The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

No / Background: Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. Aim: The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods: A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results: The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusio: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.

People with schizophrenia are at an increased risk for type 2 diabetes and other metabolic abnormalities such as obesity and cardiovascular disease. Lifestyle choices of physical inactivity and diets high in fat and refined carbohydrates are significant contributory factors for obesity and diabetes in people living with schizophrenia, but there is a growing body of research and interest into the additive factor of psychotropic medications on weight gain and diabetes risk. The incidence of diabetes and the morbidity and mortality rates are reported to be approximately 2 to 3 times higher in the population with schizophrenia compared to the general population. This increased vulnerability for health complications is reflected in the profound challenges that are experienced in the population with schizophrenia. My aim for this qualitative research inquiry has been to place into questioning the encounter with diabetes mellitus for people living with schizophrenia. I entered into dialogue with seven participants to explore new possibilities of understanding that emerged between the understandings that we each bring to the conversations. It was also my intent to bring into flux the assumptions of living with two interrelated chronic iv conditions and to increase the understanding of that experience through a reflexive process that illuminates that which may be hidden or obscured. I approached this inquiry mainly drawing on Gadamerian hermeneutics; the main task being the study of ‘texts’ that give evidence to what being human means and the analysis of how different interpretations and understandings are variable depending on their cultural and historical contexts. I expect this work to contribute to the generation of a richer understanding of these co-existing conditions and to create an opportunity and desire for ethical action in diabetes prevention and management for this high-risk population.

Introduction: In recent decades, there has been considerable international attention directed towards minimising healthcare-associated harm and improving the safety of hospital care. More recently, this attention has broadened to include primary medical care. In 2002, the World Health Assembly recognised the issue of inadequate levels of patient safety as a major threat to global public health. In the following years, many countries have developed national strategies for the measurement, monitoring and prevention of patient safety incidents (PSIs) and their outcomes. Experience accumulated from secondary care has shown that the initial steps for understanding patient safety include the systematic identification of the most frequent and most harmful threats. However, the safety profile of primary care dentistry remains poorly investigated. As a result, current evidence cannot provide reliable estimates of the types of PSIs in primary care dentistry, the causes of these incidents, or the associated disease burden caused by such incidents. In medicine, improvements in patient safety were achieved at a national level by developing a shared conceptual understanding, the standardisation of terminology and through preventive initiatives such as the introduction of a national incident reporting and learning system. In the United Kingdom (UK), the England and Wales’ National Reporting Learning System (NRLS) has been an important source of insight, from the perspectives of the reporter, into understanding why PSIs occur. This initiative has led to the implementation of patient safety oriented policies to monitor and reduce cases of healthcare-associated harm. Examples of such policy initiatives include national guidelines and national safety recommendations to encourage the reporting of serious reportable events called ‘never events’ (NEs). These are defined as serious, preventable PSIs that should not occur if the available preventive measures are implemented. At a national level, serious incidents and NEs must be reported to the NRLS and/or other reporting systems. However, little is known about NEs in dentistry as wrong-tooth extractions are the only currently defined NE that has a clear application in dentistry. Although surgical NEs, such as wrong-site surgery and wrong implants may be related to dental procedures, these overlap with procedures conducted in secondary care. As a result, there is no agreed list of NEs for primary care dentistry. The overall aim of my PhD was to explore patient safety, its concepts, including error and harm, and how these can help to create an understanding of the types of PSIs that occur in primary care dentistry, their contributory factors and their consequences. In addition, I also aimed to identify NEs with the greatest need and opportunity for future intervention strategies, in order to improve patient safety in primary care dentistry. Methodology and methods: My PhD was conducted in three phases. For the first phase, I conducted a systematic scoping review of the empirical evidence published over a 20-year period (1994-2014). To achieve this, I searched MEDLINE and EMBASE for articles reporting incidents that could have or did result in unnecessary harm from primary dental care. I also extracted and synthesised data on the types and frequencies of PSIs (including NEs) and adverse outcomes. Then, for the second phase, I undertook an exploratory sequential mixed-methods evaluation, which involved the qualitative exploration and analysis of a weighted-by-year randomised sample (n=2,000) of the most severe incident reports from primary care dentistry submitted to the England and Wales’ NRLS. This approach generated three coding frameworks, aligned to the International Classification for Patient Safety developed by the World Health Organization, for i) the classification of incidents, ii) contributor y factors and iii) incident outcomes. These coding frameworks informed the quantitative analysis, during which myself together with a trained second coder, applied codes to deconstruct the narrative of these patient safety incident reports whilst retaining the meaning of the report. To assess inter-rater reliability, Cohen’s Kappa statistic was calculated for the primary incident type which was defined as “the incident that resulted in the outcome experienced by the patient.” Finally, for the third phase, I undertook an electronic Delphi exercise to achieve international agreement on NEs for primary care dentistry. The results obtained from Phases 1 and 2 were used to identify candidate NEs. I then invited an international panel of 41 experts to complete two rounds of questionnaires; 32 (78%) agreed to participate and completed the first round, and 29 (91%) completed the second round. I provided anonymised controlled feedback between rounds and used a cut-off of 80% agreement to define consensus. The results from the first stage built the evidence base for the second and third phases. Likewise, the results from the second phase further informed the third and final stage of my PhD. Results: I undertook a systematic scoping review which demonstrated: a) there were considerable differences in definitions for terms used to describe patient safety, b) that a range of populations had been studied, and c) that major differences in sampling strategies exist between studies. The main five PSIs I identified were errors in i) diagnosis/examination, ii) treatment planning, iii) communication, iv) procedural errors and v) the accidental ingestion or inhalation of foreign objects. However, little attention has been paid to wider organisational factors such as problems within the physical environment, scheduling (e.g. errors in managing appointments) and patient access, management and lines of responsibility. Also there is very little evidence of interest in researching into the influence of policies for either quality or patient safety assurance. The retrieved evidence was used to build a conceptual literature-derived model of patient safety risks in primary care dentistry. This model helped to bring structure to the analysis of the 1,456 patient incident reports that were eligible for analysis out of a total of 2,000. These reports described incidents across the preoperative (40.3%; n=587), intra-operative (56.1%; n=817) and post-operative (3.6%; n=52) clinical stages of care delivery. Further analysis showed the more frequently reported incidents were related to a) delays in treatment (333/1,456; 22.9%), b) procedural errors (220/11,456; 15.1%), c) medication-related adverse incidents (160/1,456; 11.0%), d) equipment failure (90/1,456; 6.2%) and e) errors in obtaining or processing x-rays (87/1,1456; 6.0%). Only 5.3% (77/1,456) of the incidents resulted in harmful outcomes. Of the 77 incidents that resulted in a harmful outcomes (n=77; 5.3%), around half were due to wrong tooth extractions (37/77; 48.1%) and resulted in unnecessary procedures. Three out of the 1,456 incidents (0.2%) resulted in death. Data from the scoping review and the mixed-method analysis informed a list of 42 candidate NEs. I further sought and achieved international consensus for 23 of these NEs. These were related to routine assessment, and pre-operative, intra-operative and post-operative stages of dental procedures. Conclusions: The findings from my PhD have revealed that patient safety research in dentistry is mostly descriptive and poorly organised with various approaches to defining and measuring PSIs and their outcomes. This poor organisation of patient safety research also includes differing study designs and patient populations studied. The evidence-based conceptual framework from the systematic scoping review, and coding frameworks from analysis of PSI reports selected from a national database, can bring structure to future work by providing a robust approach to classifying PSIs, their contributory factors and outcomes. / My research findings also show that PSI reports are an important source of information that can generate important insights about patient safety in primary care dentistry. The mixed-method analysis of PSI reports showed that most incidents in primary dental care do not result in harm. PSIs that resulted in harmful outcomes more frequently occurred intra-operatively. My findings also reveal that unsafe care in dentistry is not limited to human error, but can also be ascribed to the presence of other administrative or organisational flaws that contribute to the reported incidents. Future initiatives to improve and research clinical practice should focus on improving administrative processes to reduce delays in treatment. Also, the reduction of procedural errors through the standardisation of x-rays, medication prescription and other clinical procedures is needed. Lastly, I have constructed the first comprehensive international list of NEs for primary care dentistry. I believe my findings, including the list of NEs, can provide an evidence-base which will encourage researchers to further expand the patient safety research and development agenda in dentistry, as well as encouraging decision-makers and professional bodies to translate my findings into quality improvement strategies.

This project provides the first comprehensive investigation into the experiences of people with dementia (PWD), their carers, and the staff who provide care in emergency departments (ED) in the UK. This is a mixed methods study which used a national survey (N=403) followed by ED observation (32 hours) and qualitative interviews with health professionals (N=29), in an iterative and sequential design to present a holistic evaluation of the current experiences of the key parties- patients, carers, and ED staff involved in receiving and providing care. The theoretical perspective of the Human Factors Approach to patient safety underpins this work. The project included people with dementia and carers as collaborators and co-designers in both the development of the research tools and in shaping the project outputs. This research explores the barriers and facilitators to safe and effective care, concluding that here are a number of barriers (poor integration of communication systems, inappropriate physical environments, misalignment of staff training and workplace staffing models), which may affect the healthcare team’s ability to provide effective dementia care. These systemic challenges both give rise to and exacerbate poor organisational and safety cultures. However, despite these challenges, there are examples of safe and effective care (positive deviants) where uncommonly good outcomes for this patient population are achieved. Examining these examples offers valuable insight into potential adaptions, which could be used to improve existing care.

The researcher is concerned about the lack of attention given to withdrawn early adolescents (WEAs) at school. During early adolescence, the foundations for lasting character, personality traits and social interaction are laid. Learners exhibiting withdrawal behaviour are described as being quiet, reserved, removed or distant. Attempts by educators to get them involved in lessons often end in failure and this causes educators to become frustrated and confused about how to deal with these learners. The aim of this study is therefore to establish the factors that contribute to withdrawal behaviour in early adolescents. The researcher devised an identification instrument that makes the identification of WEAs much easier for educators. He also established the deep seated fears and anxieties of WEAs and ascertained how they would like to be treated by their educators. / Psychology of Education / M. Ed. (Psychology of Education)

The researcher is concerned about the lack of attention given to withdrawn early adolescents (WEAs) at school. During early adolescence, the foundations for lasting character, personality traits and social interaction are laid. Learners exhibiting withdrawal behaviour are described as being quiet, reserved, removed or distant. Attempts by educators to get them involved in lessons often end in failure and this causes educators to become frustrated and confused about how to deal with these learners. The aim of this study is therefore to establish the factors that contribute to withdrawal behaviour in early adolescents. The researcher devised an identification instrument that makes the identification of WEAs much easier for educators. He also established the deep seated fears and anxieties of WEAs and ascertained how they would like to be treated by their educators. / Psychology of Education / M. Ed. (Psychology of Education)

Esta tese tem como finalidade propor um método de coleta, tratamento e análise de dados de acidentes de trânsito para aplicação no Brasil. Este método tem como um de seus objetivos reconhecer os fatores que contribuem para a ocorrência dos acidentes, visto que identificar as causas dos acidentes é fundamental na busca por soluções para o problema da acidentalidade. No Brasil as bases de dados de acidentes de trânsito são, em geral, estruturadas a partir dos registros policiais e carecem de informações adequadas para a análise da segurança viária. O método proposto neste trabalho permite registrar acidentes de modo a contemplar: as características do acidente, as circunstâncias do momento, a identificação e as características dos veículos e pessoas envolvidas. Além disso, o método permite relacionar essas informações com os fatores que contribuíram para a ocorrência dos acidentes. Nesse contexto, a criação de uma base de dados de acidentes e seus fatores contribuintes, vem suprir a carência de informações essenciais para o diagnóstico e encaminhamento de soluções adequadas para os problemas motivadores dos acidentes de trânsito. A proposta desta tese está baseada em uma abordagem que combina aspectos qualitativos e quantitativos, alinhada às melhores práticas internacionais na área de segurança viária. Como resultado do desenvolvimento do método, foram elaborados instrumentos de coleta de dados contendo um formulário, um manual e procedimentos para a coleta de dados. Como resultado da aplicação prática desses instrumentos, foi criada a estrutura de uma base de dados que permitiu a definição do método proposto para a análise das causas de acidentes de trânsito. Como meio de validar o método proposto, foi realizado um estudo aplicado e são apresentadas as análises de dados dos acidentes de trânsito observados. / This thesis has the purpose of presenting a method for collecting and processing data on traffic accidents to be applied in Brazil. This method aims to acknowledge the contributor factors for the occurrence of accidents, since identifying the causes of accidents is crucial on the search for effective solutions for the road safety problem. Traffic accidents database in Brazil are generally structured based on police reports, therefore lacking adequate information for the analyses of road safety. The method proposes a registry of the accidents comprising accident characteristics, scene circumstances, vehicle as well as involved people identification and characteristics. Moreover, it allows relating that information with the accident contributory factors. In this scenery, the creation of an accident database and its contributory factors emerge to supply the lack of essential information for the diagnosis and adequate solution for traffic accidents. This thesis’ proposal has an approach that combines both quantitative and qualitative aspects, seeking to level up to the best international practice on the road safety area. As a result of the development of the method, data collection instruments were elaborated: a form, a manual, and procedures for data collection. Besides, as a result of the practical application of these instruments, a database - which allowed the definition of the method proposed for analysis of the causes of traffic accidents - was created. As a mean of validation of the method, an applied study and the data analysis of the observed traffic accidents are presented.

Esta tese tem como finalidade propor um método de coleta, tratamento e análise de dados de acidentes de trânsito para aplicação no Brasil. Este método tem como um de seus objetivos reconhecer os fatores que contribuem para a ocorrência dos acidentes, visto que identificar as causas dos acidentes é fundamental na busca por soluções para o problema da acidentalidade. No Brasil as bases de dados de acidentes de trânsito são, em geral, estruturadas a partir dos registros policiais e carecem de informações adequadas para a análise da segurança viária. O método proposto neste trabalho permite registrar acidentes de modo a contemplar: as características do acidente, as circunstâncias do momento, a identificação e as características dos veículos e pessoas envolvidas. Além disso, o método permite relacionar essas informações com os fatores que contribuíram para a ocorrência dos acidentes. Nesse contexto, a criação de uma base de dados de acidentes e seus fatores contribuintes, vem suprir a carência de informações essenciais para o diagnóstico e encaminhamento de soluções adequadas para os problemas motivadores dos acidentes de trânsito. A proposta desta tese está baseada em uma abordagem que combina aspectos qualitativos e quantitativos, alinhada às melhores práticas internacionais na área de segurança viária. Como resultado do desenvolvimento do método, foram elaborados instrumentos de coleta de dados contendo um formulário, um manual e procedimentos para a coleta de dados. Como resultado da aplicação prática desses instrumentos, foi criada a estrutura de uma base de dados que permitiu a definição do método proposto para a análise das causas de acidentes de trânsito. Como meio de validar o método proposto, foi realizado um estudo aplicado e são apresentadas as análises de dados dos acidentes de trânsito observados. / This thesis has the purpose of presenting a method for collecting and processing data on traffic accidents to be applied in Brazil. This method aims to acknowledge the contributor factors for the occurrence of accidents, since identifying the causes of accidents is crucial on the search for effective solutions for the road safety problem. Traffic accidents database in Brazil are generally structured based on police reports, therefore lacking adequate information for the analyses of road safety. The method proposes a registry of the accidents comprising accident characteristics, scene circumstances, vehicle as well as involved people identification and characteristics. Moreover, it allows relating that information with the accident contributory factors. In this scenery, the creation of an accident database and its contributory factors emerge to supply the lack of essential information for the diagnosis and adequate solution for traffic accidents. This thesis’ proposal has an approach that combines both quantitative and qualitative aspects, seeking to level up to the best international practice on the road safety area. As a result of the development of the method, data collection instruments were elaborated: a form, a manual, and procedures for data collection. Besides, as a result of the practical application of these instruments, a database - which allowed the definition of the method proposed for analysis of the causes of traffic accidents - was created. As a mean of validation of the method, an applied study and the data analysis of the observed traffic accidents are presented.