Blame the Patient,Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.     

On the ‘transmission sense of information’

In order to illuminate the role of information in biology, Bergstrom and Rosvall (Biol Philos 26:159–176, 2011a; Biol Philos 26:195–200, 2011b) propose a ‘transmission sense of information’ which builds on Shannon’s theory. At the core of the transmission sense is an appeal to the reduction in uncertainty in receivers and to etiological function. I explore several ways of cashing out uncertainty reduction as well as the consequences of appealing to function.     

Making sense of ‘mixture’: states and the classification of ‘mixed’ people

Caribbean diaspora intellectuals have contributed significantly to African-American political struggles over the years, despite arguments by some African-American intellectuals about what they discern as West Indian negativism, extremism, and divisiveness in American political life. This essay examines the legacy of a representative sample of diasporic Caribbean intellectuals since the time of the Harlem Renaissance in the 1920s and culminating in the 1970s, notably, Garvey, members of the African Blood Brotherhood [ABB], C.L.R. James, and Walter Rodney, to demonstrate the phenomenal ideological vision, organizational capability, and political activism they have brought into fostering solidarity with African Americans in the struggle for fundamental change. The focus here is on their respective contributions to the debate on the relationship between class and race in America and the black diaspora generally, which has helped to shape the form, and orient the direction of African-American and Caribbean diasporic struggles for the better part of the twentieth century.     

On the correct use of ‘data’

Acknowledgement  Thanks are due to Drs. Paul Johnston (P.Johnston@ exeter.ac.uk) and E. William Beese (ebeese@t-online.de) for kindly providing dictionary definitions and for sharing their thoughts about the correct use of ‘data’.     

Stochasticity or the fatal ‘imperfection’ of cloning

The concept of clone is analysed with the aim of exploring the limits to which a phenotype can be said to be determined geneticaly. First of all, mutations that result from the replication, topological manipulation or lesion of DNA introduce a source of heritable variation in an otherwise identical genetic background. But more important, stochastic effects in many biological processes may superimpose a phenotypic variation which is not encoded in the genome. The source of stochasticity ranges from the random selection of alleles or whole chromosomes to be expressed in small cell populations, to fluctuations in processes such as gene expression, due to limiting amounts of the players involved. The picture emerging is that the term clone is a statistical over-simplification representing a series of individuals having essentially the same genome but capable of exhibiting wide phenotypic variation. Finally, to what extent fluctuations in biological processes, usually thought of as noise, are in fact signal is also discussed.     

‘Gender’ and the Concerns of Carnal Self-Consumption

This article analyses the co-occurrence of two concerns often expressed by indigenous leaders involved with reparations for victims of paramilitaries in Colombia. These concerns revolve around discomfort with the intense use of hegemonic ‘gender’ discourses in the context of the reparations, and a feeling that leaders' involvement in the latter brings about a betrayal of the family and of themselves. By engaging with the local category of eirruku (flesh), I argue that ways of engaging women in reparations entail the commoditisation of caring relationships. This article, based on 13 months of fieldwork with an indigenous organisation and the communities integrated into it between 2007 and 2008, contributes to the understanding of the articulation of gender and ethnic/racial identification in the context of contemporary forms of governance of indigenous peoples, while delving into ‘carnality’ as a concept to understand gendered forms of reproduction, reparation and selfhood.     

Phylogeny and taxonomy of the ‘manna lichens’

We present ataxonomic revision of the ‘manna lichens’ based on morphological, chemical, ecological and molecular data. A large number of herbarium specimens and fresh collections were examined. Phylogenetic analyses were performed using nuclear ribosomal (nrITS, nrLSU) and mitochondrial small subunit (mtSSU) sequences. Some notable phenotypic characters were plotted on the phylogenetic tree, and the analysis reveals that some of these characters are useful for genus and species level distinction of certain ‘manna lichens.’ Phylogeny of the Megasporaceae was revised using a combined data set of nrLSU and mtSSU and performing parsimony and Bayesian analyses. Five genera (Aspicilia, Circinaria, Lobothallia, Megaspora and Sagedia) are recognized. Further, the relationships of five presumably closely related genera of ‘manna lichens’, namely Agrestia (vagrant), Aspicilia (crustose) Circinaria (crustose), Chlorangium (vagrant) and Sphaerothallia (vagrant) with different growth forms were analysed. The analyses revealed that ‘manna lichens’ do not form a monophyletic group but occur in different clades within the genus Circinaria. The genera Agrestia, Chlorangium and Sphaerothallia are assigned as new synonyms under the genus Circinaria and no vagrant or erratic species remain in the genus Aspicilia. The analyses also show that five new erratic, vagrant and crustose species can be recognized. In this study two ‘manna lichens’, viz. Circinaria rostamii sp. nov. (Azerbaijan, Iran and Turkey), and Circinaria gyrosa sp. nov. (Armenia, Azerbaijan, Iran, Turkey, Turkmenistan and Spain) are described as new to science. Three potentially new species with crustose and erratic forms need additional study. Aspicilia fruticolosofoliacea is reduced to synonymy under C. alpicola, and a lectotype is designated for C. aspera. Thirteen new combinations in Circinaria are presented. The phenomenon of vagrancy is briefly discussed, and the biogeography of the ‘manna lichens’ is outlined. Illustrations, distribution maps, and an identification key to the species are provided.     

‘Placebos’ and the logic of placebo comparison

Robin Nunn has argued that we should stop using the terms ‘placebo’ and ‘placebo effect’. I argue in support of Nunn’s position by considering the logic of why we perform placebo comparisons. Like all comparisons, placebo comparison is just a case of comparing one thing with another, but it is a mistake, I argue, to think of placebo comparison as a case where something is compared to ‘a placebo’. Rather, placebo comparison should be understood as a situation which sets-up the treatment and control groups in a particular way; not as a case involving objects or procedures called ‘placebos’ employed in order to control for ‘placebo effects’.     

Microbiology of the fermentation of ‘iru pete’ and ‘iru woro’ obtained from local producers

Summary The microorganisms responsible for the fermentation of iru, obtained from local producers, were isolated and identified. Only bacteria were involved in the fermentation; the species areMicrococcus luteus, Staphylococcus aureus, Bacillus subtilis, Lactobacillus plantarum, Citrobacter freundii, Lactobacillus salivarius andStreptococcus pyogenes. Microbial population, temperature, pH and moisture content increased with increase in period of fermentation. A progressive in titratable acidity accompanied the fermentation.

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Resumen Se aislaron e identificaron los microorganismos responsables de la fermentación de iru obtenido de productores locales. En el proceso de fermentación unicamente estaban implicadas bacterias que se identificaron como:Micrococcus luteus, Staphylococcus aureus, Bacillus subtilis, Lactobacillus plantarum, Citrobacter freundii, Lactobacillus salivarius yStreptococcus pyogenes. La población microbiana, la temperatura, el pH y el contenido en humedad se incrementaron al aumentar el periodo de fermentación. Se observó un decremento progresivo del título de acidez a lo largo de la fermentación.

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Résumé Les microorganismes responsables de la fermentation des iru obtenus de producteurs locaux ont été isolés et identifiés. Seules des bactéries sont impliquées dans la fermentation. Les espèces sontMicrococcus luteus, Staphylococcus aureus, Bacillus subtilis, Lactobacillus plantarum, Citrobacter freundii, Lactobacillus salivarius etStreptococcus pyogenes. La population microbienne, la température, le pH et la teneur en eau agumentent avec l'augmentation du temps de fermentation. Une baisse progressive de l'acidité titrable accompagne la fermentation.

     

Starter culture for the production of ‘soyiru’

Bacillus subtilis or licheniformis facilitated production of soyiru with the best results being given by using both together. Fermentation employing Streptococcus enterococcus was unsuccessful.H.A. Suberu is with the Department of Biological Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria. J.A. Akinyanju is with the Department of Biological Sciences, University of Ilorin, P.M.B. 1515, Ilorin, Nigeria.     

Taking the ‘Error’ Out of Ruse‘s Error Theory

Michael Ruses Darwinian metaethics has come under just criticism from Peter Woolcock (1993). But with modification it remains defensible. Ruse (1986) holds that people ordinarily have a false belief that there are objective moral obligations. He argues that the evolutionary story should be taken as an error theory, i.e., as a theory which explains the belief that there are obligations as arising from non-rational causes, rather than from inference or evidential reasons. Woolcock quite rightly objects that this position entails moral nihilism. However, I argue here that people generally have justified true beliefs about which acts promote their most coherent set of moral values, and hence, by definition, about which acts are right. What the evolutionary story explains is the existence of these values, but it is not an error theory for moral beliefs. Ordinary beliefs correspond to real moral properties, though these are not objective or absolute properties independent of anyones subjective states. On its best footing, therefore, a Darwinian metaethics of the type Ruse offers is not an error theory and does not entail moral nihilism.     

A texture-processing model of the ‘visual sense of number’

It has been suggested that numerosity is an elementary quality of perception, similar to colour. If so (and despite considerable investigation), its mechanism remains unknown. Here, we show that observers require on average a massive difference of approximately 40% to detect a change in the number of objects that vary irrelevantly in blur, contrast and spatial separation, and that some naive observers require even more than this. We suggest that relative numerosity is a type of texture discrimination and that a simple model computing the contrast energy at fine spatial scales in the image can perform at least as well as human observers. Like some human observers, this mechanism finds it harder to discriminate relative numerosity in two patterns with different degrees of blur, but it still outpaces the human. We propose energy discrimination as a benchmark model against which more complex models and new data can be tested.     

Darwin without borders? Looking at ‘generalised Darwinism’ through the prism of the ‘hourglass model’

This article critically analyzes the arguments of the ‘generalized Darwinism’ recently proposed for the analysis of social-economical systems. We argue that ‘generalized Darwinism’ is both restrictive and empty. It is restrictive because it excludes alternative (non-selectionist) evolutionary mechanisms such as orthogenesis, saltationism and mutationism without any examination of their suitability for modeling socio-economic processes and ignoring their important roles in the development of contemporary evolutionary theory. It is empty, because it reduces Darwinism to an abstract triple-principle scheme (variation, selection and inheritance) thus ignoring the actual structure of Darwinism as a complex and dynamic theoretical structure inseparable from a very detailed system of theoretical constraints. Arguing against ‘generalised Darwinism’ we present our vision of the history of evolutionary biology with the help of the ‘hourglass model’ reflecting the internal dynamic of competing theories of evolution.     

Biocultural Diversity: Moving Beyond the Realm of ‘Indigenous’ and ‘Local’ People

During the past decade the relationship between biodiversity and human diversity has received increased attention, resulting in the identification of what the Declaration of Belém calls an ‘inextricable link’ between biological and cultural diversity. Although the term biocultural diversity, introduced to denote this link, is being used increasingly, there has been little critical reflection on what it precisely refers to. I argue that it is used with particular reference to ‘indigenous traditional’ people, but that there is scope for extending its application within biocultural discourse. I therefore review the concept of culture and discuss what constitutes cultural values of the natural environment. I conclude that the concept of culture must be understood as involving a dynamic process of transcultural exchange and constant re-articulations of tradition resulting in the persistence of certain cultural practices. This approach ultimately reveals that the concept of biocultural diversity is also applicable to non-indigenous traditional communities.