Near misses: Paradoxical realities in everyday clinical practice

Critical Review of the qualitative research paper

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Introduction

This critique is based on the paradoxical realities in the everyday clinical practice in the

health care organizations. This qualitative study was conducted to define and describe what

constitutes and contributes to near miss occurrences in the health-care system and what is

needed to ensure safer processes of care. Health care organizations are considered as the most

complex adaptive systems which affect the quality and safety of the patients in the health care

organizations. Being a complex adaptive system the delivery of health care is quite difficult

and not a reality the things look like simple. This study was done to analyse the research and

practiced experience of the health care organizations and delivery of health care in different

organizations and institutions. (Armstrong, E. C. 2009) The gaps were identified in the study

and to understand constitutes and contributed near miss occurrences and also it was analysed

about what should be safer process for the health care organizations to deliver the safe health

care to the patients.

Methodology

To understand the paradoxical realities in the everyday clinical practices an exploratory

qualitative design was introduced to analyse the existing realities and activities in the health

care organizations. It can’t be done with having surveys and all and then analyse the data to

get the results. For this there was collected data for the almost 13 health care organizations in

Canada, and in this survey the health care organizations delivery approaches, facilities, health

care professionals, and health care consumers (or patients) were examined and interviewed.

After this there was an ethics approval from the Research Ethics Board and from REBs for

each of the 13 health care organizations. (Dale, A. E. 2010) There have been categorised

different segments for the survey as the age group, expertise group, early admitted patients,

long dated admitted patients, delivery approaches, and communication skills among the

patients and to the health care professionals. The questions were focused basically that

provide the answer to the paradoxical realities in the survey. Some questions include like

what to near misses mean? What contribute to the clinical practices for safety? In health care

system what are the mitigate strategies for safety? So there have been surveyed these kind of

questions among all the participants in the surveys. (Roberts, J. & Di Censo, A. 2008)

In this survey the data was gathered through the questions series and reviews to the same kind

of group at a time and it was for atleast 1 – 1.5 hrs a group so that it can be better understand.

The surveys were done on the focused group so that the correct and exact data can be

collected from the single group in particular segment. (Tucker AL and Spears SJ.2007) With

the experienced professionals in the health care and the patients who were in hospitals for a

long time the personal key interviews sessions were conducted from more than 45 minutes to

1.5 hrs because these segment have the specific and reliable information for analysis of the

paradoxical realities? (Mick JM et al, 2007) For this key interviews the experienced nurse in

the health care unit were appointed so that she /he can ask the questions perfectly and

understand then easily because the nurses were trained about the qualitative interviews and

surveys in the health care industry. (Van der Schaaf TW. 2009) There was developed a

content analysis schema to analyse the answers in the surveys and the trend can be observed

of the surveys in different categories. This content was segmented in the different micro

levels to understand the micro level realities. The requirement was of the experts because to

know better and in depth they were only options as qualitative support to come up with the

final exact result. (Kanse L and Van der Schaaf et al, 2007) In the survey the multi level

content analysis definitely gave the good result at micro level because of categorisation in

different levels. The used methodologies were good and up to the standards and also the

observed results and analysis were perfect.

Check List

Consolidated criteria for reporting qualitative studies (COREQ):

Domain 1: Research team and reflexivity

Personal Characteristics

1. Interviewer/facilitator – Experienced and Trained nurses

2. Credentials – Hospitals experienced nurses

3. Occupation - Nurses

4. Gender – Generally Female

5. Experience and training – Highly extensive qualitative experience and also in medical

industry (Coyle GA, 1992)

Relationship with participants

6. Relationship established – Yes for a long time

7. Participant knowledge of the interviewer – Yes very much, nurses worked in the same

health care organizations

8. Interviewer characteristics – Was quite flexible and bias on the research topic

Domain 2: study design

Theoretical framework

9. Methodological orientation and Theory

Surveys and content analysis were done

10. Sampling – Based on their experience, age group and sector

11. Method of approach – face to face or in group

12. Sample size – not more than 5 at a time

13. Non-participation - None

14. Setting of data collection – Mostly at Clinic

15. Presence of non-participants – No, participant self

16. Description of sample - Age, Gender, Health care, and admitted time in the hospitals

Data collection

17. Interview guide - Yes, basic formats were prepared for the interview

18. Repeat interviews – No repeat interviews

19. Audio/visual recording – No, it was orally

20. Field notes – Yes, during the interview and surveys as well as after the surveys

21. Duration – 1- 1.5 hr in a group and for key interview it was 45 -90 minutes

22. Data saturation – No

23. Transcripts returned – No (Godfrey MM et al, 2011)

Domain 3: analysis and findings

Data analysis

24. Number of data coders – minimum of two individual’s coded and third individual then

reviewed the coding data

25. Description of the coding tree – yes, it was given

26. Derivation of themes – yes it was levelled in different themes for better understanding

27. Software – The analysis were done on the spread sheet or excel and statistical software

28. Participant checking - yes

Reporting

29. Quotations presented – Yes, the number of participants and their feedback were reported

30. Data and findings consistent – yes, it was

31. Clarity of major themes – yeah, as it was based on the different segment so easily

represented the themes, generally there were four major themes

32. Clarity of minor themes – yes, generally there were 2 minor themes

Critical Appraisal

1. Was there a clear statement of the aims of the research?

The goal of the research was to find out the paradoxical realities in the everyday clinical

practices. This is important to analyse because the present condition of the health care is

changing and need the perfect system for the safety of the patients.

2. Is a qualitative methodology appropriate?

Yes, in this kind of research the qualitative methodology is appropriate because it gives the

real life scenarios and the happening in the surrounding for which the information is needed.

3. Was the research design appropriate to address the aims of the research?

Yes the research design was appropriate because it gave the exact result as expected in the

health care clinical practice realities. The sampling was based on different criterion.

4. Was the recruitment strategy appropriate to the aims of the research?

Yes as the experienced nursed were hired for the assessment and surveys and they were given

appropriate training. The participants belong to the different age group and experiences so it

was right decision.

5. Were the data collected in a way that addressed the research issue?

Yes the decision and design for the data collection was right and the data was collected

through the micro levelling surveys through interviews, reviews etc. Yes the method chosen

were justified by the researchers and the key interviews, focused group discussion and

individual interviews were conducted. (Institute of Medicine, 2002)

6. Has the relationship between researcher and participants been adequately

considered?

The relationships between the researchers and the participants have been adequately

considered as because of the nurses were from the same hospitals and also the patients were

from the same hospitals. The researches responded the participants query very rightly.

7. Have ethical issues been taken into consideration?

Yes critical ethical issues have been taken in to consideration during the interviews and

sampling surveys. The participants were given some written documents mentioning about the

procedure and maintaining the ethical standards.

8. Was the data analysis sufficiently rigorous?

Yes the data analysis were sufficiently rigorous because it was based on the micro levelling

of the research questions and were analysed using the spreadsheet methodologies and also

have the complete description. The categories were divided and then the data analyses were

done and found the trend. (Pronovost PJ et al, 2008)

9. Is there a clear statement of findings?

The findings from the research are explicit and give the complete conclusion and direction of

the paradoxical realities in the clinical practices. There have been analysed six themes in the

research.

10. How valuable is the research?

The research done to analyse the paradoxical realities in the everyday clinical practices and

the research based on the data collection and the result is valuable.

Results

The results were analysed based on the themes in the research of the paradoxical realities in

the everyday practice life. There were identified six themes in total as follows:

Theme 1: Near miss as metaphor of system vulnerabilities

This explains that the complexity in the paradoxical realities lies because of the changing

conditions in the health care organizations on daily basis.

Theme 2: Near miss as constructive interruption in the pathway of error

This explains that the phenomenon in the health care is because of the error in the inherent

clinical practice. (Tourangeau AE et al, 2007)

Theme 3: Illusion of patient-centred care eludes patient safety

These are due the symbolic change in the family members and are unable to think how to

protect the loves ones in a health care system.

Theme 4: Meaninglessness in practice fuels near misses

Clinical experience is very random and haphazard so it is meaningless for the care of the

patients.

Theme 5: Diligent and vigilant pattern recognition prompts recovery patterns

Health professionals are unable to find the clues so not able to help the patients with perfect

medicines and cure. (Roberts, J. & Di Censo, A. 2008)

Theme 6: Re-orchestrate system to create synergy in care processes

There is need to have the restructure and accountability of the health care system for the

better practices and perfect care.

Implications for clinical practice

This research implies that the there are lots of problems in the clinical practices because of

the changing medical or health care activities and conditions that need to focus on the new

system and methodologies to correct that and also should focus on the safety and delivery of

the health care to the patients. (Roberts, J. & Di Censo, A. 2008) Clinical practices should be

fair and need to learn the behaviour of the patients and to understand the happening in the

surrounding in health care so that the better practices can be done.

Further Research

The further research can be done to get the exact data based on the qualitative research and

can be verified the obtained results through the quantitative research methodologies. Based

on the obtained reliable results the final decision can be taken to integrate the new

technologies and health care system.

References

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