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Sixty teachers from the Ottawa-Carleton region of Canada were surveyed to measure their knowledge of child maltreatment risk indicators, knowledge of reporting procedures, and the frequency of reporting sexual abuse, physical abuse, and neglect. Correlations did not support the hypothesis of a significant relationship between knowledge and actual reporting frequency. Multiple Regression analyses demonstrated that the knowledge of child maltreatment risk factors and the knowledge of reporting procedures were not predictive of reporting. It was found that the teachers sampled were very knowledgeable of the basic risk indicators of child maltreatment and reporting procedures and policy. However, the findings did not support the hypotheses of a significant relationship between knowledge of child maltreatment risk factors and of reporting procedures and actual reporting frequency. These findings are discussed in consideration of the limitations of the current study, the implications for practice and the possibilities for further research.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

This thesis investigates the effectiveness of communication between assurors and assurance report users, and the role that assurance reports play in this process. It comprises two behavioural experiments undertaken in the context of: (i) wording changes to the audit report (developed product) using shareholders as participants; and (ii) the role of assurance and type of assurance provider for corporate social responsibility reporting (evolving product), using financial analysts as participants. In both studies effectiveness of communication is examined in terms of report users?? perceptions and investment decision-making. The theoretical framework used in these studies is adapted from a communications model developed by Shannon and Weaver (1949), and supplemented by psychology research focused on source credibility (Birnbaum and Stegner, 1979). Two key elements of the communication process are recognised; the: (i) message transmitted; and (ii) source of the message. The first element is considered in the first experiment; the second element in the second study. Useful feedback is provided to standard-setters. From the first study, report users?? perceptions are not impacted by changes to the wording of the audit report. However, in the second experiment they are affected by differences in the source of the message. In terms of trustworthiness, financial analysts perceive the credibility of the source of corporate social responsibility information to be significantly greater when assured. For a company in an industry with stronger incentives to report positive corporate social responsibility information, they perceive the credibility (trustworthiness, overall credibility) of the source of the information to be significantly greater when assured. They also discern differences between types of assuror whereby the credibility (trustworthiness, expertise, overall credibility) of the source of information is perceived to be greater when assured by a professional accountant than a sustainability expert. A contribution of these experiments is the analysis of report users?? investment decision-making, as well as their perceptions. Differences in the message and source of the message for assurance reporting have no impact on report users?? investment decisions. Differences in characteristics of report users (familiarity with reports, extent to which reports are understandable) appear to impact report users?? perceptions and merits further examination.

In the lead-up to the Johannesburg World Summit on Sustainable Development in 2002, several documents were published by the mining industry declaring the important role that public sustainability reporting had to play in driving sustainable development and pointing to the Global Reporting Initiative???s (GRI) 2002 Sustainability Reporting Guidelines as a suitable vehicle for this. With the aim of finding ways to improve the quantity and quality of public sustainability reporting within the Australian coal mining industry, this study set out to investigate the current sustainability reporting practices of companies involved in the industry. A survey was conducted of the public financial and non-financial reporting practices of all companies with a significant interest in a New South Wales or Queensland coal mine. Three survey cycles were completed covering the 2001, 2002 and 2003 calendar years and the 2001/02, 2002/03 and 2003/04 financial years. The reporting practices were determined both in terms of frequency of report production and contents of reports. A GRI-based content analysis tool was used to measure the amount of sustainability information contained in the company reports. It was found that only around a quarter of companies produced a nonfinancial report and that almost half did not produce any public reports, with the number of unlisted companies publicly reporting particularly low. Whilst a wide range of reporting practices were observed with regard to content, the frequency of Economic, Environmental and Social Performance Indicators in reports was generally found to be low. An investigation of the regulatory reporting requirements on companies was then conducted to determine what sustainability information companies could report with data that they already had at hand. The same GRI-based content analysis tool was used to analyse a variety of regulatory documents. It was found that companies did not publicly disclose a significant amount of the environmental data that they are required to report to regulators. The study also evaluated the reporting capacity of non-reporters and found that, with the exception of Governance Structure and Management Systems elements, large unlisted companies had similar regulatory reporting requirements to listed companies. However, smaller unlisted companies had fewer requirements to report Profile and Economic elements. Finally, the influences of company ownership structure, non-financial reporting status, industrial sector, nationality and participation in voluntary initiatives on sustainability reporting practices were investigated. It was concluded that in order for public sustainability reporting to be a useful tool in driving sustainable development, focus needed to shift from ???best practice??? to ???common practice??? so that a critical mass of reporters is amassed to allow benchmarking of performance.

This thesis investigates the effectiveness of communication between assurors and assurance report users, and the role that assurance reports play in this process. It comprises two behavioural experiments undertaken in the context of: (i) wording changes to the audit report (developed product) using shareholders as participants; and (ii) the role of assurance and type of assurance provider for corporate social responsibility reporting (evolving product), using financial analysts as participants. In both studies effectiveness of communication is examined in terms of report users?? perceptions and investment decision-making. The theoretical framework used in these studies is adapted from a communications model developed by Shannon and Weaver (1949), and supplemented by psychology research focused on source credibility (Birnbaum and Stegner, 1979). Two key elements of the communication process are recognised; the: (i) message transmitted; and (ii) source of the message. The first element is considered in the first experiment; the second element in the second study. Useful feedback is provided to standard-setters. From the first study, report users?? perceptions are not impacted by changes to the wording of the audit report. However, in the second experiment they are affected by differences in the source of the message. In terms of trustworthiness, financial analysts perceive the credibility of the source of corporate social responsibility information to be significantly greater when assured. For a company in an industry with stronger incentives to report positive corporate social responsibility information, they perceive the credibility (trustworthiness, overall credibility) of the source of the information to be significantly greater when assured. They also discern differences between types of assuror whereby the credibility (trustworthiness, expertise, overall credibility) of the source of information is perceived to be greater when assured by a professional accountant than a sustainability expert. A contribution of these experiments is the analysis of report users?? investment decision-making, as well as their perceptions. Differences in the message and source of the message for assurance reporting have no impact on report users?? investment decisions. Differences in characteristics of report users (familiarity with reports, extent to which reports are understandable) appear to impact report users?? perceptions and merits further examination.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Zugl.: Freiberg (Sachsen), Techn. Universiẗat, Diss., 2007.

Zugl.: Bremen, Univ., veränd. Diss., 2007

Zugl.: Berlin, Humboldt-Universiẗat, Diss., 2007.