Issues
Volume 200 Issue 4
In this issue
The power of systems thinking in medicine
The convergence of seemingly small events accruing over time can have severe consequences. This is a central message of many aircraft accident investigations. For instance, an attempt to streamline maintenance procedures for an engine mount created the conditions for the United States’ deadliest aeroplane crash in 1979 (http://www.airdisaster.com/reports/ntsb/AAR79-17.pdf). The investigation found a constellation of interacting factors — design deficiencies, faulty maintenance practice, failures of regulatory oversight and flawed aviation industry economics. As noted in relation to a later aeroplane crash (http://www.theatlantic.com/magazine/archive/1998/03/the-lessons-of-valujet-592/306534), it was a “system accident”. The complexity of aviation systems creates conditions for small changes to interact with other system elements across technical, organisational and cultural domains to produce significant outcomes that are hard to predict and control. All clinicians recognise the complexity of health care delivery. The system accident idea has been adopted enthusiastically by some exponents of ways to improve clinical safety, despite more recent reservations about its applicability (Health Serv Res 2006; 41: 1654-1676). Nevertheless, the assessment of clinical mishaps and adverse events requires a systems approach (not only technical, but also organisational, social and cultural). As a starting point, registries are powerful tools for systematically detecting and monitoring clinical problems and adverse events, and for informing interventions. The study by Roxanas and colleagues of Australia and New Zealand Dialysis and Transplant Registry data (doi: 10.5694/mja13.10435) shows that the incidence of end-stage renal failure due to lithium therapy, although small, is growing. They express concern that accepted doses of lithium over a long time may result in irreversible renal impairment and end-stage disease, reinforcing the need for regular and frequent monitoring of renal function. Registry data analysis is the monitoring system providing the backbone for reducing risks for those receiving lithium therapy. There is also a need for systems to oversee and analyse incidents in whole areas of health care. Cunningham and colleagues (doi: 10.5694/mja13.11347) point out that, in the case of chiropractic practice, there is little in place for monitoring for adverse incidents. Without such a system, proper investigation of incidents in chiropractic care cannot occur. Significantly greater challenges exist in assessing health impacts of activities with complex influences from societal and cultural practices in the community. Clenbuterol — a β2-adrenergic agonist with anabolic as well as bronchodilating properties, registered only for veterinary use and banned in sport — is now illicitly used in the community to aid bodybuilding and weight loss. Brett and colleagues (doi: 10.5694/mja13.10982) report a case series of clenbuterol toxicity reported to the NSW Poisons Information Centre. Details of cases suggest that it is also being used for deliberate self-harm, and that accidental ingestion has occurred. While the authors acknowledge that the study presents an incomplete picture of actual use in the community, would a deeper engagement with ideas from complexity science help in understanding the complexity of substance misuse? What additional systems need to be put in place for us to know and perhaps anticipate changing patterns of use? No matter how complex the health problem, data registries will always have a central role in disease and health care monitoring and practice. Presently, patients often need to explicitly consent to their information being added to a registry. Olver (doi: 10.5694/mja13.10695) examines the ethical dimensions of opt-out consent, where patient data are automatically added unless consent is expressly refused. He argues that this approach is acceptable in the context of low-risk research and for improving clinical quality. Although not called a registry, the concept has been used for decades in civil aviation for mandatorily collecting flight data and operational feedback from aviation personnel. Only relatively recently have similar approaches taken hold across a broad range of health care activities. Decades of research and application of safety assurance and improvement systems in aviation and other industries have resulted in a critical respect for the complexity of many human endeavours — the importance of monitoring outcomes and processes, understanding why and how incidents happen, and appreciating the multifaceted nature of the solutions. There are certainly limitations to mapping approaches to aviation safety to health care systems. But the analogy provides a useful starting point and source of ideas. Preventing adverse health outcomes and health care incidents matters enormously to the community. Just as a systems approach has led to civil aviation being appreciably safer, it should also be pursued by those wanting well founded solutions to complex, multidimensional problems in health.
Astika Kappagoda
Highlights from our archives
Highlights from our archives
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Editorial
Age, CKD and other kidney messages
World Kidney Day 2014 will promote discerning management for older patients
David C Harris MD, BS, FRACP · John Feehally DM, FRCP
Learning by MOOC or by crook
Many health-related “massive open online courses” have been created by some of the world’s best universities
Richard F Heller MD, FRACP, FAFPHM
In brief
From NPS MedicineWise
The full content of this article is available by downloading the PDF.
News
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Perspectives
Self-regulation of autologous cell therapies
A first step for a virtually unregulated industry
Bernard E Tuch FRACP, PhD, GAICD · Dominic M Wall BSc(Hons), FFSc(RCPA), PhD
Lack of appropriate imaging before breast augmentation can have serious patient consequences
For women getting breast implants in Australia or overseas, preoperative screening should be routine
Kathy L Flitcroft BBSc, MA, PhD · Andrew J Spillane MD, FRACS · Rebecca L Read MB BS, DPhil, FRACS
Dear Minister, please save yourself from activity-based funding
As the states maintain control over public hospitals, the federal government needs a simple, outcomes-based funding model
Johannes U Stoelwinder MD, FRACMA, FAFPHM
Opting in for opt-out consent
Waiving the requirement for participant consent in low-risk research may provide important community benefits
Ian N Olver MD, PhD, FRACP
Letters
The need for a chiropractic adverse events reporting system in Australia
Bringing chiropractors in line with other Australian health professionals
John E Cunningham · Joanne Benhamu · David Hawkes
Inadvertent dispensing of Coumadin instead of Coversyl
Two simple strategies could minimise substitution errors
Alexander M Owen · Sara L Hungerford
Population-based genetic carrier screening for cystic fibrosis in Victoria
Screening can be undertaken successfully before or in the early stages of pregnancy
Alison D Archibald · John Massie · Melanie J Smith · Deborah G Dalton · Desirée du Sart · David J Amor
Taking the inferior out of inferior vena cava filter follow-up
Simple strategies can be used to improve filter monitoring and removal
Nicholas I Brown · Reade Deleacy · Chloe Szikla · Ashu Jhamb
Renal sympathetic denervation for resistant hypertension in a patient with a single kidney
An effective and well-tolerated treatment for resistant hypertension
Bo Xu · Robert J Whitbourn
Finally . . . an evidence-based tool to find primary health care evidence
An improved capacity to retrieve relevant evidence helps support policy and practice
Jennifer J Tieman · Ruth M Sladek · Ellen McIntyre
Methylisothiazolinone in baby wipes: a rising star among causes of contact dermatitis
A preservative commonly used in personal products is a leading cause of contact dermatitis
Jennifer L Cahill · Ryan W Toholka · Rosemary L Nixon
For debate
Harms unknown: health uncertainties cast doubt on the role of unconventional gas in Australia's energy future
Health risks, uncertain greenhouse profile and cost of unconventional gas weigh against proposed future development
Alicia Coram PhD · Jeremy Moss PhD · Grant Blashki MD
Research
Evaluation of the impact of National Breast Cancer Foundation-funded research
Timely study with pressure on funders to provide evidence of wider impacts of research
Claire Donovan MA, BA(Hons), DPhil · Linda Butler BEcon · Alison J Butt BSc(Hons), PhD · Teresa H Jones BSc, MSc · Stephen R Hanney PhD, MA, BSc(SocSci)
Clenbuterol toxicity: a NSW Poisons Information Centre experience
Clenbuterol use for body building and slimming has increased dramatically, often with dangerous consequences
Jonathan Brett MB BS(Hons), BMedSci(Hons) · Andrew H Dawson MB BS, FRCP, FRACP · Jared A Brown BPharm, MPH, GradDipClinEpi(ClinTox)
Vision screening in preschoolers: the New South Wales Statewide Eyesight Preschooler Screening program
StEPS program is close to achieving its aim of offering vision screening to at least 90% of 4-year-olds in NSW
Stephanie J Blows MB BS, MPH(Hons), PhD · Elisabeth P Murphy MB BS(Hons), MPaed, FAFPHM · Frank J Martin MB BS, FRANZCO, FRACS · Robyn M Davies DipAppSci(Orth), GCertPubSecMgmt
Renal replacement therapy associated with lithium nephrotoxicity in Australia
Clinicians should exercise discretion and check renal function regularly when prescribing lithium
Milton Roxanas MB BS, FRANZCP · Blair S Grace PhD, BSc · Charles R P George MB BS, PhD, FRACP
Reflections
The cat and the nap
While dogs can detect some cancers, cats might have other diagnostic talents
William H Seligman BA(Hons), BM BCh · Ari Manuel MB BS, MRCP, BSc
A functional dependence? A social history of the medical use of morphine in Australia
Morphine’s use in Australia has shaped public perception and current challenges
Matthew Grant MB BS, DipPallMed, MBioethics · Jennifer Philip PhD, FAChPM, MB BS · Anna Ugalde BA(Hons), PhD
Correction
Risk assessment to guide prostate cancer screening decisions: a cost-effectiveness analysis
CorrectionError in calculating costs of screening: In “Risk assessment to guide prostate cancer screening decisions: a cost-effectiveness analysis” in the 3 June 2013 issue of the Journal (Med J Aust 2013; 198: 546-550), there was an error in the way screening costs were calculated. These corrections do not alter the study conclusions. The corrected figures are in bold as follows. Results section of the abstract (page 546): “The ...
Andrew J Martin PhD · Sarah J Lord MB BS, MS(Epi) · Hannah E Verry BEcon · Martin R Stockler MB BS, MSc, FRACP · Jon D Emery MB BCh, MA, DPhil
Careers
Strength in numbers
As the exodus from solo practice continues, we look at why and how the group practice environment can work so well.
Annabel McGilvray
Caring for immigrants with cancer
Medical psychologist Professor Phyllis Butow spends her time finding ways of improving the care we offer immigrants with cancer
Cate Swannell
Drug-resistant tuberculosis: collaborative regional leadership required
Suman S Majumdar MPH · Ben J Marais MD, PhD · Justin T Denholm MPH · Warwick J Britton PhD, FRACP, FRCPA,
Clostridium difficile — what is the Australian story?
Paul D R Johnson MB BS, PhD, FRACP · Rhonda L Stuart MB BS, PhD, FRACP
Policies — clinical and political — for better health
Stephen Leeder
Cardiology networks: improving the management of acute coronary syndromes
Gerard E Carroll AM, MB BS(Hons), FRACP FCSANZ · Peter L Thompson AM, FRACP, FACC, MBA
A decade of promises in personalised cancer medicine: is the honeymoon over?
Robyn L Ward MB BS(Hons), FRACP, PhD