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Review of Ethics Issues related to Clinical Audit and Quality Improvement Activities — Nancy Dixon


The ethical duty of healthcare practitioners and healthcare organizations to carry out quality improvement (QI) activities, including clinical audit, is established. However, the potential ethical issues associated with these activities aren’t always recognized and handled effectively. As clinical audit and QI activities become increasingly more sophisticated, it is inappropriate to use the distinction between research and clinical audit or QI as the basis for deciding if an activity needs ethical review. 

The purposes of this review from 2009 were to identify: ethical issues related to clinical audit or QI; clinical audit or QI circumstances for which a review of ethical issues is needed; and structures, mechanisms or processes in healthcare organizations for reviewing and resolving ethical issues related to clinical audit or QI.


A number of ethical issues related to clinical audit and QI were identified, occurring at three stages in the clinical audit or QI process: proposal development and approval; data collection and analysis; and assessment of the effectiveness of actions taken in response to findings. There are also ethical issues that relate to a clinical audit or QI programme in a healthcare organization. A variety of structural, systems and process oversight options are available to enable a healthcare organization to be accountable for identifying and handling ethical concerns related to clinical audit or QI. 


Ethics screening questions should be applied to proposals for all clinical audit and QI activities to ensure that the activities benefit and avoid or minimize risk to patients. Healthcare organizations should have robust structures and processes in place for oversight of clinical audits and QI projects in order to protect patients and avoid waste of scarce healthcare resources.

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Ethics and clinical audit, Appendix 1 — Nancy Dixon.

Ethics and clinical audit, Appendix 1 — Nancy Dixon.
In: Burgess R, editor. New Principles for Best Practice in Clinical Audit. Oxford: Radcliffe Publishing; 2011; pp. 107–27.


Key points

  • It is a misconception that ethical review is needed for research but not for clinical audit or quality improvement projects.

  • There may be a lack of clarity about what ethics involves.

  • Clinical audit and quality improvement activities can raise ethical issues.

  • Clinical audits can overlap with quality improvement research, so criteria for making a decision on the nature of the activity are needed.


    Healthcare organizations need to have a policy that guides handling the ethical issues related to clinical audit and quality improvement and a structure in place to oversee ethical issues relating to these activities.

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    Writing for publication on research with young children

    Writing for publication on research with young children, Nancy Dixon. In: Saracho ON, editor.Handbook of Research Methods in Early Childhood Education. Charlotte NC: Information Age Publishing; 2015. Updated in 2023, in press.


    Carrying out research studies and sharing the findings of the studies go hand in hand as professional activities; therefore, the skills involved in carrying out a research study and writing about the research should be developed simultaneously. Writing a journal article on a research study brings absolute focus on the importance of the research to the field and on the key messages about the research to be communicated to colleagues. The discipline of explaining a research study concisely helps a doctoral student to clarify the background to the research, the justification for the research methodology, and the importance of the research findings.

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    Good Practice in Clinical Audit, Evidence to Support Criteria for Clinical Audit — Nancy Dixon

    Good Practice in Clinical Audit, Evidence to Support Criteria for Clinical Audit — Nancy Dixon, London: National Centre for Clinical Audit, 1996.


    To contribute to improving the quality of clinical audit activities, the former National Centre for Clinical Audit (NCCA) established criteria for good practice in clinical audit. The criteria were based on synthesis of expert opinion about essential attributes of the audit process, practitioners’ views about how audit works successfully in practice, and a review of the literature on the audit process. This summary focused on selected literature of relevance to criteria for good practice in clinical audit. The review is descriptive of the relevance of criteria for good practice rather than analytic of the literature on clinical audit.

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    Contemporary Perspectives on Reseach

    Contemporary Perspectives on Research on Immigration in Early Childhood Education


    For educators involved with immigrant children, a summary of the health issues that these children experience and how educators can help meet their health needs 

    Immigrant children around the world experience a range of health-related problems. Some of the problems can be identified and addressed relatively easily, such as lack of recommended immunizations. Other problems, such as serious diseases and mental health issues provoked by the trauma associated with immigration, can require access to complex healthcare services. Countries vary in their policies about access to healthcare systems for immigrant children. These children can be dependent on teachers in their schools to identify a serious health issue and guide a child’s parents or carers through accessing the healthcare system.

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    Patient information


    We have provided workshops for clinical staff on how to prepare information for patients.


    Using the practical guidance developed for the workshop, we have designed and produced patient information leaflets on a wide range of subjects for a university hospital including on:  care of the elderly; coping with a traumatic event; coping with anxiety; depression; facial paresis; flexion tendon injuries; hospital-acquired infections; patient consent; varicose vein surgery; what a clinical psychologist does; and on physiotherapy exercises for a range of orthopaedic conditions. 

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