning from error, mainly relying on incident-reporting systems. Existing frameworks which aim to identify latent causes of error rely almost exclusively on evidence from non-healthcare settings. In view of this, the Yorkshire Contributory Factors Framework (YCFF) was developed in the hospital setting. Eighty-five percent of healthcare contacts occur in primary care. As a result, this review will build on the work that produced the YCFF, by examining the empirical evidence that relates to the contributory factors of error within a primary care setting. METHODS/DESIGN: Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. The database search will be supplemented by additional search methodologies including citation searching and snowballing strategies which include reviewing reference lists and reviewing relevant journal table of contents, that is, BMJ Quality and Safety. Our search strategy will include search combinations of three key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies conducted in a primary care setting. They will include some description of the factors that contribute to patient safety. One reviewer (SG) will screen all the titles and abstracts, whilst a second reviewer will screen 50% of the abstracts. Two reviewers (SG and AH) will perform study selection, quality assessment and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), patient safety incident type and characteristics, practice characteristics and study outcomes. DISCUSSION: The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of health care.

Achieving 'sustainability education' in primary schools as a result of the Victorian Science in Schools Research Project

The purpose of this paper is to discuss the experiences of primary schools involved in the Victorian Science in Schools Research Project which was concerned with improving science teaching and learning strategies but which also unexpectedly led to more environmental (sustainability) education occurring. The paper also suggests a curriculum strategy for achieving more widespread acceptance and implementation of 'sustainability education' through primary school science curricula.

Enhancing the creative process for learning in primary technology education

When undertaking design and technology activities, children are provided with opportunities to create solutions to problems in new and innovative ways. The mental processes involved in the generation of new ideas may be enhanced when children’s attention is not focussed and is allowed to wander in a relaxed and uncompetitive environment. Research indicates that the two mental states, generative and non-generative, cannot exist simultaneously. This paper reports on a research project which investigated the impact on children’s thinking when a period of non-focussed thinking became part of the technology process. The results support the previous proposition that a child’s non-generative/analytical mental state needs to give way to a generative state so that a child can be more fully creative. Moreover, from this study that documented children’s ideas during their involvement in a design and technology activity, teachers are urged to provide an incubation period as part of the technological process in the classroom, so that children’s creativity can be fostered.

Empowering Australian students in African music: experiential education in primary teacher training

Luckman (1996) defines experiential education as a "process through which a learner constructs knowledge, skill and value from direct experience" (p. 7). The core of such learning is practical engagement, contextualised by concepts and skills in guided experiences. This process, to be most effective, should be supported by reflection. This paper considers an experiential program in African music that is part of pre-service primary teacher education for generalist teacher trainees. As part of the Bachelor of Primary Education degree, offered by Deakin University (Australia) students can select an elective subject on African music in the final year of their four-year course. In this subject students learn African music experientially, by playing, singing and moving. These students completed a questionnaire and were interviewed at the conclusion of the unit in 2003. Data collected showed the effectiveness of using an unknown music to explore musical concepts and understandings in an Australian educational setting.

Effectiveness of fire safety education in primary school children

Young children have been identified as a high-risk group in relation to fire-related deaths because of their limited ability to understand the intinsic dangers of fire, to foresee the consequences of playing with fire, or to manage a fire if it were to become out of control.  Children are also not equipped to respond in a meaningful way in the event of a fire.  It is therefore essential that fire safety education be imparted to children in an effective manner so as to equip them to deal with a fire efficiently.  The objective of the present study was to evaluate the 'Fire Ed' program conducted by the Melbourne Metropolitan Fire Brigade for primary school children to determine whether exposure to the curriculum will influence children's knowledge of fire safety behaviours.  Although the program has numerous positive features, its overall effectivenedd has not been evaluated.  It was hypothesised that: a) children will not be aware of essential fire safety information prior to attending the 'Fire Ed' program, and b) children will display a significant gain in fire safety knowledge after participation in the program.  Sixty children from six primary schools participated in the study and they were tested on their level of fire safety knowledge prior to and after partcipation in the 'Fire Ed' program.  Results show that the children's knowledge of fire safety procedures improved significantly after participation in the program when tested after three weeks, however, when their knowledge was examined after five weeks, a significant decline was seen.  The findings show that regular evaluations of fire safety programs are required and that they could be improved by considering the different stages of cognitive development in children.

Species-specific cell-matrix interactions are essential for differentiation of alveoli like structures and milk gene expression in primary mammary cells of the Cape fur seal (Arctocephalus pusillus pusillus)

Few models are in place for analysis of extreme lactation patterns such as that of the fur seals which are capable of extended down regulation of milk production in the absence of involution. During a 10–12 month lactation period, female fur seals suckle pups on shore for 2–3 days, and then undertake long foraging trips at sea for up to 28 days, resulting in the longest intersuckling bouts recorded. During this time the mammary gland down regulates milk production. We have induced Cape fur seal (Arctocephalus pusillus pusillus) mammary cells in vitro to form mammospheres up to 900 μm in diameter, larger than any of their mammalian counterparts. Mammosphere lumens were shown to form via apoptosis and cells comprising the cellular boundary stained vimentin positive. The Cape fur seal GAPDH gene was cloned and used in RT-PCR as a normalization tool to examine comparative expression of milk protein genes (αS2-casein, β-lactoglobulin and lysozyme C) which were prolactin responsive. Cape fur seal mammary cells were found to be unique; they did not require Matrigel for rapid mammosphere formation and instead deposited their own matrix within 2 days of culture. When grown on Matrigel, cells exhibited branching/stellate morphogenesis highlighting the species-specific nature of cell–matrix interactions during morphological differentiation. Matrix produced in vitro by cells did not support formation of human breast cancer cell line, PMC42 mammospheres. This novel model system will help define the molecular pathways controlling the regulation of milk protein expression and species specific requirements of the extracellular matrix in the cape fur seal.

Interobserver reproducibility of histopathologic prognostic variables in primary cutaneous melanomas

Background: The prognosis for patients with localized primary cutaneous melanoma is known to depend principally on tumor thickness, and to a lesser extent on ulcerative state and Clark level. We have recently found in an analysis of 3661 patients that tumor mitotic rate (TMR) is also an important prognostic parameter, ranking second only to tumor thickness. However, few studies have assessed the accuracy and reproducibility with which these features of a melanoma are recorded by histopathologists.
Aim: To assess interobserver reproducibility of major pathologic prognostic parameters in cutaneous melanoma.
Methods: Single hematoxylin and eosin-stained slides of 69 dermally invasive primary cutaneous melanomas were circulated among six pathologists with differing experience in the assessment of melanocytic tumors. The observers independently determined the tumor thickness, Clark level of invasion, ulcerative state, and TMR for each lesion. Intraclass correlation coefficients and kappa scores for multiple ratings per subject were calculated.
Results: The intraclass correlation coefficients were 0.96 for tumor thickness and 0.76 for TMR. The kappa scores were 0.83 for ulcerative state and 0.60 for Clark level. These results indicated excellent agreement among the pathologists for measurements of tumor thickness, ulcerative state, and TMR and fair to good agreement for Clark level.
Conclusions: Appropriately trained and experienced histopathologists can assess prognostically important features of melanomas accurately and reproducibly. Given our recent finding of the significance of TMR in determining prognosis, it is important that this feature be assessed by a standardized method and documented for all primary cutaneous melanomas.

Intrinsic resistance of female hearts to an ischemic insult is abrogated in primary cardiac hypertrophy

Important sex differences in cardiovascular disease outcomes exist, including conditions of hypertrophic cardiomyopathy and cardiac ischemia. Studies of sex differences in the extent to which load-independent (primary) hypertrophy modulates the response to ischemia-reperfusion (I/R) damage have not been characterized. We have previously described a model of primary genetic cardiac hypertrophy, the hypertrophic heart rat (HHR). In this study the sex differences in HHR cardiac function and responses to I/R [compared to control normal heart rat (NHR)] were investigated ex vivo. The ventricular weight index was markedly increased in HHR female (7.82 ± 0.49 vs. 4.80 ± 0.10 mg/g; P < 0.05) and male (5.76 ± 0.22 vs. 4.62 ± 0.07 mg/g; P < 0.05) hearts. Female hearts of both strains exhibited a reduced basal contractility compared with strain-matched males [maximum first derivative of pressure (dP/dtmax): NHR, 4,036 ± 171 vs. 4,258 ± 152 mmHg/s; and HHR, 3,974 ± 160 vs. 4,540 ± 259 mmHg/s; P < 0.05]. HHR hearts were more susceptible to I/R (I = 25 min, and R = 30 min) injury than NHR hearts (decreased functional recovery, and increased lactate dehydrogenase efflux). Female NHR hearts exhibited a significantly greater recovery (dP/dtmax) post-I/R relative to male NHR (95.0 ± 12.2% vs. 60.5 ± 9.4%), a resistance to postischemic dysfunction not evident in female HHR (29.0 ± 5.6% vs. 25.9 ± 6.3%). Ventricular fibrillation was suppressed, and expression levels of Akt and ERK1/2 were selectively elevated in female NHR hearts. Thus the occurrence of load-independent primary cardiac hypertrophy undermines the intrinsic resistance of female hearts to I/R insult, with the observed abrogation of endogenous cardioprotective signaling pathways consistent with a potential mechanistic role in this loss of protection.