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There is a multiplicity of signals and evidence of avoidable harm and lack of quality in health care. In parallel the medical results often are excellent. Better understanding and knowledge is needed regarding how different factors interact in a complex way resulting in both good and bad outcomes. That would improve the possibilities for better patient safety as well as even better medical results. Evaluation and follow-up of safety and results always in itself influences the processes. Evaluation has to be done in a balanced and well elaborated way to provide a basis for wise governance and improvement. There is need of a leadership that keeps focus on safety and quality even when there is a competition with economy and other challenges.

Background: The vast majority of patient safety research has focused on somatic health care. Although specific adverse events (AEs) within psychiatric healthcare have been explored, the overall level and nature of AEs is sparsely investigated., Methods: Cohort study using a retrospective record review based on a two-step trigger tool methodology in the charts of randomly selected patients 18 years or older admitted to the psychiatric acute care departments in all Swedish regions from January 1 to June 30, 2017. Hospital care together with corresponding outpatient care were reviewed as a continuum, over a maximum of 3 months. The AEs were categorised according to type, severity and preventability., Results: In total, the medical records of 2552 patients were reviewed. Among the patients, 50.4% were women and 49.6% were men. The median (range) age was 44 (18-97) years for women and 44.5 (18-93) years for men. In 438 of the reviewed records, 720 AEs were identified, corresponding to the AEs identified in 17.2% [95% confidence interval, 15.7-18.6] of the records. The majority of AEs resulted in less or moderate harm, and 46.2% were considered preventable. Prolonged disease progression and deliberate self-harm were the most common types of AEs. AEs were significantly more common in women (21.5%) than in men (12.7%) but showed no difference between age groups. Severe or catastrophic harm was found in 2.3% of the records, and the majority affected were women (61%). Triggers pointing at deficient quality of care were found in 78% of the records, with the absence of a treatment plan being the most common., Conclusions: AEs are common in psychiatric care. Aside from further patient safety work, systematic interventions are also warranted to improve the quality of psychiatric care.

Purpose This paper investigates the prospects and difficulties of multi-professional teamwork in human services from a professional identity perspective. The purpose of this paper is to explore the mutual interplay between professional identity formation and team activities. Design/methodology/approach This is a process study of two cases of multi-professional teamwork in family care. Data were collected through in-depth interviews with team members and managers. The analysis follows a stepwise approach alternating between the individual and team levels. Findings In showing the mutual interplay between teamwork processes and individual identity formation, the study contributes knowledge on professional identity formation of mature professionals; in particular showing how unique individual identification processes have different consequences for multi-professional team activities. Further, alternative shapes of interplay between individual identity formation and team-level processes are identified. Research limitations/implications Despite the fact that the sample is small and that collaboration intensity was relatively low, the paper succeeds in conceptualising the links between professional identity formation and multi-professional teamwork. Practical implications In managing multi-professional teams, team composition and the team's early developments seem determining for whether the team will reach its collaborative intentions. Originality/value This paper is original in its exploration of the ongoing interplay between individual identity formation and multi-professional team endeavours. Further, the paper contributes knowledge on mature professionals' identity formation, particularly concerning individual variation within and between professional groups.

Objectives: To describe the implementation of a trigger tool in Sweden and present the national incidence of adverse events (AEs) over a 4-year period during which an ongoing national patient safety initiative was terminated., Design: Cohort study using retrospective record review based on a trigger tool methodology., Setting and Participants: Patients ≥18 years admitted to all somatic acute care hospitals in Sweden from 2013 to 2016 were randomised into the study., Primary and Secondary Outcome Measures: Primary outcome measure was the incidence of AEs, and secondary measures were type of injury, severity of harm, preventability of AEs, estimated healthcare cost of AEs and incidence of AEs in patients cared for in another type of unit than the one specialised for their medical needs ('off-site')., Results: In a review of 64 917 admissions, the average AE rates in 2014 (11.6%), 2015 (10.9%) and 2016 (11.4%) were significantly lower than in 2013 (13.1%). The decrease in the AE rates was seen in different age groups, in both genders and for preventable and non-preventable AEs. The decrease comprised only the least severe AEs. The types of AEs that decreased were hospital-acquired infections, urinary bladder distention and compromised vital signs. Patients cared for 'off-site' had 84% more preventable AEs than patients cared for in the appropriate units. The cost of increased length of stay associated with preventable AEs corresponded to 13%-14% of the total cost of somatic hospital care in Sweden., Conclusions: The rate of AEs in Swedish somatic hospitals has decreased from 2013 to 2016. Retrospective record review can be used to monitor patient safety over time, to assess the effects of national patient safety interventions and analyse challenges to patient safety such as the increasing care of patients 'off-site'. It was found that the economic burden of preventable AEs is high., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: In this paper, we explore similarities and differences in hospital adverse event (AE) rates between Norway and Sweden by reviewing medical records with the Global Trigger Tool (GTT)., Design: All acute care hospitals in both countries performed medical record reviews, except one in Norway. Records were randomly selected from all eligible admissions in 2013. Eligible admissions were patients 18 years of age or older, undergoing care with an in-hospital stay of at least 24 hours, excluding psychiatric and care and rehabilitation. Reviews were done according to GTT methodology., Setting: Similar contexts for healthcare and similar socioeconomic and demographic characteristics have inspired the Nordic countries to exchange experiences from measuring and monitoring quality and patient safety in healthcare. The co-operation has promoted the use of GTT to monitor national and local rates of AEs in hospital care., Participants: 10 986 medical records were reviewed in Norway and 19 141 medical records in Sweden., Results: No significant difference between overall AE rates was found between the two countries. The rate was 13.0% (95% CI 11.7% to 14.3%) in Norway and 14.4% (95% CI 12.6% to 16.3%) in Sweden. There were significantly higher AE rates of surgical complications in Norwegian hospitals compared with Swedish hospitals. Swedish hospitals had significantly higher rates of pressure ulcers, falls and 'other' AEs. Among more severe AEs, Norwegian hospitals had significantly higher rates of surgical complications than Swedish hospitals. Swedish hospitals had significantly higher rates of postpartum AEs., Conclusions: The level of patient safety in acute care hospitals, as assessed by GTT, was essentially the same in both countries. The differences between the countries in the rates of several types of AEs provide new incentives for Norwegian and Swedish governing bodies to address patient safety issues., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients., Methods: Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children's hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units., Results: Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1-27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1-22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0-176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers., Conclusions: AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.

Aim: The aim of this project was to establish the importance of a pharmacist in the health-care team in improving drug use in an oncology ward in the Department of Oncology, Karolinska University Hospital, Stockholm, Sweden., Methods and Patients: The pharmacist participated in the medical round in the mornings and worked as a member of the health-care team. Drug-related problems (DRPs) were identified by drug chart reviews based on data from medical files, laboratory tests and interviews with patients and/or relatives. A questionnaire to physicians and nurses was used to evaluate their experiences of the pharmacist's contribution to the oncology ward., Results: In total, 114 DRPs were identified in 58 patients. For each DRP, the pharmacist gave proposals for solutions. Sixty-eight suggestions out of 114 (59.6%) were implemented by the physician. Two suggestions (1.8%) were partly followed. For 32 suggestions (28.0%) it was unclear if they had caused any change in medication. Twelve suggestions (10.5%) were not followed. Most of the physicians and nurses acknowledged the pharmacist's contribution to improved drug use in the ward., Conclusion: A pharmacist can improve drug use in an oncology ward as a member of the health-care team. The pharmacist contributes with a systematic focus on the patient from a drug perspective.

The present study prospectively investigated changes in patient satisfaction at an outpatient clinic for patients with breast cancer. Consecutive patients were asked to anonymously complete a questionnaire after their medical examination. The questionnaire consisted of 12 multiple-choice items concerning waiting time, interpersonal skills of physician and nurse, continuity of care, length of medical visit, communication and expectations. Finally, patients were asked for suggestions for improvements at the clinic in an open-ended question. The first measurement was conducted in 2000/2001 and the last in 2004, and between the two points of assessments efforts to develop care were introduced. Statistically significant improvements were found in eight of the 12 items: waiting time, length of medical visit, information, expectations and continuity of care. In conclusion, the questionnaire captured positive changes in patient satisfaction between the two measurements. Further changes for the better were still requested concerning continuity of care despite reported improvement.

A prospective survey of radiotherapy practice in Sweden was conducted during 12 weeks in the autumn of 2001. All hospitals that provided radiotherapy participated, and all patients who started radiotherapy during the study period were included. The final patient sample comprised 5,105 treatments given to 4,171 patients. The results were compared with those of a similar survey conducted in 1992, and the following conclusions were drawn: A substantial increase in the use of radiotherapy was noted; The estimated proportion of cancer cases receiving radiotherapy (compared to the incident number of cases) had increased from 32% in 1992 to 47%; The proportion of cancer patients receiving radiotherapy was estimated at between 37 and 46%; 54% of treatments were given with curative intent, a small increase since 1992; The difference between regional and county departments for proportion of treatments with curative intent had diminished; Treatments with curative intent used a higher proportion of resources measured in terms of fractions; The proportion of palliative treatment was slightly lower than in 1992, but the absolute number of treatments had increased by more than 20%; No improvement in participation in clinical trials was noted; Treatments given with curative intent were more complex with more fields; Hyperfractionation was used, mainly in treatments of cancers of the head and neck, lung, and bladder; The use of brachytherapy for non-gynaecological malignancies had increased dramatically; Treatment of bone metastases with a single or few fractions was used much more frequently; Dose planning and patient set-up showed a high standard but quality control of dosimetry of given treatment did not fully comply with Swedish and European recommendations; The treatment devices seem to be used more efficiently.

A systematic assessment of radiotherapy for cancer was conducted by The Swedish Council on Technology Assessment in Health Care (SBU) and published in 1996. The assessment reviewed the scientific literature up to 1993 on the use of radiotherapy in the treatment of solid tumours, and estimated the costs associated with radiotherapy. It also described the current practise of radiotherapy in Sweden 1992 and compared practise with scientific knowledge. The SBU has now conducted a follow-up study on radiotherapy for cancer, including a review of the scientific literature from 1994 and a prospective survey of radiotherapy practise in Sweden 2001. The following conclusions were drawn: The role of radiotherapy as an important form of treatment for cancer with both curative and palliative intent has been further confirmed. The use of radiotherapy in Sweden has increased and is now at the internationally recommended level. Radiotherapy in Sweden is mostly given in accordance with the scientific evidence but may still be underutilized in certain situations. The resources for radiotherapy are being utilized more efficiently. The costs of radiotherapy are still 5% of the total cost of cancer care, while the cost of an individual treatment (fraction) has decreased. The need for radiotherapy capacity will increase. In addition, half of the treatment equipment will have to be replaced in the next few years.

A systematic assessment of radiotherapy for cancer was conducted by The Swedish Council on Technology Assessment in Health Care (SBU) in 2001. The assessment included a review of radiotherapy techniques in current use in Sweden. The following conclusions were drawn: Radiotherapy demands adequate knowledge of diagnostic methods, anatomy, cancer biology and of the physical and biological properties of ionizing radiation. Well-functioning teamwork on the part of the oncologist, medical physicist and oncology nurse is important. Radiotherapy has a high degree of technical sophistication, including the use of computers, which necessitates expert technical support. Technical development is rapid, and since the previous report, multileaf collimators and electronic portal imaging have been introduced in the clinical routine. The use of brachytherapy for treatment of non-gynaecological malignancies is rapidly increasing. The need for quality assurance in all steps of the radiotherapy procedure is stressed. A critical review of the literature on intraoperative radiotherapy is also included as an Appendix.

Clinical (Dimery and Hong, J Nat Cancer Inst 1993; 85: 95- 111) and experimental studies (Scanlon et al., Proc Natl Acad Sci USA 1986; 83: 8923-5; Lewin et al., In Vivo 1990; 4: 277-82) have indicated an increased cytotoxic effect, when cisplatin (CDDP) is combined with 5-fluorouracil (5-FU). Addition of 5-FU abolishes the G2-arrest induced by CDDP (Lewin et al., In Vivo 1990; 4: 277-82; Nylén et al., Acta Oncol 1996; 35: 229 35). The mechanism for the synergy is unclear. Activation of p34cdc2 is necessary for progression from G2 to mitosis (Lewin et al., Anti-Cancer Drugs 1995; 6: 465-70). The aim was to study p34cdc2, cdc25C and weel after treatment of mammalian tumour cells in vivo with CDDP as single agent or in combination with 5-FU. CDDP prevented activation of p34cdc2 by keeping cdc25C inactive and weel active. Addition of 5-FU to CDDP decreased the expression of weel and promoted cdc25C-activation. p34cdc2 was dephosphorylated by cdc25C and activated. Alterations in activity of cdc25C and weel after drug combination were due to changes in the protein amount, rather than to changes in the phosphorylation degree.

The effects on incorporation into DNA of the deoxyribonucleotides dCTP and dTTP and the DNA synthesis rate after treatment with cisplatin (CDDP), 5-fluorouracil (5-FU) or a combination of CDDP and 5-FU were studied in ascites sarcoma (Bp8) growing in mice. Single administration of CDDP gave an early (1 h) transient increase in the DNA-synthesis followed by a decrease. 5-FU as single agent did increase the rate of DNA synthesis after 6 h with a maximum at 10 h. The combination of CDDP and 5-FU markedly increased the rate of DNA synthesis up to 6 h as compared to single drug treatment. Although the dCTP pool increased after combined treatment, while the dTTP pool was unchanged, no alterations in the proportions of dTTP and dCTP incorporated into DNA could be detected. Hence, misincorporation of pyrimidines is not the mechanism for the synergistic effect of the combination of CDDP and 5-FU.

Metastases in the choroid of the eye are frequent in patients with disseminated malignancy. We here report the results using the precision radiotherapy technique described by Schipper et al. to treat 14 of 17 consecutive patients (21 eyes) with symptoms from such metastases. A beam defining collimator was used and a lateral field was given with the treated eye individually fixed. Varying fractionations and doses were used. The biologically effective dose for early effects (BED3) was 47 to 90 Gy and for late effects (BED10) 28 to 59 Gy. In 14 eyes (82%) the metastases regressed completely. The visual acuity was stabilized or improved in all patients and none needed local surgery. Three patients developed signs of radiation retinopathy, but only in one case the visual function was compromised. With this standardized technique no individualized dose planning was needed, the risk of radiation cataract was minimized and a dry eye avoided.

L-asparaginase was immobilized under aseptic conditions in spherical microparticles of polyacrylamide. To avoid direct contact between blood and enzyme, we have applied the immobilized L-asparaginase in microparticles on the outer surface of the capillary fibers of a hemofilter. The hemofilters were very efficient in the transformation of L-asparagine to L-aspartic acid, both in vitro and in vivo. L-Asparagine in buffer (50 microM in 5 liters) was converted to L-aspartic acid within 60 min after circulation through a hemofilter containing 2000 I.U. of L-asparaginase. Circulating L-asparagine in healthy sheep (about 40-50 microM was reduced to low levels after 2 to 3 hr of perfusion with a unit containing 2000 I.U. of L-asparaginase. The reduction persisted for 3 to 4 hr after terminated treatment. Repeated, extracorporeal treatments in sheep showed that the L-asparagine decrease induced an increased resynthesis of L-asparagine, probably due to the action of the L-asparagine synthetase.