Did governments in different countries regulate common concerns about patient safety differently? If so how and why did they do this? This thesis undertakes a historical comparison of the regulation of patient safety in Britain and Canada between 1980 and 2005. These jurisdictions began the period with very similar regulatory frameworks, but by 2005 there were distinct differences in each jurisdiction‘s regulatory response to patient safety. Britain was very actively regulating all aspects of service provision within its health system in the name of patient safety, whereas Canada‘s regulatory direction showed adherence to the 1980s model with only scattered incremental developments. This thesis assesses the broader sociopolitical context and the structure of the health systems in each jurisdiction and concludes there are differences in the logics of these systems that established a foundation for future regulatory divergence. It is argued that between 1980 and 2005 there were two factors that influenced regulatory directionality in each jurisdiction: changing political norms associated with the development of neoliberalism and the New Public Management; and events or scandals associated with the provision of health services. The differing levels of penetration of both the changing political norms into governance cultures and of scandals into the public and political consciousness are critical to explaining regulatory differences between jurisdictions. The thesis concludes that what and how governments chose to regulate is a function of the perceived need for action and the dominant social and political norms within that society. Context is everything in the formulation of regulatory approaches to address pressing social problems.

Research into adverse events in home care is at a very early stage worldwide. Adverse event research in other health care sectors has demonstrated that patients can and do suffer harm, much of which is preventable, during the receipt of health care services. A stratified, random sample of patients who had received home care nursing service and were discharged in 2004/05 from three Ontario home care programs was studied to develop basic exploratory and descriptive evidence to advance the understanding of AEs in home care. The outcome is an estimate of the incidence of adverse events among patients, description of adverse event types and factors associated with adverse events, and the development of models predictive of home care patients with higher and lower potential for adverse events, and of the location of patients with adverse events. Positive critical indicators were identified in 66.5% of 430 cases. Sixty-one adverse events were identified in 55 (19.2%) of these 286 cases. When adjusted for sampling methodology, the adverse event rate was 13.2 per 100 patients (95%, CI 10.4% - 16.6%, SE 1.6%). Thirty-three percent of the adverse events were rated as having more than a 50% probability of preventability; 1.4% of all patients experienced an adverse event related death. Eight of the 45 factors significantly associated with adverse events formed a single factor model predictive of adverse events. Six two-factor interactions and the absence of one factor were also predictive of the occurrence of adverse events. Five of the 12 critical indicators significantly related to adverse events, as well as 7 critical indicator combinations formed models that reliably located about two-thirds of patients who had, and almost all patients who had not, experienced an adverse event. This study suggests that a significant number of home care patients experience adverse events, two-thirds of which are preventable. Use of adverse event sensitive factors as a screening tool for patients that may benefit from enhanced case management and clinical vigilance, and those unlikely to be placed at increased adverse event risk by maintaining current levels of vigilance, presents an opportunity to improve patient safety. Retrospective critical indicator models identifying home care patients who have experienced an adverse event can be used to estimate adverse event incidence rates and changes in rates over time.

Research into adverse events in home care is at a very early stage worldwide. Adverse event research in other health care sectors has demonstrated that patients can and do suffer harm, much of which is preventable, during the receipt of health care services. A stratified, random sample of patients who had received home care nursing service and were discharged in 2004/05 from three Ontario home care programs was studied to develop basic exploratory and descriptive evidence to advance the understanding of AEs in home care. The outcome is an estimate of the incidence of adverse events among patients, description of adverse event types and factors associated with adverse events, and the development of models predictive of home care patients with higher and lower potential for adverse events, and of the location of patients with adverse events. Positive critical indicators were identified in 66.5% of 430 cases. Sixty-one adverse events were identified in 55 (19.2%) of these 286 cases. When adjusted for sampling methodology, the adverse event rate was 13.2 per 100 patients (95%, CI 10.4% - 16.6%, SE 1.6%). Thirty-three percent of the adverse events were rated as having more than a 50% probability of preventability; 1.4% of all patients experienced an adverse event related death. Eight of the 45 factors significantly associated with adverse events formed a single factor model predictive of adverse events. Six two-factor interactions and the absence of one factor were also predictive of the occurrence of adverse events. Five of the 12 critical indicators significantly related to adverse events, as well as 7 critical indicator combinations formed models that reliably located about two-thirds of patients who had, and almost all patients who had not, experienced an adverse event. This study suggests that a significant number of home care patients experience adverse events, two-thirds of which are preventable. Use of adverse event sensitive factors as a screening tool for patients that may benefit from enhanced case management and clinical vigilance, and those unlikely to be placed at increased adverse event risk by maintaining current levels of vigilance, presents an opportunity to improve patient safety. Retrospective critical indicator models identifying home care patients who have experienced an adverse event can be used to estimate adverse event incidence rates and changes in rates over time.

Bakgrund: Cytostatika har sedan 1960-talet använts för att bota flera olika cancerformer. Cytostatika skadar tumörer men påverkar även friska celler vilket ofta medför en rad olika biverkningar. Cancerpatienter befinner sig ofta i en sårbar situation vilket kräver omsorgsfull omvårdnad. Syfte: Syftet med studien var att studera patienters upplevelser av vanligt förekommande cytostatikaorsakade biverkningar (illamående och kräkningar, fatigue, hårförlust, smak-och luktförändringar) samt vilka hanteringsstrategier de använder sig av. Metod: Denna litteraturstudie baseras på nio kvalitativa artiklar. Artikelsökningen genomfördes i databaserna PubMed och CINAHL. Artiklarna har analyserats genom innehållsanalys. Resultat: Biverkningarna kunde upplevas som fruktansvärda, olustiga, obehagliga och utmattande. Dessa påverkade det dagliga livet vad gällande bl.a. relationer och självständighet. Hanteringsstrategierna innefattade exempelvis vila, fysisk aktivitet och särskild kost. Slutsats: Många patienter upplever cytostatikaorsakade biverkningar som påfrestande och att de påverkar det dagliga livet negativt, men vissa patienter upplever tvärtom att de inte påverkar deras dagliga liv nämnvärt. Upplevelserna av biverkningarna och dess följder kan påverkas av patienternas förmåga att hitta fungerande hanteringsstrategier. Resultatet visar på skillnader mellan olika cancerpatienters upplevelser och strategier, vilket kan kräva personcentrerad vård. / Background: Chemotherapy has since the 1960’s been used to cure various forms of cancer. Chemotherapy damages tumors but also effects healthy cells which often result in a variety of side effects. Cancer patients often find themselves in a vulnerable situation which requires careful nursing. Aim: The aim of this study was to explore patients experiences of commonly occuring adverse effects (nausea and vomiting, fatigue, alopecia, smell- and tastealterations) and their management strategies. Method: This literature study is based on nine qualitative articles. The searching of articles was performed in the data bases PubMed and CINAHL. The articles has been analysed with content analysis. Results: The side effects could be perceived as awful, uncomfortable, unpleasant and exhausting. These effected the daily life including factors like relationships and independence. Management strategies included for example rest, physical activities and special diets. Conclusion: Many patients experience adverse effects from chemotherapy as distressing and that they effects their daily life in a negative way, but occasional patients experience the contrary that they don’t effect their daily lives significantly. The experiences and their consequenses can be affected by patients ability to find useful management strategies. The result shows the difference between different cancer patients’ expericences and management strategies, wich may require person-centred care.

Objective: To examine the prevalence of adverse childhood experiences and associations with early alcohol use initiation and alcohol use patterns among high-risk urban youth in Kampala, Uganda. Methodology: Data from the Kampala Youth Survey (N=457) conducted in May through June 2011 in Kampala, Uganda was used for analysis. Indicators of adverse childhood experiences (ACEs) included: hunger, having parents, talking to parents, ever having lived on the street, parents hitting each other, parents hitting children and parental use of alcohol. These were dichotomized as either possessing the characteristic or not. Alcohol outcomes assessed were; age at alcohol initiation (age 13 was the cutoff point), frequent drinking and heavy drinking. Bivariate and multinomial logistic regression analyses were computed to determine statistical association between ACEs and alcohol use. Results: Findings in this study showed that parents hitting the youth, parental alcohol use, hunger, having ever lived on the street, and having been raped were significantly associated with the youth’s age of alcohol initiation by age 13, frequent drinking and heavy drinking in bivariate analyses. Results also showed gender differences for: parental alcohol use, parents hitting each other, being hungry, ever having lived on the street and having been raped. Girls reported higher values for most measures. Parental use of alcohol, having ever lived on the street and having been raped were particularly significant included in a multivariate model. Conclusion: This study demonstrates that adverse childhood experiences are strongly associated with early alcohol use initiation as well as frequent and heavy drinking.

Cancer represents a major cause of human morbidity and mortality. There is no scientific consensus regarding cancer causality or prevention. Occupational exposure potentially remains a major contributor to the incidence of this group of diseases, but the data to assess its impact continues to elude researchers and public health advocates. Among women in industrialised countries, breast cancer is the most prevalent cancer. The known or suspected risk factors, including family history and lifetime oestrogen load, can account for less than 50 percent of the cases. New hypotheses about the role of xenoestrogens and endocrine disrupting compounds are challenging the previous scientific precepts regarding cancer causality. Within this context, the extent to which a community-based occupational history data collection initiative can contribute to advancing our scientific understanding of associations between cancer and work is explored. The possibility that occupational histories data can find associations missed in conventional breast cancer research that ignore occupation is also explored. More specifically, the extent to which data derived from an occupational history questionnaire can provide insight into the potential association between breast cancer risk and farming is examined. Occupational histories of cancer patients contain data that could help to elucidate and inform our understanding of cancer aetiology and prevention. In the community of Windsor, Ontario, Canada a local cancer treatment centre responded to community concerns by cooperating in a collaborative research project to collect the occupational histories of cancer patients. 'Computerised Record of Occupation Made Easy' (CROME) was an innovative method that allowed individual patients to document their lifetime work histories. This data collection process represented the first time a local Canadian cancer treatment center had undertaken such an initiative. Based on the hypothesis generated by CROME, a new research study was launched - Lifetime Occupational History Record (LOHR). Over a two-and-a-half year period, all female patients at the Windsor Regional Cancer Centre with new incident breast cancer were invited to participate in a population-based case-control study along with an equivalent number of randomly selected community controls. A comprehensive lifetime history questionnaire was administered to subjects by interview. Data gathered included known or suspected risk factors along with a complete occupational history of all jobs ever worked. An occupational history of farming alone produced an Odds Ratio (OR) = 2.8 (Cl, 95%, 1.6-4.8). These findings are important for our understanding of cancer causality with implications for resolving the current scientific conflict regarding the role of occupationally caused carcinogenesis. Such collaborative, community-based studies also demonstrate the importance of community participation in the scientific research process.

Darbo tikslas: ištirti hospitalizacijų dėl vaistų sukeltų nepageidaujamų reakcijų ypatybes bei dėsningumus. Uždaviniai: 1) nustatyti hospitalizacijų dėl NRV dažnumą, sunkumą bei įvertinti pasekmes; 2) identifikuoti vaistų grupes, dėl kurių sukeltų NRV ligonius dažniausiai reikia hospitalizuoti; 3) nustatyti priežastis, kurios galėjo padidinti hospitalizacijų dėl NRV dažnį; 4) nustatyti rizikos veiksnius, kurie gali didinti hospitalizacijų dėl NRV dažnį; 5) paruošti praktines rekomendacijas, kaip sumažinti hospitalizacijų dėl NRV dažnį. Metodika: buvo peržiūrimos pacientų, kurie per 5 mėnesius gydėsi Vidaus ligų diagnostikos skyriuje, ligos istorijos. Įtarus, kad pacientas galėjo būti hospitalizuotas dėl NRV, atvejis būdavo nagrinėjamas. NRV tikėtinumas buvo vertinamas pagal Naranjo tikėtinumo metodą. NRV išvengiamumas buvo nustatynėjamas analizuojant ligos istorijų anamnezes ir kitus paciento duomenis ir vertinamas panaudojant specifinį 10 klausimų klausimyną. Visi duomenys buvo renkami ir apdorojami su statistinės duomenų analizės programos SPSS 20.0 versija. Rezultatai: nustatyta 41 NRV sukelta hospitalizacija (4,4 proc.). 53,7 proc. hospitalizacijų dėl NRV buvo vidutinio intensyvumo (p < 0,05). Nustatyti 3 mirties atvejai (7,3 proc.) dėl NRV hospitalizuotų moterų grupėje. Išgyvenusiems pacientams po NRV sukeltų hospitalizacijų buvo reikalingas papildomas ambulatorinis gydymas (92,8 proc., p < 0,05). 73,2 proc. pasireiškė gretutinių ligų pablogėjimas (p < 0,05), 70,7 proc... [toliau žr. visą tekstą] / Objective: To examine characteristics and patterns of hospitalizations caused by adverse drug reactions. Methods: During 5 month period, medical records of Internal Diagnostic section patients were evaluated to determine hospitalizations caused by adverse drug reactions. In case of suspicion that the patient could be hospitalized due to adverse drug reaction, the case was examining. Probability was evaluated according to Naranjo Adverse Drug Reaction Probability Scale. Preventability was determined while using specific questioniere from 10 questions. Statistical data was collected and evaluated with SPSS version 20.0. Results: 41 hospitalizations occured due to ADR (4,4%). 53,7% of them were evaluated as mild severity (p < 0,05). 3 deaths (7,3%) occured in hospitalized women group because of ADR. Patients who outlived after ADR hospitalizations were in need of additional out-patient treatment (92,8%, p < 0,05). 73,2% experienced worsening of the underlying diseases (p < 0,05), 70,7% were hospitalized for more than 7 days (p < 0,05). Approximate cost of one hospitalization was 3 617,70 Lt, while others, not related to ADE - 2 729,05 Lt. Most of ADR hospitalzitions were caused by anticoagulants (53,7%, p < 0,05): warfarin (41,5%), acetylsalicylic acid (9,8%). Major reasons which might have enhanced hospitalizations due to ADR risks were evaluated as drug interactions (24,4 proc.), overdose (22,0%), drug use to the discretion of the patient's (17,1%), drug prescribing regardless... [to full text]

Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

Clinical characteristics of idiosyncratic drug reactions (IDRs) suggest that they are immune mediated. Penicillamine-induced autoimmunity in Brown Norway rats was used as a tool for mechanistic studies of this type of IDR. It has been shown that T helper 17 (Th17) cells play a central role in many types of autoimmune diseases. This study was designed to test whether Th17 cells are involved in the pathogenesis of penicillamine-induced autoimmunity. In sick animals, interleukin (IL) 6 and transforming growth factor-β1, known to be driving forces of Th17 differentiation, were consistently increased following penicillamine treatment. IL-17 and IL-22, characteristic cytokines produced by Th17 cells, were increased in sick animals. Furthermore, the percentage of IL-17-producing CD4 T cells was significantly increased, but only in sick animals. Retinoic acid, which has been reported to inhibit Th17 cell development, made the autoimmunity worse, increased IL-6 production, and did not decrease the number of Th17 cells. An infiltration of CD8 cytotoxic T cells in the liver suggests that they may be the key player in causing liver toxicity induced by D-penicillamine. Drug-induced liver injury (DILI) is one of the major causes of morbidity, mortality, and drug candidate failure. Recently, it has been suggested that Th17 cells may play an active role in inflammatory human liver diseases. In a study of patients being treated with isoniazid, some patients developed mild liver injury. The percentage of Th17 cells in the blood of these patients significantly increased when the ALT increased, and this suggests that they play a role in the mechanism of this liver injury. Furthermore, IL-10-producing T cells also increased and this may have prevented the development of severe liver injury. In another study, two hours after treatment of mice with acetaminophen there was a significant increase in Th17 cells in the liver. This rapid response suggests that Th17 cells can be part of the innate immune response to liver injury. Our data provided evidence that Th17 cells are involved in both “toxic” and idiosyncratic liver toxicity. This pathway could be a new target for the therapeutic interventions to treat DILI.

This thesis began as an investigation of the effect of adverse possession upon the land market where the adverse possession extends only to a small portion of the abutting parcel and the subject land is under a title registration scheme. The consequence of such adverse possession on part only of a parcel is that the location of the boundary demarcating the limits of the respective domains of two adjoining land parcels may be displaced. / If part parcel adverse possession effectively transfers ownership of a small portion of an abutting parcel, the boundaries are shifted consequent to long term occupation, and will prevail over the strict technical legal boundary. In a registered title land system the occupational boundary then prevails over the legal boundary as certified in the register notwithstanding that registered title schemes purport to confer conclusiveness upon register entries. Alternatively, the registered proprietor’s estate is not paramount where any part of the proprietor's parcel has been adversely occupied. Consequently the occupier has an interest in the proprietor's land that is not disclosed in the register. Inspection of the register and reliance upon the inspection is insufficient to ascertain the complete legal status of the particular land holding. Inspection with consequent reliance upon the register is the major function of a registered title scheme. Alternatively, if part parcel adverse possession is ineffective to transfer ownership of registered land, the technical legal boundary prevails over the occupational boundary despite the fact that it is not the boundary accepted by the parties involved as governing. / Both alternatives present a problem to the orderly conduct of the land market. Where occupations prevail, the prudent market participant takes precautions besides relying on inspection of the register. Where the legal boundary prevails, the participant seeks confirmation that the occupational and legal boundaries coincide. / Another alternative utilised in some registered title jurisdictions empowers a court to transfer small sections to an adjoining landholder where a building or similar improvement is erected so that it encroaches upon the adjacent holding. This alternative was included within the ambit of the thesis as it developed. / The aim of this research was the formulation of the best solution suitable for a registered land system with particular reference towards a uniform solution suitable for adoption in all Australian jurisdictions. The existing systems utilising adverse possession and statutory encroachment were evaluated against three recent law cases that illustrate the workings of these systems including perceived shortcomings. These lawsuits serve as a test against which the existing systems are compared and evaluated and were also used to evaluate the proposed solution. The results suggest that adverse possession alone should not override the purpose of the register which is to fully disclose the proprietary interests in land parcels. It was concluded that a necessary step in acquiring title to land through adverse possession involves the registration of the interest acquired. Whereas the present modes of dealing with the boundary problem are adequate, it is concluded that the best mode is that of statutory encroachment because it best serves several competing interests. Adopting the proposed solution would involve change and compromise in some of the Australian jurisdictions; these being necessary to adopt a uniform scheme throughout Australia. The proposed solution has added benefits of removing an illogicality from some of the present systems, eliminating encouragement for an off-register land market, and fosters an accurate public land register.