There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.

No abstract

ObjectiveTo describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT).MethodsFive existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger.ResultsNurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT.ConclusionsThe CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

Objectives: The concept of clinical champions has been widely promoted, yet empirically underdeveloped in health services literature. The objectives of this study are to investigate the role of the clinical champion and how it contributes to effective patient safety change.Methods: Case study design was used to examine the role of champions in the implementation of rapid response teams in two hospitals. Central themes were derived through qualitative analysis of semi-structured interviews with key informants.Results: Analysis revealed a typology of champions: clinical, managerial, and executive.Champions engaged in five core activities: disseminating knowledge, advocating, building relationships, navigating boundaries, and facilitating consensus. Individuals became champions by informal emergence or by formal appointment combined with informal emergence.Conclusions: This study furthered understanding of patient safety champions by revealing types, activities, and modes of emergence. Findings will allow health care professionals to use an evidence-based approach to identifying and supporting champions.iii This work is dedicated to my grandmother, Mah Mah.iv

No abstract

This paper explores the factors that influence the persistence of unsafe practice in an interprofessional team setting in health care, towards the development of a descriptive theoretical model for analyzing problematic practice routines. Using data collected during a mixed method interview study of 28 members of an operating room team, participants' approaches to unsafe practice were analyzed using the following three theoretical models from organizational and cognitive psychology: Reason's theory of ''vulnerable system syndrome'', Tucker and Edmondson's concept of first and second order problem solving, and Amalberti's model of practice migration. These three theoretical approaches provide a critical insight into key trends in the interview data, including team members' definition of error as the breaching of standards of practice, nurses' sense of scope of practice as a constraint on their reporting behaviours, and participants' reports of the forces influencing tacit agreements to work around safety regulations. However, the relational factors underlying unsafe practice routines are poorly accounted for in these theoretical approaches. Incorporating an additional theoretical construct such as ''relational coordination'' to account for the emotional human features of team practice would provide a more comprehensive theoretical approach for use in exploring unsafe practice routines and the forces that sustain them in healthcare team settings.

No abstract

BackgroundEfforts to improve the implementation of effective practice and to speed up improvements in quality and patient safety continue to pose challenges for researchers and policy makers. Organisational research, and, in particular, case studies of quality improvement, offer methods to improve understanding of the role of organisational and microsystem contexts for improving care and the development of theories which might guide improvement strategies.MethodsThis paper reviews examples of such research and details the methodological issues in constructing and analysing case studies. Case study research typically collects a wide array of data from interviews, documents and other sources.ConclusionAdvances in methods for coding and analysing these data are improving the quality of reports from these studies.