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14\cf0\f0\charscalex100 {326}\par\column\pard\li0\ri0\sl-213\slmult0 \fs22\cf0\f
0\charscalex100 {COMMENTARIES}\par\pard\sect\sectd\sbknone\cols3\colno1\colw3973
\colsr-0\colno2\colw3186\colsr-0\colno3\colw4280\pard\li786\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li786\ri0\sl-266\slmult0 \fs16\cf0\f0\charscalex100 {that coul
d do more to prevent death and}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\c
harscalex100 {other serious non-fatal events. The pros-}\par\pard\li786\ri0\sl-2
00\slmult0 \fs14\cf0\f0\charscalex100 {pect of managing performance in pri-}\par
\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {mary care to improve
key outcomes is}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {a
ttractive but speculative; more evidence}\par\pard\li786\ri0\sl-200\slmult0 \fs1
4\cf0\f0\charscalex100 {about the sensitivity of monitoring and}\par\pard\li786\
ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {its feasibility in routine use is
required.}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {Nevert
heless, there is an important les-}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\
f0\charscalex100 {son for all with an interest in safety and}\par\pard\li786\ri0
\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {quality improvement\uc1\u8212Xalways
monitor}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {key outc
omes. If you don\uc1\u8217Xt, you won\uc1\u8217Xt}\par\pard\li786\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li786\ri0\sl
-373\slmult0 \fs18\cf0\f0\charscalex100 {Ethnography in health care}\par\column\
pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs16\cf0\
f0\charscalex100 {know when the outcomes are poor. Why}\par\pard\li0\ri0\sl-200\
slmult0 \fs16\cf0\f0\charscalex100 {then should your patients trust you?}\par\pa
rd\li0\ri0\sl-266\slmult0 \fs14\cf0\f0\charscalex100 {Qual Saf Health Care }\fs1
4\cf0\f0\charscalex100 {2003;}\fs14\cf0\f0\charscalex100 {12}\fs14\cf0\f0\charsc
alex100 {:325\uc1\u8211X326}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\ch
arscalex100 {. . . . . . . . . . . . . . . . . . . . .}\par\pard\li0\ri0\sl-240\
slmult0 \fs16\cf0\f0\charscalex100 {Author\uc1\u8217Xs affiliation}\par\pard\li0
\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {R Baker,}{ }\fs12\cf0\f0\charsca
lex100 {Director, University of Leicester School}\par\pard\li0\ri0\sl-160\slmult
0 \fs14\cf0\f0\charscalex100 {of Medicine, Clinical Governance Research and}\par
\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {Development Unit, Facul
ty of Medicine, Leicester}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscal
ex100 {LE5 4PW, UK; rb14@le.ac.uk}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\cf0\f0\charscalex100 {REFERENCES}\par\
pard\li160\ri0\sl-266\slmult0 \*\tx306\fs12\cf0\f0\charscalex100 {1}\tab \fs12\c
f0\f0\charscalex100 {Beaumont B}\fs12\cf0\f0\charscalex100 {, Hurwitz B. Is it p
ossible and}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {worth
keeping track of deaths within general}\par\pard\li306\ri0\sl-173\slmult0 \fs12
\cf0\f0\charscalex100 {practice}\fs12\cf0\f0\charscalex100 {?}{ }\fs12\cf0\f0\ch
arscalex100 {Results of a 15 year observational}\par\pard\li306\ri0\sl-160\slmul
t0 \fs12\cf0\f0\charscalex100 {study.}{ }\fs12\cf0\f0\charscalex100 {Qual Saf He
alth Care}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {2003;}\
fs12\cf0\f0\charscalex100 {12}\fs12\cf0\f0\charscalex100 {:337\uc1\u8211X42.}\pa
r\pard\li160\ri0\sl-146\slmult0 \*\tx306\fs12\cf0\f0\charscalex100 {2}\tab \fs12
\cf0\f0\charscalex100 {Baker R}\fs12\cf0\f0\charscalex100 {, Jones D, Goldblatt
P. Monitoring}\par\pard\li306\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {mor
tality in primary care.}{ }\fs12\cf0\f0\charscalex100 {BMJ}\par\pard\li306\ri0\s
l-146\slmult0 \fs12\cf0\f0\charscalex100 {2003;}\fs12\cf0\f0\charscalex100 {326}
\fs12\cf0\f0\charscalex100 {:274\uc1\u8211X6.}\par\pard\li160\ri0\sl-160\slmult0
\*\tx306\fs12\cf0\f0\charscalex100 {3}\tab \fs12\cf0\f0\charscalex100 {Baker R}
\fs12\cf0\f0\charscalex100 {.}{ }\fs12\cf0\f0\charscalex100 {Harold Shipman\uc1\

u8217Xs clinical practice,}\par\pard\li306\ri0\sl-160\slmult0 \fs12\cf0\f0\chars

calex100 {1974\uc1\u8211X1998. A review commissioned by the}\par\pard\li306\ri0\
sl-146\slmult0 \fs12\cf0\f0\charscalex100 {Chief Medical Officer}\fs12\cf0\f0\ch
arscalex100 {. London: HMSO,}\par\pard\li306\ri0\sl-160\slmult0 \fs12\cf0\f0\cha
rscalex100 {2001.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl
-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-360\slmult0 \fs16\cf0\f0\charscalex10
0 {subsequently produced. Some research-}\par\pard\sect\sectd\sbknone\cols2\coln
o1\colw7160\colsr-0\colno2\colw4280\pard\li786\ri0\sl-186\slmult0 \fs12\cf0\f0\c
harscalex100 {. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . .}\par\pard\li786\ri0\sl-626\slmult0 \fs38\cf0\f0\charscalex10
0 {What can ethnography do for quality}\par\pard\li786\ri0\sl-493\slmult0 \fs38\
cf0\f0\charscalex100 {and safety in health care}\fs38\cf0\f0\charscalex100 {?}\p
ar\pard\li786\ri0\sl-266\slmult0 \fs22\cf0\f0\charscalex100 {M Dixon-Woods}\par\
pard\li786\ri0\sl-266\slmult0 \fs10\cf0\f0\charscalex100 {. . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .}\par\pard\li786\
ri0\sl-400\slmult0 \fs22\cf0\f0\charscalex100 {Used carefully, ethnography can i
dentify errors in health care}\par\pard\li786\ri0\sl-240\slmult0 \fs22\cf0\f0\ch
arscalex100 {and provide explanations for their occurrence.}\par\column\pard\li0
\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {ers begin to feel voyeuristic an
d exploita-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {tive in
some settings, or to experience}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\c
harscalex100 {con\uc1\u64258Xicting loyalties. Ethical dilemmas}\par\pard\li0\ri
0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {about when and how to intervene are
}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {not uncommon. In a
ddition, ethno-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {gra
phic research will also be subject to}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0
\f0\charscalex100 {criticism of its apparent subjectivity, and}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {researchers can \uc1\u64257Xnd thems
elves accused}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {of pr
oducing partisan, partial, or mis-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0
\charscalex100 {leading accounts.}\par\pard\li186\ri0\sl-186\slmult0 \fs14\cf0\f
0\charscalex100 {Many of these dif\uc1\u64257Xculties should and}\par\pard\li0\r
i0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {can be overcome, particularly in m
aking}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {a contributio
n to quality and safety in}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charsca
lex100 {health care. Much can be learned rel-}\par\pard\sect\sectd\sbknone\cols3
\colno1\colw3973\colsr-0\colno2\colw3186\colsr-0\colno3\colw4280{\trowd\trleft78
6\trkeep\trftsWidth1\trpaddl0\trpaddr0\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\br
drnone\clbrdrl\brdrnone\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clft
sWidth3\clwWidth573\clpadt0\clpadr0\clpadft3\clpadfr3\cellx2026 \pard\li0\ri0\sl
-733\widctlpar\intbl \fs66\cf0\f0\charscalex100 {O}\cell\clvertalt\clbrdrt\brdrn
one\clbrdrl\brdrnone\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clftsWi
dth3\clwWidth2560\clpadt0\clpadr0\clpadft3\clpadfr3\cellx4440 \pard\li0\ri0\sl-2
13\widctlpar\intbl \fs16\cf0\f0\charscalex100 {riginally developed within an-}\p
ar\pard\li0\ri0\sl-200\widctlpar\intbl \fs16\cf0\f0\charscalex100 {thropology, e
thnography is one}\par\pard\li0\ri0\sl-186\widctlpar\intbl \fs16\cf0\f0\charscal
ex100 {of the most longstanding social}\cell\row}\column\pard\li173\ri0\sl-200\s
lmult0 \fs16\cf0\f0\charscalex100 {Ethnography is not for the faint}\par\pard\li
0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {hearted. It is a time consuming
and}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {demanding rese
arch process and can be}\par\column\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\cha
rscalex100 {evant to quality and safety from already}\par\pard\li0\ri0\sl-200\sl
mult0 \fs16\cf0\f0\charscalex100 {published ethnographies. Strong\uc1\u8217Xs ac
-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {count of the \uc1
\u8220Xetiquette rules\uc1\u8221X governing}\par\pard\sect\sectd\sbknone\cols3\c
olno1\colw3973\colsr-0\colno2\colw3186\colsr-0\colno3\colw4280\pard\li786\ri0\sl
-160\slmult0 \fs16\cf0\f0\charscalex100 {science research approaches. Its empha}\par\pard\li786\ri0\sl-160\slmult0 \fs14\cf0\f0\charscalex100 {sis is on the de

scription and analysis of}\par\pard\li786\ri0\sl-160\slmult0 \fs14\cf0\f0\charsc

alex100 {\uc1\u8220Xthe everyday\uc1\u8221X\uc1\u8212Xroutine behaviours in}\par
\pard\li786\ri0\sl-160\slmult0 \fs14\cf0\f0\charscalex100 {their natural setting
s. Many would char-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex10
0 {acterise ethnography as the process of}\par\pard\li786\ri0\sl-200\slmult0 \fs
14\cf0\f0\charscalex100 {querying understandings and practices}\par\pard\li786\r
i0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {that are taken for granted: it ren
ders the}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {everyday
world problematic by making}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\cha
rscalex100 {the \uc1\u8220Xordinary\uc1\u8221X into the \uc1\u8220Xextraordinary
\uc1\u8221X.}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {It i
s best understood as a holistic ap-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0
\f0\charscalex100 {proach that does not rely on any single}\par\pard\li786\ri0\s
l-200\slmult0 \fs14\cf0\f0\charscalex100 {method of data collection. Observation
,}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {which may be un
structured \uc1\u8220Xhanging}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\ch
arscalex100 {out\uc1\u8221X or more structured and purposeful}\par\pard\li786\ri
0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {scrutiny of situations to look for
particu-}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {lar thin
gs, is perhaps the de\uc1\u64257Xning feature}\par\pard\li786\ri0\sl-186\slmult0
\fs14\cf0\f0\charscalex100 {of ethnography. These observations are}\par\pard\li
786\ri0\sl-200\slmult0 \*\tx1373\*\tx2613\*\tx2986\fs16\cf0\f0\charscalex100 {of
ten}\tab \fs16\cf0\f0\charscalex100 {supplemented}\tab \fs16\cf0\f0\charscalex10
0 {by}\tab \fs16\cf0\f0\charscalex100 {interviews}\par\pard\li786\ri0\sl-186\slm
ult0 \fs14\cf0\f0\charscalex100 {(sometimes very informal and part of the}\par\p
ard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {\uc1\u8220Xhanging out\
uc1\u8221X process) or documentary}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\
f0\charscalex100 {materials collected from the setting (e.g.}\par\pard\li786\ri0
\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {posters, internal memos, reports of
meet-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {ings), phot
ographs, artefacts, and so on.}\par\pard\li960\ri0\sl-200\slmult0 \fs16\cf0\f0\c
harscalex100 {The interpretation of these data is very}\par\pard\li786\ri0\sl-20
0\slmult0 \fs14\cf0\f0\charscalex100 {much a function of the researcher\uc1\u821
7Xs own}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {skills an
d judgement,}{\super \fs6\up3\cf0\f0\charscalex100 {1}}\fs14\cf0\f0\charscalex10
0 {and will usually}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex10
0 {involve searching for themes and pat-}\par\pard\li786\ri0\sl-200\slmult0 \fs1
4\cf0\f0\charscalex100 {terns in the data and generating expla-}\par\pard\li786\
ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {nations and theories grounded in
them.}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {Like litera
ry criticism, there is no pre-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\c
harscalex100 {scribed set of procedures or techniques}\par\pard\li786\ri0\sl-200
\slmult0 \fs14\cf0\f0\charscalex100 {but there are expectations of good}\par\par
d\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {practice. For example, re
searchers are}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {req
uired to be re\uc1\u64258Xexive\uc1\u8212Xthat is, to}\par\pard\li786\ri0\sl-186
\slmult0 \fs14\cf0\f0\charscalex100 {re\uc1\u64258Xect on and be able to give an
account}\par\pard\li786\ri0\sl-200\slmult0 \*\tx1213\*\tx1813\*\tx2426\*\tx3400
\fs16\cf0\f0\charscalex100 {of}\tab \fs16\cf0\f0\charscalex100 {how}\tab \fs16\c
f0\f0\charscalex100 {they}\tab \fs16\cf0\f0\charscalex100 {produced}\tab \fs16\c
f0\f0\charscalex100 {their}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\chars
calex100 {interpretations\uc1\u8212Xand to be able to show}\par\pard\li786\ri0\s
l-200\slmult0 \fs14\cf0\f0\charscalex100 {that their interpretation is warranted
by}\par\pard\li786\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {the data.}\pa
r\pard\li786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li786\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li786\ri0\sl-320\slmult0 \fs14\cf0\f0\charscalex100 {www.qshc.com
}\par\column\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {a profoundl
y uncomfortable experience}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charsca
lex100 {for the researcher. Ethnographers have}\par\pard\li0\ri0\sl-160\slmult0
\fs16\cf0\f0\charscalex100 {often identi\uc1\u64257Xed a natural af\uc1\u64257Xn

ity for}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {their metho

ds with relatively disadvan-}\par\pard\li0\ri0\sl-173\slmult0 \fs16\cf0\f0\chars
calex100 {taged groups, seeing themselves as offer-}\par\pard\li0\ri0\sl-200\slm
ult0 \fs16\cf0\f0\charscalex100 {ing these groups a voice and a means of}\par\pa
rd\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {making explicit systems of
oppression}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {and coe
rcion. When the ethnographer\uc1\u8217Xs}\par\pard\li0\ri0\sl-186\slmult0 \fs16\
cf0\f0\charscalex100 {role changes to one where s/he is}\par\pard\li0\ri0\sl-200
\slmult0 \fs16\cf0\f0\charscalex100 {attempting to explain professional prac-}\p
ar\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {tices, important prob
lems can arise.}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {Acc
ess to the \uc1\u64257Xeld may be dif\uc1\u64257Xcult to}\par\pard\li0\ri0\sl-18
6\slmult0 \fs16\cf0\f0\charscalex100 {negotiate. When that has been gained,}\par
\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {further challenges lie
ahead. It can}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {somet
imes be dif\uc1\u64257Xcult to access the}\par\pard\li0\ri0\sl-200\slmult0 \fs16
\cf0\f0\charscalex100 {people who may be most important to}\par\pard\li0\ri0\sl186\slmult0 \fs16\cf0\f0\charscalex100 {understanding a particular phenom-}\par\
pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {enon: they may be imposs
ible to get hold}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {of
, or unwilling to speak or be seen. Cov-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\
cf0\f0\charscalex100 {ert observation may be ethically unac-}\par\pard\li0\ri0\s
l-186\slmult0 \fs16\cf0\f0\charscalex100 {ceptable, but clearly obtaining consen
t to}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {observations i
s not always easy and}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex10
0 {introduces risks of the ethnographer}\par\pard\li0\ri0\sl-200\slmult0 \fs16\c
f0\f0\charscalex100 {in\uc1\u64258Xuencing the behaviours under obser-}\par\pard
\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {vation. Participants in the
process can}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {begin t
o feel they are being inspected}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\ch
arscalex100 {and judged, and to feel disempowered.}\par\pard\li0\ri0\sl-200\slmu
lt0 \fs16\cf0\f0\charscalex100 {They may \uc1\u8220Xact up\uc1\u8221X in the pre
sence of the}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {resear
cher. The participants may also}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\ch
arscalex100 {become hostile or uncooperative, and}\par\pard\li0\ri0\sl-186\slmul
t0 \fs16\cf0\f0\charscalex100 {much depends on the skill of the}\par\pard\li0\ri
0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {researcher to overcome these obstac
les.}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {Sometimes this
is done by creating an}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex
100 {\uc1\u8220Xinsider\uc1\u8221X status, identifying the re-}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {searcher with the group being studie
d\uc1\u8212X}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {for ex
ample, a nurse studying nurses.}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\ch
arscalex100 {However, such groups, having accepted}\par\pard\li0\ri0\sl-200\slmu
lt0 \fs16\cf0\f0\charscalex100 {the researcher as \uc1\u8220Xone of us\uc1\u8221
X, may feel}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {betraye
d by the research account that is}\par\column\pard\li0\ri0\sl-160\slmult0 \fs16\
cf0\f0\charscalex100 {face-to-face interactions between par-}\par\pard\li0\ri0\s
l-173\slmult0 \fs16\cf0\f0\charscalex100 {ents and doctors}{\super \fs8\up3\cf0\
f0\charscalex100 {2}}\fs16\cf0\f0\charscalex100 {demonstrates how dif-}\par\pard
\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {\uc1\u64257Xcult it is for p
atients to raise concerns}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscal
ex100 {about possible errors: to do so disrupts}\par\pard\li0\ri0\sl-160\slmult0
\fs16\cf0\f0\charscalex100 {the \uc1\u8220Xceremonial order\uc1\u8221X of consu
ltations}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {and puts t
heir status as \uc1\u8220Xgood patients\uc1\u8221X}\par\pard\li0\ri0\sl-186\slmu
lt0 \fs16\cf0\f0\charscalex100 {at risk. Patients may therefore be si-}\par\pard
\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {lenced when it comes to poin
ting out}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {things the
y are concerned about. Pope\uc1\u8217Xs}\par\pard\li0\ri0\sl-200\slmult0 \fs16\c

f0\f0\charscalex100 {work on waiting lists demonstrated the}\par\pard\li0\ri0\sl

-186\slmult0 \fs16\cf0\f0\charscalex100 {importance of gatekeepers, both clinica
l}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {and administrativ
e, in controlling access}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscale
x100 {to health care.}{\super \fs8\up3\cf0\f0\charscalex100 {3}}\fs16\cf0\f0\cha
rscalex100 {An ethnographic study of}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\
f0\charscalex100 {interactions between consumers and}\par\pard\li0\ri0\sl-186\sl
mult0 \fs16\cf0\f0\charscalex100 {pharmacy staff and patient interviews}{\super
\fs8\up3\cf0\f0\charscalex100 {4}}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\
charscalex100 {challenges traditional professional as-}\par\pard\li0\ri0\sl-186\
slmult0 \fs16\cf0\f0\charscalex100 {sumptions about how the public under-}\par\p
ard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {stands the role of pharma
cists, with}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {importa
nt implications for medication}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\cha
rscalex100 {safety. Findings from ethnography can}\par\pard\li0\ri0\sl-186\slmul
t0 \fs16\cf0\f0\charscalex100 {also be integrated with \uc1\u64257Xndings from}\
par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {other study types in
cluding quantitative}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100
{or other qualitative research.}{\super \fs8\up3\cf0\f0\charscalex100 {5}}\par\
pard\li186\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {Generally, however, th
e obvious poten-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {ti
al for ethnographic approaches to make}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
0\f0\charscalex100 {a contribution to the study of safety and}\par\pard\li0\ri0\
sl-200\slmult0 \fs16\cf0\f0\charscalex100 {quality in health care has been under
-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {exploited. Ethnog
raphic research is well}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex
100 {suited to identifying conditions of risk,}\par\pard\li0\ri0\sl-200\slmult0
\fs16\cf0\f0\charscalex100 {particularly where these involve human}\par\pard\li0
\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {performance, organisational and
cultural}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {dynamics,
and interactions between}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscale
x100 {people and technology. Ethnography is}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf0\f0\charscalex100 {especially good at probing into areas}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {where measurement is not easy, where
}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {the issues are sen
sitive and multifaceted,}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscale
x100 {and where it is important to get at the}\par\pard\li0\ri0\sl-200\slmult0 \
fs16\cf0\f0\charscalex100 {tacit, not the already evident. It can cap-}\par\pard
\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {ture the winks, sighs, head
shaking, and}\par\pard\sect\sectd\sbknone\pard\sect\sectd\sbkpage\pgwsxn12240\pg
hsxn15840\marglsxn666\margrsxn133\margtsxn506\margbsxn66\cols2\colno1\colw9853\c
olsr-0\colno2\colw1586\pard\li786\ri0\sl-213\slmult0 \fs22\cf0\f0\charscalex100
{COMMENTARIES}\par\column\pard\li0\ri0\sl-213\slmult0 \fs14\cf0\f0\charscalex100
{327}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn1
33\cols3\colno1\colw3973\colsr-0\colno2\colw3186\colsr-0\colno3\colw4280\pard\li
786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li786\ri0\sl-266\slmult0 \fs16\cf0\f0\
charscalex100 {gossip that may be exceptionally power-}\par\pard\li786\ri0\sl-18
6\slmult0 \fs14\cf0\f0\charscalex100 {ful in explaining why mistakes happen,}\pa
r\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {but which more forma
l methods will}\par\pard\li786\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {mi
ss.}\par\pard\li960\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {The paper by
Taxis and Barber}{\super \fs6\up3\cf0\f0\charscalex100 {6}}\fs14\cf0\f0\charscal
ex100 {in this}\par\pard\li786\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {is
sue of}{ }\fs16\cf0\f0\charscalex100\i {QSHC}\i0 { }\fs16\cf0\f0\charscalex100 {
makes a welcome addition}\par\pard\li786\ri0\sl-173\slmult0 \fs14\cf0\f0\charsca
lex100 {to the canon. It shows how, used}\par\pard\li786\ri0\sl-200\slmult0 \fs1
4\cf0\f0\charscalex100 {carefully, ethnography can identify types}\par\pard\li78
6\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {of errors and provide explanati
ons for}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {why these
occur, through interrogating}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\ch

arscalex100 {the everyday understandings that staff}\par\pard\li786\ri0\sl-200\s

lmult0 \*\tx1306\*\tx1626\*\tx2146\*\tx2653\*\tx3466\fs16\cf0\f0\charscalex100 {
have}\tab \fs16\cf0\f0\charscalex100 {of}\tab \fs16\cf0\f0\charscalex100 {their}
\tab \fs16\cf0\f0\charscalex100 {own}\tab \fs16\cf0\f0\charscalex100 {practices}
\tab \fs16\cf0\f0\charscalex100 {and}\par\pard\li786\ri0\sl-200\slmult0 \fs16\cf
0\f0\charscalex100 {identifying the cultural contexts of prac-}\par\pard\li786\r
i0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {tice. It is dif\uc1\u64257Xcult to
see how the latent}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex10
0 {conditions for error described in this}\par\pard\li786\ri0\sl-186\slmult0 \fs
14\cf0\f0\charscalex100 {paper, which are likely to be hugely}\par\pard\li786\ri
0\sl-213\slmult0 \fs18\cf0\par\pard\li786\ri0\sl-213\slmult0 \fs18\cf0\par\pard\
li786\ri0\sl-373\slmult0 \fs18\cf0\f0\charscalex100 {Clinical databases}\par\col
umn\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs16\
cf0\f0\charscalex100 {important, could have been character-}\par\pard\li0\ri0\sl
-200\slmult0 \fs16\cf0\f0\charscalex100 {ised appropriately using any approach}\
par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {other than ethnograp
hy. Much more}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {resea
rch of this kind is needed, particu-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\
f0\charscalex100 {larly in complex areas where long chains}\par\pard\li0\ri0\sl186\slmult0 \fs16\cf0\f0\charscalex100 {of causation exist in terms of health an
d}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {safety outcomes.}
\par\pard\li0\ri0\sl-280\slmult0 \fs14\cf0\f0\charscalex100 {Qual Saf Health Car
e 2003;}\fs14\cf0\f0\charscalex100 {12}\fs14\cf0\f0\charscalex100 {:326\uc1\u821
1X327}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {. . . . .
. . . . . . . . . . . . . . . .}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf0\f0\c
harscalex100 {Author\uc1\u8217Xs affiliation}\par\pard\li0\ri0\sl-186\slmult0 \f
s14\cf0\f0\charscalex100 {M Dixon-Woods,}{ }\fs14\cf0\f0\charscalex100 {Senior L
ecturer in Social}\par\pard\li0\ri0\sl-160\slmult0 \fs14\cf0\f0\charscalex100 {S
cience and Health, Department of Health}\par\pard\li0\ri0\sl-160\slmult0 \fs12\c
f0\f0\charscalex100 {Sciences, University of Leicester, Leicester}\par\pard\li0\
ri0\sl-160\slmult0 \fs12\cf0\f0\charscalex100 {LE1 6TP, UK; md11@leicester.ac.uk
}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmul
t0 \fs18\cf0\f0\charscalex100 {REFERENCES}\par\pard\li160\ri0\sl-173\slmult0 \*\
tx306\fs12\cf0\f0\charscalex100 {1}\tab \fs12\cf0\f0\charscalex100 {Hammersley M
}\fs12\cf0\f0\charscalex100 {, Atkinson P.}{ }\fs12\cf0\f0\charscalex100 {Ethnog
raphy:}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {principles
in practice}\fs12\cf0\f0\charscalex100 {. 2nd ed. London:}\par\pard\li306\ri0\s
l-146\slmult0 \fs12\cf0\f0\charscalex100 {Routledge, 1995.}\par\pard\li160\ri0\s
l-146\slmult0 \*\tx306\fs12\cf0\f0\charscalex100 {2}\tab \fs12\cf0\f0\charscalex
100 {Strong PM}\fs12\cf0\f0\charscalex100 {.}{ }\fs12\cf0\f0\charscalex100 {The
ceremonial order of the}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscal
ex100 {clinic: parents, doctors and medical}\par\pard\li306\ri0\sl-146\slmult0 \
fs12\cf0\f0\charscalex100 {bureaucracies}\fs12\cf0\f0\charscalex100 {. London: R
outledge and Kegan}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100
{Paul, 1979.}\par\pard\li160\ri0\sl-146\slmult0 \*\tx306\fs12\cf0\f0\charscalex
100 {3}\tab \fs12\cf0\f0\charscalex100 {Pope C}\fs12\cf0\f0\charscalex100 {. Tro
uble in store: some thoughts on}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\
charscalex100 {the management of waiting lists.}{ }\fs12\cf0\f0\charscalex100 {S
ociol Health}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {Illn
ess }\fs12\cf0\f0\charscalex100 {1991;}\fs12\cf0\f0\charscalex100 {13}\fs12\cf0\
f0\charscalex100 {:193\uc1\u8211X212.}\par\pard\li160\ri0\sl-146\slmult0 \*\tx30
6\fs12\cf0\f0\charscalex100 {4}\tab \fs12\cf0\f0\charscalex100 {Hassell K}\fs12\
cf0\f0\charscalex100 {, Noyce P, Rogers A,}{ }\fs12\cf0\f0\charscalex100 {et al}
\fs12\cf0\f0\charscalex100 {. Advice}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf
0\f0\charscalex100 {provided in British community pharmacies:}\par\pard\li306\ri
0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {what people want and what they get.
}{ }\fs12\cf0\f0\charscalex100 {J Health}\par\pard\li306\ri0\sl-146\slmult0 \fs1
2\cf0\f0\charscalex100 {Serv Res Policy }\fs12\cf0\f0\charscalex100 {1998;}\fs12
\cf0\f0\charscalex100 {3}\fs12\cf0\f0\charscalex100 {:219\uc1\u8211X25.}\par\par

d\li160\ri0\sl-146\slmult0 \*\tx306\fs12\cf0\f0\charscalex100 {5}\tab \fs12\cf0\

f0\charscalex100 {Tashakkori A}\fs12\cf0\f0\charscalex100 {, Teddlie C.}{ }\fs12
\cf0\f0\charscalex100 {Mixed}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\cha
rscalex100 {methodology: combining qualitative and}\par\pard\li306\ri0\sl-146\sl
mult0 \fs10\cf0\f0\charscalex100 {quantitative approaches}\fs10\cf0\f0\charscale
x100 {. Thousand Oaks, CA:}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\chars
calex100 {Sage, 1998}\par\pard\li160\ri0\sl-146\slmult0 \*\tx306\fs12\cf0\f0\cha
rscalex100 {6}\tab \fs12\cf0\f0\charscalex100 {Taxis K}\fs12\cf0\f0\charscalex10
0 {, Barber N. Causes of intravenous}\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf
0\f0\charscalex100 {medication errors: an ethnographic study.}\par\pard\li306\ri
0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {Qual Saf Health Care 2003;}\fs12\cf
0\f0\charscalex100 {12}\fs12\cf0\f0\charscalex100 {:343\uc1\u8211X7.}\par\pard\l
i0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li0\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {validity of the data (accu
racy and sus-}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\m
argrsxn133\cols2\colno1\colw7160\colsr-0\colno2\colw4280\pard\li786\ri0\sl-186\s
lmult0 \fs12\cf0\f0\charscalex100 {. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . .}\par\pard\li786\ri0\sl-626\slmult0 \fs3
8\cf0\f0\charscalex100 {Basing decisions on better quality}\par\pard\li786\ri0\s
l-413\slmult0 \fs38\cf0\f0\charscalex100 {routine clinical data}\par\pard\li786\
ri0\sl-360\slmult0 \fs22\cf0\f0\charscalex100 {T A Sheldon}\par\pard\li786\ri0\s
l-240\slmult0 \fs10\cf0\f0\charscalex100 {. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .}\par\pard\li786\ri0\sl-413\slmul
t0 \fs22\cf0\f0\charscalex100 {Clinical databases, properly used, have the poten
tial to}\par\pard\li786\ri0\sl-240\slmult0 \fs22\cf0\f0\charscalex100 {contribut
e to quality improvement.}\par\column\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\c
harscalex100 {ceptibility to bias), usefulness for com-}\par\pard\li0\ri0\sl-200
\slmult0 \fs16\cf0\f0\charscalex100 {parative work, and national representa-}\pa
r\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {tiveness. With suf\uc1
\u64257Xcient investment this}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\char
scalex100 {directory could develop into an impor-}\par\pard\li0\ri0\sl-200\slmul
t0 \fs16\cf0\f0\charscalex100 {tant national and possibly international}\par\par
d\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {resource.}\par\pard\li186\r
i0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {While the development and prolifer
a-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {tion of clinical
databases will inevitably}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charsca
lex100 {contribute to audit and research, there is}\par\pard\li0\ri0\sl-200\slmu
lt0 \fs16\cf0\f0\charscalex100 {a danger that they will be misused. In}\par\pard
\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {England, for example, the De
partment of}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {Health
has made a commitment to pub-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\char
scalex100 {lish cardiac surgeon speci\uc1\u64257Xc mortality}\par\pard\li0\ri0\s
l-200\slmult0 \fs16\cf0\f0\charscalex100 {data based on the UK Cardiac Surgical}
\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\col
s3\colno1\colw3973\colsr-0\colno2\colw3186\colsr-0\colno3\colw4280{\trowd\trleft
786\trkeep\trftsWidth1\trpaddl0\trpaddr0\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\
brdrnone\clbrdrl\brdrnone\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\cl
ftsWidth3\clwWidth573\clpadt0\clpadr0\clpadft3\clpadfr3\cellx2026 \pard\li0\ri0\
sl-733\widctlpar\intbl \fs66\cf0\f0\charscalex100 {O}\cell\clvertalt\clbrdrt\brd
rnone\clbrdrl\brdrnone\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clfts
Width3\clwWidth2560\clpadt0\clpadr0\clpadft3\clpadfr3\cellx4440 \pard\li0\ri0\sl
-213\widctlpar\intbl \fs16\cf0\f0\charscalex100 {ver the last decade there has}\
par\pard\li0\ri0\sl-200\widctlpar\intbl \fs16\cf0\f0\charscalex100 {been increas
ing pressure to make}\par\pard\li0\ri0\sl-186\widctlpar\intbl \fs16\cf0\f0\chars
calex100 {health care more accountable}\cell\row}\column\pard\li0\ri0\sl-186\slm
ult0 \fs16\cf0\f0\charscalex100 {that we have enough information to be}\par\pard
\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {able to interpret the result
s of studies}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {based

on them and to decide if they are}\par\column\pard\li0\ri0\sl-200\slmult0 \fs16\

cf0\f0\charscalex100 {register developed by the Society of Car-}\par\pard\li0\ri
0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {diac Surgeons. Sampling of this dat
abase}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {revealed it t
o be both incomplete and}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\ma
rglsxn666\margrsxn133\cols3\colno1\colw3973\colsr-0\colno2\colw3186\colsr-0\coln
o3\colw4280\pard\li786\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {and to ide
ntify variations suggesting}\par\pard\li786\ri0\sl-160\slmult0 \fs14\cf0\f0\char
scalex100 {poor quality care which can be im-}\par\pard\li786\ri0\sl-160\slmult0
\fs14\cf0\f0\charscalex100 {proved. While special studies can be}\par\pard\li78
6\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {conducted with these aims in mi
nd,}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {quality impro
vement activity will only}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charsc
alex100 {become part of the fabric of health serv-}\par\pard\li786\ri0\sl-200\sl
mult0 \fs14\cf0\f0\charscalex100 {ices if it can draw on data that are}\par\pard
\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {routinely collected. In No
rth America}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {exten
sive hospital data have been avail-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0
\f0\charscalex100 {able; however, because they are gener-}\par\pard\li786\ri0\sl
-200\slmult0 \fs14\cf0\f0\charscalex100 {ated as byproducts of administrative}\p
ar\pard\li786\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {systems collected f
or other (usually}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100
{\uc1\u64257Xnancial) purposes, they are severely}\par\pard\li786\ri0\sl-200\slm
ult0 \fs14\cf0\f0\charscalex100 {limited. Without the ability to adjust for}\par
\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {patient case mix, for
example, incorrect}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex10
0 {inferences about the cause of variations}\par\pard\li786\ri0\sl-200\slmult0 \
fs16\cf0\f0\charscalex100 {in patient outcomes are likely.}{\super \fs8\up3\cf0\
f0\charscalex100 {1}}\fs16\cf0\f0\charscalex100 {The sort}\par\pard\li786\ri0\sl
-200\slmult0 \fs14\cf0\f0\charscalex100 {of detailed clinical data needed to mak
e}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {sensible analys
es of patient outcomes}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscale
x100 {are rarely generated from routine sys-}\par\pard\li786\ri0\sl-200\slmult0
\fs14\cf0\f0\charscalex100 {tems, and it may not be feasible or cost}\par\pard\l
i786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {effective for this to be a c
ore administra-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100 {t
ive function. Instead, bespoke clinical}\par\pard\li786\ri0\sl-200\slmult0 \fs14
\cf0\f0\charscalex100 {databases have been developed in paral-}\par\pard\li786\r
i0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {lel, often as the result of the co
operative}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {efforts
of clinicians seeking reliable data}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf
0\f0\charscalex100 {on their practice and ways in which}\par\pard\li786\ri0\sl-1
86\slmult0 \fs16\cf0\f0\charscalex100 {quality might be monitored and im-}\par\p
ard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {proved. However, as one
\uc1\u64257Xnds with other}\par\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\char
scalex100 {sources of data collection, the validity}\par\pard\li786\ri0\sl-200\s
lmult0 \fs16\cf0\f0\charscalex100 {and reliability of clinical databases are}\pa
r\pard\li786\ri0\sl-200\slmult0 \fs14\cf0\f0\charscalex100 {variable. As the num
ber of such data-}\par\pard\li786\ri0\sl-186\slmult0 \fs14\cf0\f0\charscalex100
{bases grows, it is important to ensure}\par\column\pard\li0\ri0\sl-160\slmult0
\fs16\cf0\f0\charscalex100 {\uc1\u64257Xt for the purpose. As with the conduct}\
par\pard\li0\ri0\sl-173\slmult0 \fs16\cf0\f0\charscalex100 {and reporting of tri
als}{\super \fs8\up3\cf0\f0\charscalex100 {2}}\fs16\cf0\f0\charscalex100 {and sy
stematic}\par\pard\li0\ri0\sl-173\slmult0 \fs16\cf0\f0\charscalex100 {reviews,}{
\super \fs8\up3\cf0\f0\charscalex100 {3}}\fs16\cf0\f0\charscalex100 {we need com
mon high stand-}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {ard
s for establishing, running and re-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f
0\charscalex100 {porting clinical databases, an appraisal}\par\pard\li0\ri0\sl-2
00\slmult0 \fs16\cf0\f0\charscalex100 {tool to assess the degree to which these}
\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {standards are being

applied, and an}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {ac

cessible source of information on}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\
charscalex100 {clinical databases and their quality.}\par\pard\li173\ri0\sl-200\
slmult0 \fs16\cf0\f0\charscalex100 {The Directory of Clinical Databases}\par\par
d\li0\ri0\sl-200\slmult0 \*\tx920\*\tx1773\*\tx2120\*\tx2693\fs16\cf0\f0\charsca
lex100 {(DoCDAT)}\tab \fs16\cf0\f0\charscalex100 {described}\tab \fs16\cf0\f0\ch
arscalex100 {by}\tab \fs16\cf0\f0\charscalex100 {Black}\tab \fs16\cf0\f0\charsca
lex100 {and}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf0\f0\charscalex100 {Payne}{
\super \fs8\up3\cf0\f0\charscalex100 {4}}\fs16\cf0\f0\charscalex100 {in this iss
ue of}{ }\fs16\cf0\f0\charscalex100\i {QSHC}\i0 { }\fs16\cf0\f0\charscalex100 {i
s the \uc1\u64257Xrst}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex10
0 {important step in providing such a}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0
\f0\charscalex100 {resource in the UK. By providing key}\par\pard\li0\ri0\sl-200
\slmult0 \fs16\cf0\f0\charscalex100 {information on and critical appraisals of}\
par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {clinical databases w
hich provide indi-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {
vidual data, it will help people to \uc1\u64257Xnd}\par\pard\li0\ri0\sl-200\slmu
lt0 \fs16\cf0\f0\charscalex100 {databases suitable to their needs and,}\par\pard
\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {more importantly, it will ac
t as a pressure}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {to
improve standards. Inevitably there}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f
0\charscalex100 {are ways in which this resource will need}\par\pard\li0\ri0\sl200\slmult0 \fs16\cf0\f0\charscalex100 {to mature. The methods of development}\p
ar\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {and validation of the
assessment instru-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100
{ment are probably not as robust or as}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
0\f0\charscalex100 {explicit as that developed for the report-}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {ing of trials or systematic reviews.
}{\super \fs8\up3\cf0\f0\charscalex100 {2 3}}\par\pard\li0\ri0\sl-200\slmult0 \f
s16\cf0\f0\charscalex100 {Ideally there should be double checking}\par\pard\li0\
ri0\sl-186\slmult0 \*\tx306\*\tx706\*\tx1600\*\tx2040\fs16\cf0\f0\charscalex100
{of}\tab \fs16\cf0\f0\charscalex100 {the}\tab \fs16\cf0\f0\charscalex100 {apprai
sals}\tab \fs16\cf0\f0\charscalex100 {and}\tab \fs16\cf0\f0\charscalex100 {indep
endent}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {veri\uc1\u64
257Xcation of the claims of the database}\par\pard\li0\ri0\sl-200\slmult0 \fs16\
cf0\f0\charscalex100 {custodians. There is also room for further}\par\pard\li0\r
i0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {conceptual development, possibly i
n-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {cluding a cleare
r separation of infor-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex1
00 {mation and criteria about the internal}\par\column\pard\li0\ri0\sl-160\slmul
t0 \fs16\cf0\f0\charscalex100 {unreliable in its ability to yield accurate,}\par
\pard\li0\ri0\sl-173\slmult0 \fs16\cf0\f0\charscalex100 {risk adjusted outcomes
data.}{\super \fs8\up3\cf0\f0\charscalex100 {5}}\fs16\cf0\f0\charscalex100 {Thus
, pub-}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\charscalex100 {lication is
likely to result in misleading}\par\pard\li0\ri0\sl-160\slmult0 \fs16\cf0\f0\cha
rscalex100 {information about individual perform-}\par\pard\li0\ri0\sl-186\slmul
t0 \fs16\cf0\f0\charscalex100 {ance entering the public domain, with}\par\pard\l
i0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {potentially damaging results.
Even if the}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {data we
re accurate and risk adjustment}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\ch
arscalex100 {suf\uc1\u64257Xcient, it is still not obvious that the}\par\pard\li
0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {individual surgeon is the right
unit of}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {analysis o
r that publishing the data is the}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\
charscalex100 {optimal way to promote quality improve-}\par\pard\li0\ri0\sl-200\
slmult0 \fs16\cf0\f0\charscalex100 {ment. Clinical databases, if properly}\par\p
ard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {used, have the potential
to contribute to}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {qu
ality improvement. However, if they}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f
0\charscalex100 {are used by those who lack suf\uc1\u64257Xcient sci-}\par\pard\

li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {enti\uc1\u64257Xc intelligenc

e or are exploited for}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex1
00 {political ends, then clinicians will be-}\par\pard\li0\ri0\sl-200\slmult0 \f
s16\cf0\f0\charscalex100 {come cynical, data quality will fall, and}\par\pard\li
0\ri0\sl-186\slmult0 \fs16\cf0\f0\charscalex100 {the public interest will not be
well}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf0\f0\charscalex100 {served.}\par\
pard\li0\ri0\sl-266\slmult0 \fs14\cf0\f0\charscalex100 {Qual Saf Health Care 200
3;}\fs14\cf0\f0\charscalex100 {12}\fs14\cf0\f0\charscalex100 {:327\uc1\u8211X328
}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-320\slmult0 \fs1
2\cf0\f0\charscalex100 {. . . . . . . . . . . . . . . . . . . . .}\par\pard\li0\
ri0\sl-240\slmult0 \fs16\cf0\f0\charscalex100 {Author\uc1\u8217Xs affiliation}\p
ar\pard\li0\ri0\sl-173\slmult0 \fs14\cf0\f0\charscalex100 {T A Sheldon,}{ }\fs14
\cf0\f0\charscalex100 {Department of Health Sciences,}\par\pard\li0\ri0\sl-160\s
lmult0 \fs12\cf0\f0\charscalex100 {University of York, York YO10 5DD, UK;}\par\p
ard\li0\ri0\sl-160\slmult0 \fs14\cf0\f0\charscalex100 {tas5@york.ac.uk}\par\pard
\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-346\slmult0 \fs18\cf0\f0\c
harscalex100 {REFERENCES}\par\pard\li160\ri0\sl-173\slmult0 \*\tx306\fs12\cf0\f0
\charscalex100 {1}\tab \fs12\cf0\f0\charscalex100 {Sowden A}\fs12\cf0\f0\charsca
lex100 {, Sheldon TA. Does volume really}\par\pard\li306\ri0\sl-173\slmult0 \fs1
2\cf0\f0\charscalex100 {affect outcome}\fs12\cf0\f0\charscalex100 {?}{ }\fs12\cf
0\f0\charscalex100 {Lessons from the evidence.}{ }\fs12\cf0\f0\charscalex100 {J}
\par\pard\li306\ri0\sl-146\slmult0 \fs12\cf0\f0\charscalex100 {Health Serv Res P
olicy }\fs12\cf0\f0\charscalex100 {1998;}\fs12\cf0\f0\charscalex100 {3}\fs12\cf0
\f0\charscalex100 {:187\uc1\u8211X90.}\par\pard\li1973\ri0\sl-213\slmult0 \fs18\
cf0\par\pard\li1973\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1973\ri0\sl-306\slmu
lt0 \fs12\cf0\f0\charscalex100 {www.qshc.com}\par}