Approaches to reducing the most important patient errors in primary health care : patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients' contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants' suggestions revealed the content of four inter-related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from 'individualised community care'. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health-care.

Competing together : assessing the dynamics of team-team and player-team synchrony in professional association football

This study investigated movement synchronization of players within and between teams during competitive association football performance. Cluster phase analysis was introduced as a method to assess synchronies between whole teams and between individual players with their team as a function of time, ball possession and field direction. Measures of dispersion (SD) and regularity (sample entropy – SampEn – and cross sample entropy – Cross-SampEn) were used to quantify the magnitude and structure of synchrony. Large synergistic relations within each professional team sport collective were observed, particularly in the longitudinal direction of the field (0.89 ± 0.12) compared to the lateral direction (0.73 ± 0.16, p < .01). The coupling between the group measures of the two teams also revealed that changes in the synchrony of each team were intimately related (Cross-SampEn values of 0.02 ± 0.01). Interestingly, ball possession did not influence team synchronization levels. In player–team synchronization, individuals tended to be coordinated under near in-phase modes with team behavior (mean ranges between −7 and 5° of relative phase). The magnitudes of variations were low, but more irregular in time, for the longitudinal (SD: 18 ± 3°; SampEn: 0.07 ± 0.01), compared to the lateral direction (SD: 28 ± 5°; SampEn: 0.06 ± 0.01, p < .05) on-field. Increases in regularity were also observed between the first (SampEn: 0.07 ± 0.01) and second half (SampEn: 0.06 ± 0.01, p < .05) of the observed competitive game. Findings suggest that the method of analysis introduced in the current study may offer a suitable tool for examining team’s synchronization behaviors and the mutual influence of each team’s cohesiveness in competing social collectives.

An investigation of early career teachers’ perceptions of professional development opportunities and career advancement for teachers in rural and remote Queensland

It is generally accepted that to live and work in the remote regions of Australia requires specific skills and expertise to accommodate the shifting demands of outback life. For professionals assigned to such areas by employing bodies, this is particularly the case, and teachers are no exception. In addition to such personal attributes, professionals such as teachers must maintain currency in their professional practice both to serve their students appropriately and to ensure that they become eligible for future promotions and transfers possibilities. This study investigated whether teachers in rural and remote regions are disadvantaged in ways that could potentially affect their teaching careers in negative ways, in particular in terms of professional development and career advancement opportunities. Such opportunities are crucial if teachers are to provide an education of high relevance to rural and remote children who are already considered to be significantly disadvantaged in terms of educational provision. The data are presented in the form of a single teacher narrative, a composite tale aimed at telling the story of rural and remote teachers, professional development provision and career advancement opportunities. It was apparent that teachers in these contexts face serious challenges in terms of their professional and career development.

Professional spaces for pre-service teachers: sites of reality, imagination and resistance

Questions about the practicum within teacher education tend to focus on the amount of time allocated to it in programs. In this research, we were interested in the quality of the experience rather than assuming ‘more is better’. To understand what is going on and where, this study focussed on the school and specially the departmental office of room as a site for workplace learning. Using qualitative methods we constructed narratives from the data provided by a cohort of four-year bachelor degree pre-service teachers during and following their final major (10 week)practicum experience. Using theories of spatiality to make sense of the data, we found that the narratives revealed stories of spaces where compliance, disappointment were the key features of the practicum, and where resistance through absence (from the departmental office) was an important strategy to manage the experience. This research challenges the ‘more is better’ argument.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

The cost-effectiveness of exercise referral schemes

Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary care setting. The primary care professional refers the patient to a third party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the patient. This paper examines the cost-effectiveness of ERS in promoting physical activity compared with usual care in primary care setting. Methods A decision analytic model was developed to estimate the cost-effectiveness of ERS from a UK NHS perspective. The costs and outcomes of ERS were modelled over the patient's lifetime. Data were derived from a systematic review of the literature on the clinical and cost-effectiveness of ERS, and on parameter inputs in the modelling framework. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). Deterministic and probabilistic sensitivity analyses investigated the impact of varying ERS cost and effectiveness assumptions. Sub-group analyses explored the cost-effectiveness of ERS in sedentary people with an underlying condition. Results Compared with usual care, the mean incremental lifetime cost per patient for ERS was £169 and the mean incremental QALY was 0.008, generating a base-case incremental cost-effectiveness ratio (ICER) for ERS at £20,876 per QALY in sedentary individuals without a diagnosed medical condition. There was a 51% probability that ERS was cost-effective at £20,000 per QALY and 88% probability that ERS was cost-effective at £30,000 per QALY. In sub-group analyses, cost per QALY for ERS in sedentary obese individuals was £14,618, and in sedentary hypertensives and sedentary individuals with depression the estimated cost per QALY was £12,834 and £8,414 respectively. Incremental lifetime costs and benefits associated with ERS were small, reflecting the preventative public health context of the intervention, with this resulting in estimates of cost-effectiveness that are sensitive to variations in the relative risk of becoming physically active and cost of ERS. Conclusions ERS is associated with modest increase in lifetime costs and benefits. The cost-effectiveness of ERS is highly sensitive to small changes in the effectiveness and cost of ERS and is subject to some significant uncertainty mainly due to limitations in the clinical effectiveness evidence base.

Consensus statement on the role of Accredited Exercise Physiologists within the treatment of mental disorders: A guide for mental health professionals

- Objective The aim is to identify the role and scope of Accredited Exercise Physiologist (AEP) services in the mental health sector and to provide insight as to how AEPs can contribute to the multidisciplinary mental health team. - Methods A modified Delphi approach was utilised. Thirteen AEPs with experience in mental health contributed to the iterative development of a national consensus statement. Six mental health professionals with expertise in psychiatry, mental health nursing, general practice and mental health research participated in the review process. Reviewers were provided with a template to systematically provide feedback on the language, content, structure and relevance to their professional group. - Results This consensus statement outlines how AEPs can contribute to the multidisciplinary mental health team, the aims and scope of AEP-led interventions in mental health services and examples of such interventions, the range of physical and mental health outcomes possible through AEP-led interventions and common referral pathways to community AEP services. - Outcome AEPs can play a key role in the treatment of individuals experiencing mental illness. The diversity of AEP interventions allows for a holistic approach to care, enhancing both physical and mental health outcomes.

Professional learning places and spaces: The staffroom as a site of beginning teacher induction and transition

This paper argues that the staffroom is an important professional learning space where beginning teachers interact to understand who they are and the nature of their professional work. The authors highlight the theoretical importance of space and place in the construction and negotiation of beginning teacher subjectivities. To illustrate the staffroom as a particular place where important professional learning could occur the authors use two narratives based on the lived experiences of two beginning teachers, one in a primary context, the other secondary. The authors conclude by calling for greater research attention to the significance of the staffroom and its interaction with teacher subjectivities. At the level of practice we also call for the teaching profession to recognise staffrooms as important sites of professional learning and places that should support induction and mentoring of beginning teachers. Such recognition could enhance the retention, satisfaction, and effectiveness of new and experienced teachers alike.

Development and validation of a sport-specific exercise protocol for elite youth soccer players

Thatcher, Rhys, and Alan Batterham, 'Development and validation of a sport-specific exercise protocol for elite youth soccer players', Journal of Sports Medicine and Physical Fitness, (2004) 44(1) pp.15-22 RAE2008

Simulation of economic benefits achieved by water quality improvement for recreational and professional users, within the SPICOSSA SSA (SPICOSSA System Approach) 11 - Guadiana estuary ecosystem sic

Dissertação de Mestrado, Gestão da Água e da Costa, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2010

Effect of Cluster Multi-Diode Light Emitting Diode Therapy (LEDT) on Exercise-Induced Skeletal Muscle Fatigue and Skeletal Muscle Recovery in Humans

Background and Objectives: There are some indications that low-level laser therapy (LLLT) may delay the development of skeletal muscle fatigue during high-intensity exercise. There have also been claims that LED cluster probes may be effective for this application however there are differences between LED and laser sources like spot size, spectral width, power output, etc. In this study we wanted to test if light emitting diode therapy (LEDT) can alter muscle performance, fatigue development and biochemical markers for skeletal muscle recovery in an experimental model of biceps humeri muscle contractions. Study Design/Materials and Methods: Ten male professional volleyball players (23.6 [SD +/- 5.6] years old) entered a randomized double-blinded placebo-controlled crossover trial. Active cluster LEDT (69 LEDs with wavelengths 660/850 nm, 10/30 mW, 30 seconds total irradiation time, 41.7J of total energy irradiated) or an identical placebo LEDT was delivered under double-blinded conditions to the middle of biceps humeri muscle immediately before exercise. All subjects performed voluntary biceps humeri contractions with a workload of 75% of their maximal voluntary contraction force (MVC) until exhaustion. Results: Active LEDT increased the number of biceps humeri contractions by 12.9% (38.60 [SD +/- 9.03] vs. 34.20 [SD +/- 8.68], P = 0.021) and extended the elapsed time to perform contractions by 11.6% (P = 0.036) versus placebo. In addition, post-exercise levels of biochemical markers decreased significantly with active LEDT: Blood Lactate (P = 0.042), Creatine Kinase (P = 0.035), and C-Reative Protein levels (P = 0.030), when compared to placebo LEDT. Conclusion: We conclude that this particular procedure and dose of LEDT immediately before exhaustive biceps humeri contractions, causes a slight delay in the development of skeletal muscle fatigue, decreases post-exercise blood lactate levels and inhibits the release of Creatine Kinase and C-Reative Protein. Lasers Surg. Med. 41:572-577, 2009. (C) 2009 Wiley-Liss, Inc.

Effect of 830 nm low-level laser therapy in exercise-induced skeletal muscle fatigue in humans

This study aimed to investigate the effect of 830 nm low-level laser therapy (LLLT) on skeletal muscle fatigue. Ten healthy male professional volleyball players entered a crossover randomized double-blinded placebo-controlled trial. Active LLLT (830 nm wavelength, 100 mW output, spot size 0.0028 cm(2), 200 s total irradiation time) or an identical placebo LLLT was delivered to four points on the biceps humeri muscle immediately before exercises. All subjects performed voluntary biceps humeri contractions with a load of 75% of the maximum voluntary contraction (MVC) force until exhaustion. After active LLLT the mean number of repetitions was significantly higher than after placebo irradiation [mean difference 4.5, standard deviation (SD) +/- 6.0, P = 0.042], the blood lactate levels increased after exercises, but there was no significant difference between the treatments. We concluded that 830 nm LLLT can delay the onset of skeletal muscle fatigue in high-intensity exercises, in spite of increased blood lactate levels.

The Effects of Physical Fitness and Body Composition on Oxygen Consumption and Heart Rate Recovery After High-Intensity Exercise

The aim of this study was to investigate the potential relationship between excess post-exercise oxygen consumption (EPOC), heart rate recovery (HRR) and their respective time constants (tvo(2) and t(HR)) and body composition and aerobic fitness (VO(2)max) variables after an anaerobic effort. 14 professional cyclists (age = 28.4 +/- 4.8 years, height = 176.0 +/- 6.7 cm, body mass = 74.4 +/- 8.1 kg, VO(2)max = 66.8 +/- 7.6 mL. kg(-1) . min(-1)) were recruited. Each athlete made 3 visits to the laboratory with 24h between each visit. During the first visit, a total and segmental body composition assessment was carried out. During the second, the athletes undertook an incremental test to determine VO(2)max. In the final visit, EPOC (15-min) and HRR were measured after an all-out 30s Wingate test. The results showed that EPOC is positively associated with % body fat (r = 0.64), total body fat (r = 0.73), fat-free mass (r = 0.61) and lower limb fat-free mass (r = 0.55) and negatively associated with HRR (r = - 0.53, p < 0.05 for all). HRR had a significant negative correlation with total body fat and % body fat (r = - 0.62, r = - 0.56 respectively, p < 0.05 for all). These findings indicate that VO(2)max does not influence HRR or EPOC after high-intensity exercise. Even in short-term exercise, the major metabolic disturbance due to higher muscle mass and total muscle mass may increase EPOC. However, body fat impedes HRR and delays recovery of oxygen consumption after effort in highly trained athletes.

Fatigue and rapid hamstring/quadriceps force capacity in professional soccer players

The aim of this study was to investigate the effect of fatigue induced by an exhaustive laboratory-based soccer-specific exercise on different hamstrings/quadriceps (H:Q) ratios of soccer players. Twenty-two male professional soccer players (23·1 ± 3·4 year) performed maximal eccentric (ecc) and concentric (con) contractions for knee extensors (KE) and flexors (KF) at 60° s-1 and 180° s-1 to assess conventional (Hcon:Qcon) and functional (Hecc:Qcon) ratios. Additionally, they performed maximal voluntary isometric contraction for KE and KF, from which the maximal muscle strength, rate of force development (RFD) and RFD H:Q strength ratio (RFDH:Q) were extracted. Thereafter, subjects were performed an exhaustive laboratory-based soccer-specific exercise and a posttest similar to the pretest. There was significant reduction in Hcon:Qcon (0·60 ± 0·06 versus 0·58 ± 0·06, P<0·05) and in Hecc:Qcon (1·29 ± 0·2 versus 1·16 ± 0·2, P<0·01) after the soccer-specific exercise. However, no significant difference between Pre and Post exercise conditions was found for RFDH:Q at 0-50 (0·53 ± 0·23 versus 0·57 ± 0·24, P>0·05) and 0-100 ms (0·53 ± 0·17 versus 0·55 ± 0·17, P>0·05). In conclusion, H:Q strength ratios based on peak force values are more affected by fatigue than RFDH:Q obtained during early contraction phase. Thus, fatigue induced by soccer-specific intermittent protocol seems not reduce the potential for knee joint stabilization during the initial phase of voluntary muscle contraction. copy; 2012 Scandinavian Society of Clinical Physiology and Nuclear Medicine.