| Id No | Entry No | Source | Source link | Source Type | Main Domain | Sub-domain 1 | Sub-domain 2 | Key Points | Citns Jan 24 |
| 634 | 95 | Tucker AL, Edmondson AC, Spear S. When problem solving prevents organizational learning. Journal of Organizational Change Management. 2002;15(2):122-137. | Link | Empirical study | Groups | Nurses | Learning - organisational | An instructive study of two very different types of reactions to problems (encountered by nurses at a rate of around one every one and a half hours or so.) The vast majority, 92 % - use first order problem solving methods that are quick and consistent with their professional ethos, but don't fix any underlying systemic issues, and therefore don't prevent recurrences. Only 8% are second order problem solvers that do try to fix the primary causes. The first order problem solvers are generally more popular with their colleagues and managers than the second, who are often viewed as "noisy disrupters" but who are the canaries in the healthcare coal mine. | 410 |
| 160 | 94 | Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-2094. | Link | Review /Overview | Individuals | Doctors | Learning | In short the answer in the authors' words was that: "..Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families" | 1,090 |
| 156 | 93 | Wennberg J, Gittelsohn A. Small Area Variations in Health Care Delivery A population-based health information system can guide planning and regulatory decision-making. Science. 1973;182(4117):1102-1108. | Link | Empirical study | Groups | Organisations - healthcare | Variation | A seminal paper from one of the pioneers in the study of the wide and often unjustified variations in clinical practices from place to place. It is worth noting and rather depressing that this important paper was rejected by several leading medical journals. In some services the importance of looking for and correcting unjustified variations in the evidence based processes, outcomes and costs of clinical practice are still overlooked. | 2,604 |
| 152 | 92 | Ward M. Appendix 6.1 on Clinical Networks in Queensland Heath Systems Review Forster Report pp 391-399. Published online 2005. | Link | Report /White paper | Groups | Organisations - healthcare | Networks - occupational | A commentary on two types of clinician leadership and a proposal that led to the formation of clinical networks in Queensland | |
| 150 | 91 | Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures. Health Affairs. 2004;23(3):103. | Link | Review /Overview | Groups | Organisations - healthcare | Cultures - organisational | Key commonalities : 1 Longstanding, 2 Well known but not well handled, 3 Cause immense harm, 4 Lack of management systems, 5) Repeated incidents 6.Not discovered by 'quality assurance' systems, Exacerbated by 'club culture'; fragmented knowledge and responsibility and a high capacity for self deception | 240 |
| 147 | 90 | Volpp KG, Grande D. Residents suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348(9):851-855. | Link | Empirical study | Individuals | Doctors | Error | A short and instructive list of the simple and seemingly obvious but often overlooked ways in which errors could have been avoided and residents lives made a lot easier | 389 |
| 137 | 89 | Tainter JA. The Collapse of Complex Societies. Cambridge Univ Pr; 1990. | Link | Book | Systems | Complexity | Collapse | It may be difficult to persuade clinicians and health service managers, or anyone else for that matter, that reading a book by an archaeologist about the causes of collapse of ancient civilizations is worth their while but a good case can be made. This is because of the ever increasing resource costs of increasing complexity as a problem solving mechanism eventually reaches the point of diminishing returns on investments whether in whole civilizations or social enterprises such as healthcare. The graph the author shows (fig 11 p103) of the sharply declining productivity of healthcare in the last century is striking. | |
| 17 | 88 | Baumol WJ, Ferranti D de, Malach M, Pablos-Mendez A, Tabish H, Wu LG. The Cost Disease: Why Computers Get Cheaper and Health Care Doesn't. Yale University Press; 2013. | Link | Book | Systems | Organisations - healthcare | Health economics | A readable account in which Baumol points out that in common with education and the performing arts healthcare costs have risen much more steeply than CPi and the manufacturing industries, and argues that this 'cost disease' arises because of difficulty in reducing labour costs by increasing productivity. Despite his (correct) prediction that costs would continue to rise disproportionately as they have he seemed to be optimistic that gains in general productivity will be able to accommodate continued services | |
| 129 | 87 | Tali Sharot: Intelligent People Have Greater Difficulty Changing Their Beliefs.; 2018. | Link | Video | Individuals | In general | Beliefs / attitudes | A clear account research showing why facts and figures often fail to persuade intelligent and well educated people to change their minds in the expected direction. The size and direction of the change is highly dependent on pre-existing beliefs | |
| 125 | 86 | Santomauro CM, Kalkman CJ, Dekker S. Second victims, organizational resilience and the role of hospital administration. Journal of Hospital Administration. 2014;3(5):p95. | Link | Review /Overview | Individuals | Clinicians | Adverse events | In the considerable and entirely appropriate efforts that are made dealing with and minimising the harm to patients afflicted by adverse events, the need for effective support and management for the clinicians involved is often overlooked. This paper outlines how this harm can be both exacerbated by inappropriate and ameliorated by appropriate organisational responses. | 35 |
| 123 | 85 | Rushmer R, Davies HTO. Unlearning in health care. Quality and safety in Health Care. 2004;13(suppl 2):ii10. | Link | Review /Overview | Groups | Organisations - healthcare | Unlearning | Much energy is rightly expended on developing effective individual and organisational learning resources and processes. Much less thought is given about the frequent need for unlearning of ineffective or harmful practices. This paper provides a good overview of both why this is needed and how it can be implemented. It also makes the important distinction between the nature of, and the very different approaches needed for, 'routine' vs 'deep' unlearning | 213 |
| 122 | 84 | Rothwell PM. External validity of randomised controlled trials: to whom do the results of this trial apply? The Lancet. 2005;365(9453):82-93. | Link | Empirical study | Groups | Patients | Statistical methods | A comprehensive account of the problems of deciding whether the results of randomised controlled trials have external validity - ie whether they are applicable in routine clinical practice - which often they do not. | 2,863 |
| 121 | 83 | Rotenstein LS, Huckman RS, Wagle NW. Making Patients and Doctors Happier ? The Potential of Patient-Reported Outcomes. New England Journal of Medicine. 2017;377(14):1309-1312. | Link | Review /Overview | Groups | Staff | Patient reported outcomes | Although patient reported outcome measurements have been rightly developed to measure this important and sometimes neglected measure of clinical effectiveness, this review describes the increasing realisation among doctors that access to this information makes their work both easier and more satisfying. | 242 |
| 119 | 82 | Roland M, Rao SR, Sibbald B, et al. Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. BMJ Quality & Safety | Link | Empirical study | Groups | Doctors | Aberrant | A comparison between the attitudes of USA and UK doctors to a range of ethical and professional issues including their interactions with colleagues they knew to be impaired or incompetent (16-18%) Sheds some light on why doctors don't deal very well with such colleagues including the interesting and (for the UK) odd and disconcerting statistic that while 72.4% of USA doctors report that they would cease referring patients to such colleagues only 17.2 % would be inhibited in the UK | 64 |
| 118 | 81 | Rogers EM. Diffusion of Innovations. Simon and Schuster; 2010. | Link | Book | Groups | In general | Communication | A, perhaps the, classic and comprehensive study of how new ideas spread, including medical developments and drugs. Memorable quotations include " 84% of population is unlikely to change its behaviour based solely on arguments of merit, scientific proof, great training or jazzy media campaigns. The majority of those who try new behaviours do so because of the influence of respected peers” ,,,, and: "... opinion leaders (have been described) as “people on the edge”: opinion leaders have a certain degree of cosmopoliteness in that they bring new ideas from outside their social group to its members. They “carry information across the boundaries between groups. They are not people at the top of things so much as people at the edge of things, not leaders within groups so much as brokers between groups” ..." Opinion leaders gain part of their perceived expertise regarding innovations by their greater contact across their system’s boundaries".... Resonates Williams description of 'boundary spanners' (Entry no 105 this database) | |
| 111 | 80 | Priesmeyer HR, Sharp LF. Phase plane analysis: Applying chaos theory in health care. Quality Management in Healthcare. 1995;4(1):62. | Link | Empirical study | Groups | Patients | Statistical methods | One small and practicable step in the direction of measuring some of the many non-linear interactions in medicine and other complex adaptive systems | 17 |
| 109 | 79 | Pisano GP, Bohmer RM, Edmondson AC. Organizational differences in rates of learning: Evidence from the adoption of minimally invasive cardiac surgery. Management Science. 2001;47(6):752-768. | Link | Empirical study | Groups | Staff | Team development | A 16 hospital comparison in the efficiency and effectiveness of surgical teams in the introduction of a new technique of minimally invasive cardiac surgery. Some services did much better than others and this, probably unsurprisingly, was achieved in those with more active surgical leadership, careful team selection and more rigorous team training. | 724 |
| 106 | 78 | Perla RJ, Parry GJ. The epistemology of quality improvement: it's all Greek. BMJ Quality & Safety. 2011;20(Suppl 1):i24-i27. | Link | Review /Overview | Groups | Teams | Knowledge management | An interesting overview of quality improvement activities in a pediatric intensive care unit using a philosophical model that views knowledge as straddling the intersection between evidence and beliefs | 40 |
| 104 | 77 | Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. New England Journal of Medicine. 2005;353(25):2673-2682. | Link | Empirical study | Groups | Students | Behaviour | A case control study showing that bad behavior as medical students is predictive of bad behaviour as doctors | 955 |
| 102 | 76 | Nolte E, McKee M. Variations in amenable mortality Trends in 16 high-income nations. Health Policy. 2011;103(1):47-52. | Link | Empirical study | Groups | Patients | Mortality | International comparisons of fatal conditions for which interventions most productively focus on attention on, and direct actions towards, those that are most amenable to known methods of prevention or treatment | 225 |