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August 18, 2020 (TORONTO) — Canada Health Infoway (Infoway) and Loblaw Companies Limited http://scoalaromaneasca.ca/who-can-buy-viagra/ (Loblaw) cheap viagra pills are pleased to announce that they have reached an agreement to advance e-prescribing in Canada. Under the agreement, Shoppers Drug Mart, Loblaw retail pharmacies and QHR Technologies’ AccuroEMR®, Canada’s largest single electronic medical record platform, will work towards connecting with PrescribeIT®, Infoway’s national e-prescribing service.As a first step in the initiative, Shoppers Drug Mart and Loblaw will begin to roll out PrescribeIT® in pharmacies already using software that is integrated with PrescribeIT®. “This agreement will accelerate the adoption of e-prescribing in Canada, bringing significant benefits to patients, prescribers and health care systems across the country,” said Ashesh Desai, Executive Vice President Pharmacy and Healthcare Businesses at Shoppers Drug Mart.“PrescribeIT® has shown tremendous momentum since it launched,” said Michael Green, President and CEO of Infoway cheap viagra pills. €œThis is an important expansion for PrescribeIT® and will help extend the benefits of the service more broadly.”Loblaw will continue to operate FreedomRx, the e-prescribing and messaging platform that is currently available predominantly to Loblaw and Shoppers Drug Mart pharmacies and physicians using AccuroEMR® as their electronic medical records system.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and more efficient delivery of health services cheap viagra pills for patients and clinicians.

Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway-inforoute.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the provinces and territories, and industry stakeholders to develop, operate and maintain the national e-prescribing cheap viagra pills service known as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice. PrescribeIT® will protect Canadians’ personal health information from being sold or cheap viagra pills used for commercial activities. Visit www.PrescribeIT.ca.About Loblaw Companies LimitedLoblaw is Canada's food and pharmacy leader, and the nation's largest retailer.

Loblaw provides Canadians with grocery, pharmacy, health and beauty, apparel, general merchandise, financial cheap viagra pills services and wireless mobile products and services. With more than 2,400 corporate, franchised and Associate-owned locations, Loblaw, its franchisees and associate-owners employ approximately 200,000 full- and part-time employees, making it one of Canada's largest private sector employers.Loblaw's purpose – Live Life Well® – puts first the needs and well-being of Canadians who make one billion transactions annually in the company's stores. Loblaw is positioned to meet and exceed those needs in many cheap viagra pills ways. Convenient locations. More than cheap viagra pills 1,050 grocery stores that span the value spectrum from discount to specialty.

Full-service pharmacies at nearly 1,400 Shoppers Drug Mart® and Pharmaprix® locations and close to 500 Loblaw locations. PC Financial® cheap viagra pills services. Affordable Joe Fresh® fashion and family apparel. And three of Canada's cheap viagra pills top-consumer brands in Life Brand, no name® and President's Choice. For more information, visit Loblaw's website at www.loblaw.ca.-30-Media InquiriesCatherine ThomasSenior Director, External CommunicationLoblaw Companies Limited This email address is being protected from spambots.

You need JavaScript enabled to view it.Inquiries about PrescribeIT®July 22, 2020 cheap viagra pills (Toronto) – Rexall Pharmacy Group Ltd. (Rexall) and Canada Health Infoway (Infoway) are pleased to announce that PrescribeIT®, Infoway’s national e-prescribing service, will soon become available in more than 250 Rexall pharmacies across Canada. PrescribeIT® enables prescribers and pharmacists to electronically create, receive, renew and cancel prescriptions, while improving overall patient care through secure clinician messaging.“Rexall is an important addition to the PrescribeIT® roster of partners and we are very pleased to have them on board,” noted Jamie Bruce, Executive Vice cheap viagra pills President, Canada Health Infoway. €œTogether we can help improve patient care through more effective medication management.”“At Rexall, we strive to build partnerships aimed at providing our pharmacists with innovative solutions to help improve overall patient care,” said Nicolas Caprio, President, Rexall. €œPrescribeIT® is a great opportunity for us to continue strengthening our digital offering, allowing pharmacists and physicians to increase their communication and ultimately positively impact patient health.”In anticipation of the agreement, Rexall has already introduced the service in key locations in cheap viagra pills Ontario, Alberta and New Brunswick.

Additional sites will start to offer PrescribeIT® starting in the next several weeks.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and more cheap viagra pills efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the cheap viagra pills provinces and territories, and industry stakeholders to develop, operate and maintain the national e-prescribing service known as PrescribeIT®. PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice.

PrescribeIT® will protect Canadians’ personal health information from being sold or cheap viagra pills used for commercial activities. Visit www.prescribeit.ca.About Rexall Pharmacy Group Ltd.With a heritage dating back over a century, Rexall is a leading drugstore operator with a dynamic history of innovation and growth, dedicated to caring for Canadians’ health…one person at a time. Operating over 400 pharmacies across cheap viagra pills Canada, Rexall’s 8,500 employees provide exceptional patient care and customer service. Rexall is part of the Rexall Pharmacy Group Ltd. And a proud member of the global cheap viagra pills McKesson Corporation family.

For more information, visit rexall.ca. Follow us cheap viagra pills on Twitter. @RexallDrugstore, on Instagram at @RexallDrugstoreOfficial and on Facebook at @RexallDrugstore.-30-Media InquiriesInquiries about PrescribeIT®Inquiries about McKesson CanadaAndrew ForgioneDirector, Media Relations and Public AffairsMcKesson Canada(905) 671-4586.

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Changi General Hospital and Singapore University of Technology and Design have developed a sensor that detects real-time bleeding from wound sites after invasive medical procedures.HOW IT WORKSThe Blood WArning Technology with Continuous Haemoglobin (BWATCH) sensor is buy viagra cvs a lightweight monitoring device placed over a patient's bandage. By combining the light absorption properties of haemoglobin with a moisture-detecting sensor, the device can differentiate blood from other bodily fluids and in turn detect bleeding episodes.BWATCH has been buy viagra cvs tested and validated in an observational clinical trial involving 250 patients at CGH. The findings of the trial were published in the journal, Scientific Reports. The developers have also patented the device in Singapore and the United States.WHY IT MATTERSAccording to a statement from CGH, buy viagra cvs in developed countries like Singapore, the incidence of acute dialysis is estimated to be at 200-300 per million population each year. If these patients encounter deterioration of their kidney functions, they will have to undergo haemodialysis.

BWATCH was developed to minimise the risk of bleeding occurring after the insertion of buy viagra cvs a catheter during vascular access procedures. BWATCH can be deployed in non-hospital settings, such as for on-site monitoring of traumatic wounds. Additionally, the device can be potentially integrated into hospital systems, such as the nurses' call system.THE LARGER TRENDFoong Shaohui, associate professor of buy viagra cvs the Department of Engineering Product Development at SUTD claimed that no commercial systems and products for fluid detection have been specifically developed for blood. "While there are other commercial systems and products that are available for fluid detection, they are only able to detect the presence of fluids by changes in physical properties such as electrical resistance, capacitance or opacity to light," he added.A device for bleeding detection during cardiac procedures was introduced in 2017 in the US. Saranas’ Early Bird has a vascular access sheath embedded with sensors for real-time detection of bleeding caused by accidental rupture of a blood vessel during transcatheter aortic valve replacement buy viagra cvs procedures.In the same year, an interoperability partnership was established between IBM Watson Health and Israeli firm MedyMatch Technology.

The latter has an AI-powered algorithm pointing out areas that may indicate potential cerebral bleeding.In separate news, CGH also teamed up with Singapore's Integrated Health Information Systems last year to develop an AI predictive engine that analyses chest radiographs to determine whether a patient is likely to have mild or severe pneumonia.ON THE RECORD"Heavy bleeding following medical procedures is rare but when it occurs, it can be life-threatening. Monitoring at short intervals is highly manpower intensive but necessary," said Chionh Chang Yin, chief consultant of the Department of Renal Medicine at CGH."However, despite close monitoring, buy viagra cvs bleeding may still occur between these inspections. BWATCH offers continuous monitoring, allowing the care team to focus on other patient-centric tasks,” he added..

Changi General Hospital and Singapore University of Technology and Design have developed a sensor that detects real-time bleeding from wound sites after http://carlfarrugia.com/items/kuncert-la-valette/ invasive medical procedures.HOW IT WORKSThe Blood WArning Technology with Continuous Haemoglobin (BWATCH) sensor is a lightweight cheap viagra pills monitoring device placed over a patient's bandage. By combining the light cheap viagra pills absorption properties of haemoglobin with a moisture-detecting sensor, the device can differentiate blood from other bodily fluids and in turn detect bleeding episodes.BWATCH has been tested and validated in an observational clinical trial involving 250 patients at CGH. The findings of the trial were published in the journal, Scientific Reports. The developers have also patented the device in Singapore and the United States.WHY IT MATTERSAccording to a statement from CGH, in developed countries like Singapore, the incidence of acute dialysis is estimated to be at 200-300 per million population each cheap viagra pills year.

If these patients encounter deterioration of their kidney functions, they will have to undergo haemodialysis. BWATCH was developed to minimise the risk of bleeding occurring after the insertion of a catheter during cheap viagra pills vascular access procedures. BWATCH can be deployed in non-hospital settings, such as for on-site monitoring of traumatic wounds. Additionally, the device can be potentially integrated into hospital systems, such as the nurses' call system.THE LARGER TRENDFoong Shaohui, associate professor of the Department of Engineering Product Development at SUTD claimed that no commercial systems and cheap viagra pills products for fluid detection have been specifically developed for blood.

"While there are other commercial systems and products that are available for fluid detection, they are only able to detect the presence of fluids by changes in physical properties such as electrical resistance, capacitance or opacity to light," he added.A device for bleeding detection during cardiac procedures was introduced in 2017 in the US. Saranas’ Early Bird cheap viagra pills has a vascular access sheath embedded with sensors for real-time detection of bleeding caused by accidental rupture of a blood vessel during transcatheter aortic valve replacement procedures.In the same year, an interoperability partnership was established between IBM Watson Health and Israeli firm MedyMatch Technology. The latter has an AI-powered algorithm pointing out areas that may indicate potential cerebral bleeding.In separate news, CGH also teamed up with Singapore's Integrated Health Information Systems last year to develop an AI predictive engine that analyses chest radiographs to determine whether a patient is likely to have mild or severe pneumonia.ON THE RECORD"Heavy bleeding following medical procedures is rare but when it occurs, it can be life-threatening. Monitoring at short intervals is highly manpower intensive but necessary," said Chionh Chang Yin, chief consultant of the Department of Renal Medicine at CGH."However, cheap viagra pills despite close monitoring, bleeding may still occur between these inspections.

BWATCH offers continuous monitoring, allowing the care team to focus on other patient-centric tasks,” he added..

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In low-and-middle-income Where to get ventolin countries (LMICs), there remain critical gaps in can women use viagra the quality of surgical care. Comparatively high rates of surgical can women use viagra adverse events occur and are likely highly preventable.1–3 There has been substantial focus on improving access to health services, including surgical care in LMICs, yet quality oversight and improvement practices remain limited in these settings.4 Over the past decade, surgical volume has doubled in the most resource-poor settings. Between 2004 and 2012, the annual number of operations jumped from 234 million to 313 million, with the biggest growth occurring in countries with the lowest amount of healthcare spending.5 6 This signals a profound shift. Whereas prior efforts were focused on s and maternal health, non-communicable can women use viagra diseases such as cancers and trauma are an increasing priority for LMIC health systems. With the rapid growth in surgical delivery, the quality and safety of care are critically important.

Poor outcomes and high morbidity breed mistrust, scepticism and fear among local populations, and thus hinder the mission of health systems to provide timely and essential services, especially risky ones like surgery.In this issue of the Journal, two articles shed some light on the challenges and opportunities for improving and maintaining high-quality surgical and can women use viagra anaesthetic services in LMICs. The first explores variation in the determinants of surgical quality across 10 hospitals in Tanzania that participated in the Safe Surgery 2020 (SS2020) programme.7 The investigators identified significant differences between what they termed high-performing and low-performing institutions. These included the perception and application of the SS2020 surgical quality improvement interventions meant to boost adherence to safety practices, enhance teamwork and communication, and improve completeness of can women use viagra documentation in patient records. These practices can women use viagra were aimed at reducing postsurgical s in hospitals implementing the intervention. The programme worked to change organisational culture, build capacity to deliver evidence-based practices in safe surgery and anaesthesia, and facilitate the sustainability of the first and second phases through in-person and virtual mentorship.The authors noted that the high-performing sites had a strong prior culture of teamwork, with references to surgery as a team effort, collective problem-solving and support of co-workers, as well as a flattened hierarchy with open communication.

These facilities used the Surgical Safety Checklist (SSC) as a tool to strengthen can women use viagra teamwork and communication. Lower performing sites gave more emphasis to individual learning than organisational learning, thought of the SSC as a means to improve outcomes rather than encourage teamwork, considered SS2020 as a programme for surgeons rather than for all members of the perioperative team and expressed higher levels of reluctance to engage in open communication because of hierarchy.The second article describes surgical service monitoring and quality control systems at district hospitals Malawi, Tanzania and Zambia.8 The authors investigated surgical surveillance at a facility level and the types of quality processes and controls in place to assess service capacity, volume, outcomes and adherence to standards. After evaluating can women use viagra 75 district hospitals, the authors noted a number of major challenges, including that data registry and recording formats were not standardised. In fact, over half of hospitals surveyed had two or more systems in place. Hospitals also lacked accountability mechanisms can women use viagra.

Of the 75 hospitals, only 43 created mortality reports for review, 11 conducted surgical audits of any kind and 22 used the SSC routinely despite numerous studies confirming its benefit to patient safety can women use viagra in these environments.Each study has its own limitations. In the article by Alidina et al, the grading used to classify high and low performers was subjectively set by the study team, the sample size of facilities was relatively small, and interviewee responses were potentially affected by recall and social desirability biases. Furthermore, high-performer hospitals were overwhelmingly from smaller-sized facilities, indicating a strong clustering effect can women use viagra. In the article by Clarke et al, self-reported information also introduces a potential for bias, there was limited interviewing of hospital administration and other stakeholders outside of perioperative providers, and the focus on district hospitals might miss more robust practices in urban and teaching hospitals.Although there have been proposals for standardised surgical and anaesthesia metrics to track service delivery and quality, there is not a firm consensus on minimum standards or an organising body to incentivise monitoring.9–12 Yet proper data collection using standardised and comparable metrics is essential for service planning, as the routine and appropriate monitoring of such information is critical for implementation of quality surgical services. As these two articles make clear, such processes are still rudimentary in can women use viagra many LMIC environments.

The challenges to improving them include a lack of properly developed registries, inappropriate formatting, technological barriers for centralised data recording and storage, absence of data interpretation and feedback, and gaps in planning mechanisms.13 These challenges are overwhelmingly due to lack of dedicated leadership in the oversight of surgical service provision and fundamental gaps in basic service management, without any proper linkage of data capture to future planning or improvement interventions. Without adequate and complete can women use viagra data, assessments of patient outcomes and safety process gap identification at the institutional level is impossible. Furthermore, strong management is critical for ensuring adherence to standards and clear standard operating procedures. While leadership training is the focus of much discussion, as it was in the article by Alidina, little has been done to elevate can women use viagra and promote management skills that are essential for efficient service provision. Work in Ghana, for example, has demonstrated that good management can women use viagra practices can avoid depletion of critical supplies14.

Yet even when service delivery increases, facility readiness and the practices that must accompany increased volume do not necessarily follow.15 16There are a number of solutions to these challenges. Hospital leaders need to emphasise quality as can women use viagra central to the hospital mission. Lessons from high-performing hospitals have demonstrated that a focus on quality by hospital leadership can raise the standards of care delivery, although under specific conditions that promote quality through accountability and transparency and with evidence from relatively small numbers of hospitals.13 Such efforts require a standardised approach to data collection and robust assessments of processes, such as compliance with critical standards of care (eg, prevention standards such as hand hygiene and antimicrobial stewardship). When implemented in a rigorous way in surgery, high-quality data and strong process adherence have tremendous beneficial effects.17 18Improvements in quality and safety also require infrastructure and a management team that sets targets for performance, benchmarks quality standards, allocates resources and assigns people with skill sets matched to clinical service needs to drive improvements.19 20 Good management practices have been correlated with improved outcomes and better compliance with known standards of care.21Unfortunately, studies from LMICs show substantial variability in the way in can women use viagra which quality of care is measured.22 Furthermore, there is a fundamental lack of appropriate guidelines and management protocols, and those that do exist are not easily implemented. Our experience indicates that integrating a proper monitoring and evaluation programme into institutional efforts to improve perioperative processes have powerful positive effects on outcomes.18 We have done this in our work through the use of process mapping, an exercise that takes a quality improvement team through the pathway of a care routine or a standard operating procedure in order to gain a complete understanding of the barriers to appropriate compliance.23 This type of process was developed for industry but has been applied in healthcare as a means of improving compliance by aligning tasks with specific process goals.

The work requires data-driven, quality-controlled can women use viagra surgical services structured in a manner that allow changes to be made to the care routine and associated processes. Assessing baseline data, understanding barriers to quality services and care, seeking local solutions, addressing knowledge gaps, standardising monitoring and rewarding can women use viagra improvements must all be integrated to achieve such change. Appropriate surgical monitoring and evaluation tools can help measure quantitative and qualitative improvements to surgical care in LMICs.24Like politics, all quality improvement is local, so a deep understanding of local context and circumstances is essential. As surgical and anaesthetic services continue to can women use viagra expand, hospital-based surgical programmes will need to engage more concertedly in research and quality improvement initiatives in order to decrease adverse outcomes and raise the quality and safety of surgical services in LMICs. As the authors of both articles note, however, these improvement mechanisms are not without substantial challenges, many will not be effective, and all require a more coordinated approach and a strengthening of management practices to ensure the quality and safety of care.Ethics statementsPatient consent for publicationNot required.In this issue we are presented with two novel and important studies in English primary care addressing the epidemiology of patient safety.

The first study, by Reeves and colleagues, retrospectively reviewed 2057 randomly selected consultations in 21 general practices can women use viagra to identify missed diagnostic opportunities, in order to estimate their incidence, origins and potential harms.1 They conclude that diagnostic errors occur in up to 4% of consultations, are multifactorial, and that 40% of them have the potential to result in moderate or severe patient harm. The second study recruited 12 randomly selected general practices and reviewed the case notes of an ‘enhanced’ sample of 14 407 patients with significant health problems.2 In this second study, Avery and colleagues were interested in actual harms that could be considered avoidable, in order to estimate their incidence and to quantify and classify the context from which they arose. They identified 74 cases of avoidable significant harm, a rate of 36/100 000 patient years, with diagnosis problems accounting for the majority (61%).Although the field of patient safety research goes can women use viagra back to the 1980s, much of it was initially focused on specialist care and hospital settings, where rates of adverse events as high as 10% were reported.3 4 In contrast, studies in primary care found that rates of adverse events were much lower, but the potential for harm, notably from prescribing errors, was significant.5 This led to developments such as PINCER, a pharmacist-led intervention to reduce clinically important medication errors that has since been widely adopted in England,6 and in the USA to a focus on preventing ‘Never Events’ or serious, preventable medical errors.7 More recently, the importance of diagnostic error in patient safety has come to the fore, with a landmark report from the US Institute of Medicine (IoM)8 and recognition that this aspect of patient safety is distinct from errors in the management of patients with a diagnosis and that it represents a global concern.9 10 The latter has been driven by early diagnosis being a policy focus in many high-income countries, particularly in relation to cancer, with misdiagnosis one of the most common reasons for malpractice claims11 and evidence that early cancer diagnosis leads to better outcomes.Diagnostic error was defined in the IoM report Improving Diagnosis in Healthcare as the ‘failure to make an accurate and timely explanation of the patient’s health problem, or to communicate that explanation to the patient’.8 The concept of ‘missed diagnostic opportunities’, proposed by Singh and colleagues and applied in the study by Reeves and colleagues, is one that works well for primary care, since it takes account of the evolving course of a patient’s presenting problem, sometimes over multiple consultations.12Preventable or avoidable harm is by definition attributable to medical error, although many errors do not lead to harm. Harm can also be a broad concept, ranging from transient anxiety through to death. Avery and colleagues have been particularly diligent in their definitions of avoidability and significant harm, deriving can women use viagra the latter from that provided by WHO,13 which in turn lies between the definitions of moderate and severe harm described by England’s National Patient Safety Agency and by Panesar and colleagues.14By drawing our attention to the extent to which errors and avoidable harms occur, these two studies also prompt us to consider ways in which we might take action to improve diagnostic safety in primary care.

One is to identify errors as soon as, or right after, they are made, which then provides an opportunity to forestall any ensuing harm or reduce can women use viagra its severity. Safety-netting is a well-established if ill-defined consultation technique where the patient is advised on the anticipated course of events and the action(s) to take if these do not follow within a specified timeframe.15 It is specifically advocated in English national guidance on management and referral of suspected cancer.16 A more systematic and technical approach is the use of e-triggers, signals of a likely error or adverse event, generated by the systematic mining of electronic patient data. These can can women use viagra prompt clinicians to the correct actions or can generate reminders when the correct actions are not performed in a timely way.17 Singh and others have also proposed the SaferDx e-Trigger Tool Framework for the future development of tools that monitor diagnostic errors and intervene for specific patients when needed.17Another way to take action to improve diagnostic safety is to use retrospective clinical record review to identify the circumstances and types of events that might threaten patient safety during the diagnostic process, in order to address these circumstances in the future. Examples include a Danish study that found ‘quality deviations’ in 30% of the 5711 patients presenting with symptoms subsequently found to be due to cancer,18 and an English national audit of 14 259 patients with cancer where GPs reported avoidable delays in 24% of the sample.19 ‘Quality deviations’ and other avoidable delays can potentially be prevented, but only with a strong professional culture that values identifying them in the first place. A culture can women use viagra of identifying and reflecting on safety incidents is well established in many countries where strong primary care systems pertain.

In the UK, significant event audit is widely practised and is part of the Royal College of General Practitioners’ patient safety toolkit. Changes in clinical practice or quality of care are often reported although not easily verified.20 However, qualitative analysis of multiple significant event audits has been used to identify opportunities for quality improvement in the diagnostic process for lung cancer.21 On the other hand, reporting of can women use viagra patient safety incidents to a central body, such as the National Reporting and Learning System in England has not been widely adopted in primary care, in contrast to secondary care, which accounts for more than 99% of patient safety incident reports. Incident reporting has also not generally been as successful as it could be in the USA, despite strong models of its importance for improvement in other fields, such as aviation.22These various approaches to identifying errors and harms that occur in primary care can all inform the design of safer systems and/or safer can women use viagra diagnosticians, to reduce the risk of error in the first place. By learning about which processes lead to errors, one can try to improve those processes and prevent errors occurring. In this way, e-triggers, for can women use viagra example, could provide the information needed for a healthcare system to identify targets for diagnostic safety, as suggested in the SaferDx framework.

For example, if triggers identified frequent failures in a particular healthcare system in the follow-up on abnormal test results, a system re-design could be put in place to prevent these. Alternatively, one can women use viagra might provide clinicians with tools that enhance their diagnostic capabilities. These could include better access to diagnostic tests or the provision of electronic clinical decision support systems. A recent systematic review confirmed can women use viagra that these have the capacity to improve diagnostic decision making for cancer in primary care.23 The two studies in this issue of the journal clearly describe the problems. Action is now needed to address them in a concerted and systematic way.Ethics statementsPatient consent for publicationNot required..

In low-and-middle-income countries (LMICs), there remain critical gaps cheap viagra pills in the quality of surgical care. Comparatively high rates of surgical adverse events occur and are likely highly preventable.1–3 There has been cheap viagra pills substantial focus on improving access to health services, including surgical care in LMICs, yet quality oversight and improvement practices remain limited in these settings.4 Over the past decade, surgical volume has doubled in the most resource-poor settings. Between 2004 and 2012, the annual number of operations jumped from 234 million to 313 million, with the biggest growth occurring in countries with the lowest amount of healthcare spending.5 6 This signals a profound shift. Whereas prior efforts were focused on s and maternal health, non-communicable diseases cheap viagra pills such as cancers and trauma are an increasing priority for LMIC health systems.

With the rapid growth in surgical delivery, the quality and safety of care are critically important. Poor outcomes and high morbidity breed mistrust, scepticism and fear among local populations, and thus hinder the mission of health systems to provide timely and essential services, especially risky ones like surgery.In this issue of the Journal, two articles shed some light on cheap viagra pills the challenges and opportunities for improving and maintaining high-quality surgical and anaesthetic services in LMICs. The first explores variation in the determinants of surgical quality across 10 hospitals in Tanzania that participated in the Safe Surgery 2020 (SS2020) programme.7 The investigators identified significant differences between what they termed high-performing and low-performing institutions. These included the perception and application of the cheap viagra pills SS2020 surgical quality improvement interventions meant to boost adherence to safety practices, enhance teamwork and communication, and improve completeness of documentation in patient records.

These practices were aimed cheap viagra pills at reducing postsurgical s in hospitals implementing the intervention. The programme worked to change organisational culture, build capacity to deliver evidence-based practices in safe surgery and anaesthesia, and facilitate the sustainability of the first and second phases through in-person and virtual mentorship.The authors noted that the high-performing sites had a strong prior culture of teamwork, with references to surgery as a team effort, collective problem-solving and support of co-workers, as well as a flattened hierarchy with open communication. These facilities used the Surgical Safety Checklist (SSC) as a tool cheap viagra pills to strengthen teamwork and communication. Lower performing sites gave more emphasis to individual learning than organisational learning, thought of the SSC as a means to improve outcomes rather than encourage teamwork, considered SS2020 as a programme for surgeons rather than for all members of the perioperative team and expressed higher levels of reluctance to engage in open communication because of hierarchy.The second article describes surgical service monitoring and quality control systems at district hospitals Malawi, Tanzania and Zambia.8 The authors investigated surgical surveillance at a facility level and the types of quality processes and controls in place to assess service capacity, volume, outcomes and adherence to standards.

After evaluating 75 district cheap viagra pills hospitals, the authors noted a number of major challenges, including that data registry and recording formats were not standardised. In fact, over half of hospitals surveyed had two or more systems in place. Hospitals also cheap viagra pills lacked accountability mechanisms. Of the 75 hospitals, only 43 created mortality reports for review, 11 conducted surgical audits of any kind and 22 used the SSC routinely despite numerous studies confirming its benefit to patient safety in these cheap viagra pills environments.Each study has its own limitations.

In the article by Alidina et al, the grading used to classify high and low performers was subjectively set by the study team, the sample size of facilities was relatively small, and interviewee responses were potentially affected by recall and social desirability biases. Furthermore, high-performer hospitals cheap viagra pills were overwhelmingly from smaller-sized facilities, indicating a strong clustering effect. In the article by Clarke et al, self-reported information also introduces a potential for bias, there was limited interviewing of hospital administration and other stakeholders outside of perioperative providers, and the focus on district hospitals might miss more robust practices in urban and teaching hospitals.Although there have been proposals for standardised surgical and anaesthesia metrics to track service delivery and quality, there is not a firm consensus on minimum standards or an organising body to incentivise monitoring.9–12 Yet proper data collection using standardised and comparable metrics is essential for service planning, as the routine and appropriate monitoring of such information is critical for implementation of quality surgical services. As these two cheap viagra pills articles make clear, such processes are still rudimentary in many LMIC environments.

The challenges to improving them include a lack of properly developed registries, inappropriate formatting, technological barriers for centralised data recording and storage, absence of data interpretation and feedback, and gaps in planning mechanisms.13 These challenges are overwhelmingly due to lack of dedicated leadership in the oversight of surgical service provision and fundamental gaps in basic service management, without any proper linkage of data capture to future planning or improvement interventions. Without adequate and complete data, assessments of patient outcomes and safety process gap identification at the cheap viagra pills institutional level is impossible. Furthermore, strong management is critical for ensuring adherence to standards and clear standard operating procedures. While leadership training is the focus of much discussion, as it was in the article by Alidina, little has been cheap viagra pills done to elevate and promote management skills that are essential for efficient service provision.

Work in Ghana, for example, has demonstrated that good management practices can cheap viagra pills avoid depletion of critical supplies14. Yet even when service delivery increases, facility readiness and the practices that must accompany increased volume do not necessarily follow.15 16There are a number of solutions to these challenges. Hospital leaders need to emphasise quality as central to cheap viagra pills the hospital mission. Lessons from high-performing hospitals have demonstrated that a focus on quality by hospital leadership can raise the standards of care delivery, although under specific conditions that promote quality through accountability and transparency and with evidence from relatively small numbers of hospitals.13 Such efforts require a standardised approach to data collection and robust assessments of processes, such as compliance with critical standards of care (eg, prevention standards such as hand hygiene and antimicrobial stewardship).

When implemented in a rigorous way in surgery, high-quality data and strong process adherence have tremendous beneficial effects.17 18Improvements in quality and safety also require infrastructure and a management team that sets targets for performance, benchmarks quality standards, allocates resources and assigns people with skill sets matched to clinical service needs to drive improvements.19 20 Good management practices have been correlated with improved outcomes and better compliance with known standards of care.21Unfortunately, studies from LMICs show substantial variability in the way in which quality of care is measured.22 cheap viagra pills Furthermore, there is a fundamental lack of appropriate guidelines and management protocols, and those that do exist are not easily implemented. Our experience indicates that integrating a proper monitoring and evaluation programme into institutional efforts to improve perioperative processes have powerful positive effects on outcomes.18 We have done this in our work through the use of process mapping, an exercise that takes a quality improvement team through the pathway of a care routine or a standard operating procedure in order to gain a complete understanding of the barriers to appropriate compliance.23 This type of process was developed for industry but has been applied in healthcare as a means of improving compliance by aligning tasks with specific process goals. The work requires data-driven, quality-controlled surgical services structured in a manner that allow changes to be cheap viagra pills made to the care routine and associated processes. Assessing baseline data, understanding barriers to quality services and care, seeking local solutions, addressing knowledge gaps, standardising monitoring and rewarding improvements must all be integrated to cheap viagra pills achieve such change.

Appropriate surgical monitoring and evaluation tools can help measure quantitative and qualitative improvements to surgical care in LMICs.24Like politics, all quality improvement is local, so a deep understanding of local context and circumstances is essential. As surgical and anaesthetic services continue to expand, hospital-based surgical programmes will need to engage more concertedly in research and quality improvement initiatives in order to decrease adverse outcomes and raise the quality cheap viagra pills and safety of surgical services in LMICs. As the authors of both articles note, however, these improvement mechanisms are not without substantial challenges, many will not be effective, and all require a more coordinated approach and a strengthening of management practices to ensure the quality and safety of care.Ethics statementsPatient consent for publicationNot required.In this issue we are presented with two novel and important studies in English primary care addressing the epidemiology of patient safety. The first study, by Reeves and colleagues, retrospectively reviewed 2057 randomly selected consultations in 21 general practices to identify missed diagnostic opportunities, in order to estimate their incidence, origins and potential harms.1 They conclude that diagnostic cheap viagra pills errors occur in up to 4% of consultations, are multifactorial, and that 40% of them have the potential to result in moderate or severe patient harm.

The second study recruited 12 randomly selected general practices and reviewed the case notes of an ‘enhanced’ sample of 14 407 patients with significant health problems.2 In this second study, Avery and colleagues were interested in actual harms that could be considered avoidable, in order to estimate their incidence and to quantify and classify the context from which they arose. They identified 74 cases of avoidable significant harm, a rate of 36/100 000 patient years, with diagnosis problems accounting for the majority (61%).Although the field of patient safety research goes back to the 1980s, much of it was initially focused on specialist care and hospital settings, where rates of adverse events as high as 10% were reported.3 4 In contrast, studies in primary care found that rates of adverse events were much lower, but the potential for harm, notably from prescribing errors, was significant.5 This led to developments such as PINCER, a pharmacist-led intervention to reduce clinically important medication errors that has since been widely adopted in England,6 and in the USA to a focus on preventing ‘Never Events’ or serious, preventable medical errors.7 More recently, the importance of diagnostic error in patient safety has come to the fore, with a landmark report from the US Institute of Medicine (IoM)8 and recognition that this aspect of patient safety is distinct from errors in the management of patients with a diagnosis and that it represents a global concern.9 10 The latter has been driven by early diagnosis being a policy focus in many high-income countries, particularly in relation to cancer, with misdiagnosis one of the most common reasons for cheap viagra pills malpractice claims11 and evidence that early cancer diagnosis leads to better outcomes.Diagnostic error was defined in the IoM report Improving Diagnosis in Healthcare as the ‘failure to make an accurate and timely explanation of the patient’s health problem, or to communicate that explanation to the patient’.8 The concept of ‘missed diagnostic opportunities’, proposed by Singh and colleagues and applied in the study by Reeves and colleagues, is one that works well for primary care, since it takes account of the evolving course of a patient’s presenting problem, sometimes over multiple consultations.12Preventable or avoidable harm is by definition attributable to medical error, although many errors do not lead to harm. Harm can also be a broad concept, ranging from transient anxiety through to death. Avery and colleagues have been particularly diligent in their definitions of avoidability and significant harm, deriving the latter from that provided by WHO,13 which in turn lies between the definitions of moderate and severe harm described by England’s National Patient Safety Agency and by Panesar and colleagues.14By drawing our attention to the extent to which errors and avoidable cheap viagra pills harms occur, these two studies also prompt us to consider ways in which we might take action to improve diagnostic safety in primary care.

One is to identify errors as soon as, or cheap viagra pills right after, they are made, which then provides an opportunity to forestall any ensuing harm or reduce its severity. Safety-netting is a well-established if ill-defined consultation technique where the patient is advised on the anticipated course of events and the action(s) to take if these do not follow within a specified timeframe.15 It is specifically advocated in English national guidance on management and referral of suspected cancer.16 A more systematic and technical approach is the use of e-triggers, signals of a likely error or adverse event, generated by the systematic mining of electronic patient data. These can prompt clinicians to the correct actions or can generate reminders when the correct actions are not performed in a timely way.17 Singh and others have also proposed the SaferDx e-Trigger Tool Framework for the future development of tools that monitor diagnostic errors and intervene for specific patients when needed.17Another way to take action to cheap viagra pills improve diagnostic safety is to use retrospective clinical record review to identify the circumstances and types of events that might threaten patient safety during the diagnostic process, in order to address these circumstances in the future. Examples include a Danish study that found ‘quality deviations’ in 30% of the 5711 patients presenting with symptoms subsequently found to be due to cancer,18 and an English national audit of 14 259 patients with cancer where GPs reported avoidable delays in 24% of the sample.19 ‘Quality deviations’ and other avoidable delays can potentially be prevented, but only with a strong professional culture that values identifying them in the first place.

A culture of identifying and reflecting cheap viagra pills on safety incidents is well established in many countries where strong primary care systems pertain. In the UK, significant event audit is widely practised and is part of the Royal College of General Practitioners’ patient safety toolkit. Changes in clinical practice or quality of care are often reported although not easily verified.20 However, qualitative analysis of multiple significant event audits has been used to identify opportunities for quality improvement in the diagnostic process for lung cancer.21 On the other hand, reporting of patient safety incidents to a central cheap viagra pills body, such as the National Reporting and Learning System in England has not been widely adopted in primary care, in contrast to secondary care, which accounts for more than 99% of patient safety incident reports. Incident reporting has also not generally cheap viagra pills been as successful as it could be in the USA, despite strong models of its importance for improvement in other fields, such as aviation.22These various approaches to identifying errors and harms that occur in primary care can all inform the design of safer systems and/or safer diagnosticians, to reduce the risk of error in the first place.

By learning about which processes lead to errors, one can try to improve those processes and prevent errors occurring. In this way, e-triggers, for example, could provide the information needed for a healthcare system cheap viagra pills to identify targets for diagnostic safety, as suggested in the SaferDx framework. For example, if triggers identified frequent failures in a particular healthcare system in the follow-up on abnormal test results, a system re-design could be put in place to prevent these. Alternatively, one cheap viagra pills might provide clinicians with tools that enhance their diagnostic capabilities.

These could include better access to diagnostic tests or the provision of electronic clinical decision support systems. A recent systematic review confirmed that these have cheap viagra pills the capacity to improve diagnostic decision making for cancer in primary care.23 The two studies in this issue of the journal clearly describe the problems. Action is now needed to address them in a concerted and systematic way.Ethics statementsPatient consent for publicationNot required..

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