ASSERT - Doctoral Theses

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    Technology-enhanced learning and proficiency based progression to investigate and mitigate ‘wrong blood in tube (WBIT)s’ in our hospitals; can we improve patient safety and reduce resource wastage?
    (University College Cork, 2020-02) O'Herlihy, Nóirín; Cahill, Mary; Gallagher, Anthony G.; Khashan, Ali
    Background: Blood sampling errors are a frequent occurrence in healthcare. Wrong Blood in Tube (WBIT) errors are a serious blood sampling error that occur when the blood in the tube is not that of the person on the tube label. WBIT can lead to serious consequences including ABO incompatible blood transfusion with a risk of mortality, inappropriate diagnosis and inappropriate treatment of patients. Blood sampling errors are recognised globally. In Cork University Hospital (CUH), to maintain INAB accreditation at the laboratory, tracking and trending of blood sampling errors including WBIT is required. Since 2010, a steady incidence of WBIT errors was identified with a peak in incidence with the intake of new doctors to the hospital each July. Teaching by the medical school on phlebotomy, awareness campaigns and efforts by the haemovigilance team in the hospital failed to reduce the incidence of WBIT at CUH. Aim: The aim of this study is to develop a novel proficiency-based progression (PBP) training programme in phlebotomy, specific for CUH to reduce the incidence of blood sampling errors, especially WBIT. Objective: 1. Engage with stakeholders in the process of phlebotomy at CUH and with experts in the field of PBP to develop metrics to define the procedure of phlebotomy at CUH. 2. Develop a PBP training programme in phlebotomy, specifically for interns commencing work in the hospital consisting of 1) Online module 2) Face-to-face training on a simulated ward 3) Mentorship of the doctors performing phlebotomy on real patients according to the metric. 3. Perform a controlled clinical trial to determine if the introduction of the training programme resulted in a reduction in blood sampling errors including WBITs in comparison to blood sampling errors in a retrospective control group in 2016 before the study commenced. 4. An observational study took place on the wards to identify the barriers and facilitators to implementation of the instructions provided in the metric. Findings: A validated metric for performing phlebotomy at CUH was developed and used to develop a PBP training programme in phlebotomy. In the haematology laboratory, 43 interns in 2016 control group had an error rate of 2.4% compared to 44 interns in the 2017 pilot study, who had an error rate of 1.2% (OR=0.50, 95% CI 0.36-0.70 p-value<0.01). 46 interns in the 2018 follow-on group had an error rate 1.9% (OR=0.89, 95% CI 0.65-1.21 p-value=0.46). There were three WBITs in 2016 and 2017 and five WBITs in 2018. In the transfusion laboratory, there was a reduction in overall error rates with the introduction PBP training, but the reduction was not statistically significant. There was no blood transfusion WBIT in 2016, there was one blood transfusion WBIT in 2017, and no blood transfusion WBIT in 2018. During observations of interns performing phlebotomy on the wards, phlebotomy was found to take a median of 20 minutes (minimum 10 minutes, maximum 45 minutes). There were often poor practices promoted by difficulty locating patients, task disturbance, poor requesting practices acting as a barrier to positive patient identification, patients not wearing wristbands to identify them, and environmental factors such as stress and lack of safety culture. Conclusion: The effect of the PBP training programme in phlebotomy on the primary outcome WBIT was difficult to determine due to the rare occurrence of WBIT. There was not sufficient sample size to reach a statistically significant conclusion. Blood sampling errors appeared to be improving, but the effect size was smaller in the second year of the study possibly due to a reduction in the number of tutors available per group on the simulation ward and confounding. Observation of phlebotomy on the wards identified numerous barriers to key elements including positive patient identification, poor access to essential equipment and task prioritisation by busy doctors. Introducing bedside label printers and promoting a culture of safety are critical factors to improve the safety and reduce WBIT errors.
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    Assessment of a novel computer aided learning tool in neuroanatomy education
    (University College Cork, 2018) Javaid, Muhammad Asim; Toulouse, André; Cryan, John F.; Schellekens, Harriët
    Impaired understanding of intricate neuroanatomical concepts and structural inter-relationships has been associated with a fear of managing neurology patients, called neurophobia, among medical trainees. As technology advances, the role of e-learning pedagogies becomes more important to supplement the traditional dissection / prosection and lecture-based pedagogies for teaching neuroanatomy to undergraduate students. However, despite the availability of a myriad of e-learning resources, the neuro (-anatomy-) phobia – neurophobia nexus prevails. The focus of the PhD was to investigate the difficulties associated with learning neuroanatomy and to develop and assess the efficacy of a novel e-learning tool for teaching neuroanatomy, in the context of the strengths and pitfalls of the currently available e-learning resources. Firstly, we sought to provide direct evidence of the medical and health science students’ perception regarding specific challenges associated with learning neuroanatomy. The initial results showed that neuroanatomy is perceived as a more difficult subject compared to other anatomy topics, with spinal pathways being the most challenging to learn. Participants believed that computer assisted learning and online resources could enhance neuroanatomy understanding and decrease their neurophobia. Next, in the context of the significance of e-learning for supplementing traditional pedagogies, we identified features of neuroanatomy web-resources that were valued by students and educators with regards to learning neuroanatomy of the spinal pathways. Participants identified strengths and weaknesses of existing neuroanatomy web-resources and ranked one resource above the others in terms of information delivery and integration of clinical, physiological and medical imaging correlates. This provides a novel user perspective on the influence of specific elements of neuroanatomy web-resources to improve instructional design and enhance learner performance. Finally, considering the data acquired from students and educators, a novel, interactive, neuroanatomy learning e-resource was developed to support teaching of the neuroanatomy of the spinal pathways. The instructional design included a discussion of the clinical interpretation of basic neuroanatomical facts to aid in neurological localization. The e-learning tool was assessed and evaluated by undergraduate medical and neuroscience students using neuroanatomy knowledge quizzes and Likert-scale perception questionnaires and compared to the previously identified best-ranked neuroanatomy e-resource. Participants’ opinion regarding the usefulness of various components of the tools was also gauged. The results showed that usage of the UCC e-resource led to a significant increase in participants’ knowledge of the neuroanatomy of the spinal pathways compared to students’ who did not use e-resources. Moreover, the participants reported a greater interest in learning neuroanatomy with the novel tool, showing a greater appreciation for it while learning clinical neurological correlates compared to those using the best available e-resource identified earlier. In summary, the prevailing problem of neurophobia could be addressed by enhancing student-interest. Technological e-learning pedagogies, with intelligently designed interactive user-interface and clinical correlation of basic neuroanatomical facts can play a pivotal role in helping students learn neuroanatomy and breaking the nexus between neuro (-anatomy-) phobia and neurophobia.