New technology to enable personal monitoring and incident reporting can transform professional culture: The potential to favourably impact the future of health care

Journal of Evaluation in Clinical Practice

Volumn 11, Issue 5, 2005, Pages 499-506

  Bolsin, Stephen ^a   Patrick, Andrew ^a   Colson, Mark ^a   Creatie, Bernie ^a   Freestone, Liadane ^a  

^a GEELONG HOSPITAL   (Australia)

Author keywords

Electronic support; Incident reporting; Medical ethics; Performance monitoring

Indexed keywords

ARTICLE; CLINICAL PRACTICE; CRIMINAL BEHAVIOR; CULTURAL ANTHROPOLOGY; DEATH; ELECTRONICS; HEALTH CARE; HEALTH CARE COST; HEALTH CARE SYSTEM; HOSTILITY; INFORMATION PROCESSING; MEDICAL ETHICS; PERSONAL MONITORING; PRIORITY JOURNAL;

EMPLOYEE PERFORMANCE APPRAISAL; ETHICS, MEDICAL; HUMANS; MALPRACTICE; QUALITY OF HEALTH CARE; RISK MANAGEMENT;

EID: 25444482185     PISSN: 13561294     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1365-2753.2005.00567.x     Document Type: Article

References (70)

1. Anon. (1948) Declaration of Geneva. Adopted by the General Assembly of World Medical Association at Geneva, September 1948. Amended Sydney 1968, amended Venice 1983, amended Stockholm 1994; http://www.cirp.org/library/ethics/ geneva/ (accessed 3 November 2004).
2. Anon. (1949) International code of medical ethics. World Medical Association Bulletin 1, 109-111.
3. Alberti K.G.M.M. (2001) Medical errors: a common problem. British Medical Journal 322 (7285), 501-502.
4. Beauchamp T.L. & Childress J.F. (1973) Principles of Biomedical Ethics. Oxford University Press, New York.
5. Bent P., Creati B., Bolsin S.N., Colson M. & Patrick A. (2002) Professional monitoring and critical incident reporting using personal digital assistants. Medical Journal of Australia 177, 496-499.
6. Bion J.F. & Heffner J.E. (2004) Challenges in the care of the acutely ill. Lancet 363, 970-977.
7. Black J. (2002) Regulatory conversations. Journal of Law and Society 29 (1), 163-196.
8. Bolsin S.N. (1998) Personal Perspective. Professional misconduct: the Bristol Case. Medical Journal of Australia 169, 369-372.
9. Bolsin S.N. (1999) More on the wisheart affair. British Medical Journal 318, 1010-1011.
10. Bolsin S.N. (2003) Whistle blowing. Medical Education 37, 294-296.
11. Bolsin S.N. & Colson M. (2003) Making the case for personal professional monitoring in health care. International Journal for Quality in Health Care 15, 1-2.
12. Bolsin S.N. & Day C.J. (1998) Risk evaluation, quality of practice and audit. In Short Practice of Anaesthesia (eds G. Hall & M. Morgan), pp. 111-122. Chapman & Hall, London.
13. Bolsin S.N., Faunce T. & Dwan K. (2005a) A new model for healthcare quality and safety: personal recording, automated analysis and evaluation of performance and critical incident data using portable digital technology. Australian Health Review (in press).
14. Bolsin S.N., Faunce T. & Oakley J. (2005b) Practical virtue ethics: using portable digital technology to transform healthcare whistle blowing. Journal of Medical Ethics (in press).
15. Bolsin S.N., Solly R. & Patrick A. (2003) The value of personal professional monitoring performance data and open disclosure policies in anaesthetic practice: a case report. International Journal for Quality in Health Care 12,295-297.
16. Brennan T.A., Leape L.L., Laird N.M., Herbert L., Localio A.R., Lawthers A.G., Newhouse J.P., Weiler P.C. & Hiatt H.H. (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324 (6), 370-376.
17. Burstin H.R., Johnson W.G., Lipsitz S.R. & Brennan T.A. (1993) Do the poor sue more? A Case-control study of malpractice claims. Journal of the American Medical Association 13, 1697-1701.
18. Chambler A.F. & Emery R.J. (1997) Lord Moynihan cuts Codman into audit. Annals of the Royal College of Surgeons of England 79 (Suppl. 4), 174-176.
19. Clarke S. & Oakley J. (2004) Informed consent and surgeon's performance. Journal of Medicine and Philosophy 29 (1), 11-35.
20. Duff E. (1998) Florence Nightingale: basing care on evidence. RCM Midwives Journal 1 (6), 192-193.
21. Dyer O. (2002) Shipman murdered more than 200 patients, inquiry finds. British Medical Journal 325, 181.
22. Faunce T. & Bolsin S. (2003) If Doctors Don't Understand Ethics, Its Time to Start Teaching Them. Sydney Morning Herald, Sydney.
23. Faunce T. & Bolsin S. (2004) Three Australian whistle-blowing sagas: lessons for internal and external regulation. Medical Journal of Australia 181, 44-47.
24. Faunce T., Bolsin S.N. & Chan W-P. (2004) Supporting whistleblowers in academic medicine. Training and respecting the courage of professional conscience. Journal of Medical Ethics 30, 40-43.
25. Fenn P. (2002) Counting the cost of medical negligence. British Medical Journal 325 (7358), 233-234.
26. Firth-Cozens J. (2002) Barriers to incident reporting. International Journal for Quality in Health Care 11 (1), 7.
27. Firth-Cozens J., Firth R.A. & Booth S. (2004) Attitudes to and experiences of reporting poor care. Clinical Governance 8 (4), 331-336.
28. Goldie J., Schwartz L. & McConnachie A. (2003) Students' attitudes and potential behaviour with regard to whistle blowing as they pass through a modern medical curriculum. Medical Education 37, 368-375.
29. Green J. & Wintfield N. (1995) Report cards on surgeons. Assessing New York State's approach. New England Journal of Medicine 332, 1229-1232.
30. Hafferty F.W. & Franks R. (1994) The Hidden Curriculum, Ethics Teaching and the structure of medical education. Academic Medicine 69, 861-871.
31. Hannan E.L., Kilburn H., Racz M., Shields E. & Chassin M. (1994) Improving the outcomes of coronary artery bypass surgery in New York State. Journal of the American Medical Association 271, 761-766.
32. Horton R. (1999) NICE: a step forward in the quality of NHS care. Lancet 353 (9158), 1028-1029.
33. Hundert E.M., Douglas-Steele D. & Bickel J. (1996) Context in medical education: the informal ethics curriculum. Medical Education 30, 353-364.
34. Kaska S.C. & Weinstein J.N. (1998) Historical perspective. Ernest Amory Codman, 1869-1940. A pioneer of evidence-based medicine: the end result idea. Spine 23 (5), 629-633.
35. Kennedy P.I. (2001) The Bristol Royal Infirmary Inquiry. Available at: http://www.bristol-inquiry.org.uk (accessed 2002).
36. Kingston M.J., Evans S.M., Smith B.J. & Berry J.G. (2004) Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Medical Journal of Australia 181 (1), 36-39.
37. Kohn C.T., Corrigan J.M. & Donaldson S. (1999) To Err is Human. Building a Safer Health System. Institute of Medicine, Washington, pp. 1-16, 101 & 110.
38. Kraman S. (2000) A risk management program based on full disclosure and trust: does everyone win? Complementary Therapy 27 (3), 253-257.
39. Kraman S. & Cranfill L. (2001) Trust works: a novel and effective risk management/patient safety program based on disclosing errors and making amends. Joint Commission Bechmark March, 6-7.
40. Larkin M. (2001) Can handheld computers improve the quality of care? Lancet 358, 1438.
41. Leape L.L., Brennan T.A., Laird N.M., Lawthers A.G., Localio A.R., Barnes B.A., Herbert L., Newhouse J.P., Weiler P.C. & Hiatt H.H. (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine 324 (6), 377-384.
42. Localio A.R., Lawthers A.G., Brennan T.A., Laird N.M., Herbert L.E., Peterson L.M., Newhouse J.P., Weiler P.C. & Hiatt H.H. (1991) Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. New England Journal of Medicine 325 (4), 245-251.
43. Monteiro L.A. (1985) Florence Nightingale on public health nursing. American Journal of Public Health 75 (2), 181-186.
44. Neil D.A., Clarke S.& Oakley J.G. (2004) Public reporting of individual surgeon performance information: United Kingdom developments and Australian issues. Medical Journal of Australia 181 (5), 266-268.
45. Nuttall P. (1983) The passionate statistician ... Florence Nightingale. Nursing Times 79 (39), 25-27.
46. O'Connor G.T., Plume S.K. & Olmsread E.M. (1996) A regional intervention to improve hospital mortality associated with coronary artery bypass graft surgery. Journal of the American Medical Association 275, 841-846.
47. Oakley J. (1998) A virtue ethics approach. In A Companion to Ethics. Khuse and Singer, pp. 86-97. Blackwell, Oxford.
48. Parker C. (2002) The Open Corporation. Effective Self-Regulation and Democracy. Cambridge University Press, London.
49. Reason J. (2000) Human error: models and management. British Medical Journal 320, 768-770.
50. Rennie S.C. & Crosby J.R. (2002) Student's perceptions of whistle blowing: implications for self regulation. A questionnaire and focus group survey. Medical Education 36 (2), 113-114.
51. Runciman W.B. (2002) Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system - is this the right model? International Journal for Quality in Health Care 11 (3), 246-251.
52. Runciman W.B., Webb R.K., Helps S.C., Thomas E.J., Sexton E.J., Studdert D.M. & Brennan T.A. (2000) A comparison of iatrogenic injury studies in Australia and the USA II: reviewer behaviour and quality of care. International Journal for Quality in Health Care 12 (5), 379-388.
53. Sharpe V.A. (2004) Accountability: Patient Safety and Policy Reform (Hastings Center Studies in Ethics). A. Virginia, Sharpe. Georgetown University Press, Washington.
54. Shortell S.M., Bennet C.L. & Byck G.R. (1998) Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. The Millbank Quarterly 76 (4), 593-624.
55. Sibbald B. (1998) Twelve deaths in Winnipeg: judge must ponder 48 000 pages of testimony. Canadian Medical Association Journnal 159, 1285-1287.
56. Smith R. (1998) All changed, changed utterly. British medicine will be transformed by the Bristol case. British Medical Journal 316 (7149), 1917-1918.
57. Spiegelhalter D., Grigg O., Kinsman R. & Treasure T. (2003) Risk-adjusted sequential probability ratio tests: applications to Bristol, Shipman and adult cardiac surgery. International Journal for Quality in Health Care 15 (1), 7-13.
58. Thomas E.J. & Brennan T.A. (2000) Incidence and types of preventable adverse events in elderly patients: population based review of medical records. British Medical Journal 320, 741-744.
59. Thomas E.J., Studdert D.M., Burstin H.R., Orav E.J., Zeena T., Williams E.J., Howard K.M., Weiler P.C. & Brennan T.A. (2000a) Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 38, 261-271.
60. Thomas E.J., Studdert D.M. et al. (2000b) A comparison of iatrogenic injury studies in Australia and the USA. I: Context, methods, casemix, population, patient and hospital characteristics. International Journal for Quality in Health Care 12 (15), 371-378.
61. Vidmar N. (1995) Medical Malpractice and the American Jury: Confronting the Myths About Jury Incompetence, Deep Pockets and Outrageous Damage Awards. University of Michigan Press, Ann Arbor.
62. Vincent C., Neale G. & Woloshynowych M. (2001) Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal 322 (7285), 517-519.
63. Vincent C., Stanhope N. & Crowley-Murphy M. (1999) Reasons for not reporting adverse incidents: an empirical study. Journal of Evaluation in Clinical Practice 5 (1), 13-21.
64. Walshe K. & Shortell S. (2004) When things go wrong: how health care organisations deal with major failures. Health Affairs 23 (3), 103-111.
65. White C. (2004) Doctors mistrust systems for reporting medical mistakes. British Medical Journal 329 (7456), 12.
66. Wilson L.L. & Fulton M. (2000) Risk management: how doctors, hospitals and MDOs can limit the cost of malpractice litigation. Medical Journal of Australia 172, 77-80.
67. Wilson R.M., Harrison B.T., Gibberd R.W. & Hamilton J.D. (1999) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Medical Journal of Australia 170, 411-415.
68. Wilson R.M., Runciman W.B., Gibberd R.W., Harrison B.T., Newby L. & Hamilton J.D. (1995) The quality in Australian healthcare study. Medical Journal of Australia 163, 458-471.
69. Wolff A.M. (1996) Limited adverse occurrence screening: using medical record review to reduce hospital adverse events. Medical Journal of Australia 164, 454-461.
70. Wolff A.M., Bourke J., Campbell I.A. & Leembruggen D.W. (2001) Detecting and reducing hospital adverse events: outcomes of the Wimmera clinical risk management program. Medical Journal of Australia 174, 621-625.