Article Text

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In this new volume of Quality in Health Care we have decided to modify the structure of the journal scan. Each issue will still include a scan of the core medical journals—BMJ, JAMA, Lancet, and New England Journal of Medicine—but, in addition, we will invite a health professional to do a scan of the published literature based on a particular theme. The theme of the scan for the articles reviewed by Ross Scrivener in this issue is risk management.

## Risk management

Bibliographic search strategy used

Medline (PubMed) was searched using the terms “medication errors” and “risk management” together. The following articles were selected from 41 articles that appeared during October 1998 to October 1999 indexed under these terms.

Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse event reporting . J Eval Clin Pract 1999 Feb; 5 :5–12.

Abstract adapted from the original article.

Objectives

To determine the reliability of adverse event reporting in two teaching hospital obstetric units by (a) establishing what proportion of adverse incidents were not reported by staff and (b) determining whether a maternity risk manager can increase the reliability of adverse incident reporting by searching through various types of documentation.

Setting

Two obstetric units serving similar populations and with comparable numbers of deliveries. Both units had established risk management programmes led by a maternity risk manager.

Methods

A retrospective review of the notes relating to 250 consecutive deliveries in each of the two obstetric units. Notes were screened for the presence of adverse incidents defined by lists of incidents to be recorded in accordance with unit protocols.

Results

A total of 196 adverse incidents were identified from the 500 deliveries. Staff reported 23% of these and the risk managers identified a further 22%. The remaining 55% of incidents were identified only by a retrospective case note review and not known to the risk manager. Staff reported about half the serious incidents (48%), but comparatively few of the moderately serious (24%) or minor ones (15%). The risk managers identified an additional 16% of serious incidents that staff did not report. Drug errors were analysed separately; only two were known to the risk managers and a further 44 were found by case note review.

Conclusions

Incident reporting systems may produce much potentially valuable information, but they seriously underestimate the true level of reportable incidents. Where one risk manager covers an entire trust rather than a single unit, reporting rates are likely to be much lower than in this study. Greater clarity is needed about the definition of reportable incidents (including drug errors). Staff should receive continuing education about the purposes and aims of clinical risk management and incident reporting and consideration should be given to designating specific members of staff with responsibility for reporting.

Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study . J Eval Clin Pract 1999 Feb; 5 :13–21.

Abstract adapted from the original article.

Objectives

To identify the reasons why so many adverse incidents are not reported.

Setting

The same two obstetric units as studied in the previous study.

Participants

Obstetricians and midwives.

Method

A questionnaire was given to 42 obstetricians and 156 midwives. Questions concerned their knowledge of their unit's incident reporting system; whether they would report a series of 10 designated adverse obstetric incidents to the risk manager; and their views on 12 potential reasons for not reporting incidents.

Results

Most staff knew about the incident reporting system in their unit, but almost 30% did not know how to find a list of the reportable incidents. Views on the necessity of reporting the 10 designated obstetric incidents varied considerably. For example, 96% of staff stated that they would always report a maternal death, whereas less than 40% would report a baby's unexpected admission to the special care baby unit. Midwives said they were more likely to report incidents than doctors, and junior staff were more likely to report than senior staff. The main reasons for not reporting were fears that junior staff would be blamed, high workload, and the belief (even though the incident was designated as reportable) that the circumstances or outcome of a particular case did not warrant a report. Junior doctors felt less supported than senior doctors.

Conclusions

Current systems of incident reporting, while providing some valuable information, do not provide a reliable index of the rate of adverse incidents. Recommended measures to increase reliability include clearer definitions of incidents, simplified methods of reporting, designated staff to report incidents and education, feedback, and reassurance to staff about the nature and purpose of such systems.

Karson AS, Bates DW. Screening for adverse events . J Eval Clin Pract 1999 Feb; 5 :23–32.

Abstract reproduced from the original article.

Adverse events (AEs) in medical patients are common, costly, and often preventable. Development of high quality improvement programmes to decrease the number and impact of AEs demands effective methods for screening for AEs on a routine basis. Here we describe the impact types and potential causes of AEs, and review various techniques for identifying them. We evaluate the use of generic screening criteria and combinations of these criteria. In general, the most sensitive screens were the least specific and no small subset of screens identified a large percentage of adverse events. Combinations of screens that are limited to administrative data were the least expensive, but none was particularly sensitive, although in practice they might be effective as routine screening is currently rarely done. As computer systems increase in sophistication, sensitivity will improve. We also discuss recent studies that suggest that programs that screen for and identify AEs can be useful in reducing AE rates. Although tools for identifying AEs have strengths and weaknesses, they can play an important part in an organisation's quality improvement portfolios.

Malpas A, Helps SC, Sexton EJ, et al. A classification for adverse drug events . J Qual Clin Pract 1999 Mar; 19 :23–6.

Abstract reproduced from the original article.

There is considerable evidence that many patients suffer adverse events arising from their healthcare management. A significant proportion of these iatrogenic injuries occur as a result of medication errors. Before prevention strategies can be developed, it is necessary to understand the types of errors that are occurring. To set priorities, it is necessary to identify the frequency and impact of the various types of medication errors. To fully investigate medication incidents, it is necessary to classify the information in a way that allows the frequencies, causes, and contributing factors to be analysed. The development of a subbranch of the “generic occurrence classification”, specific to medication incidents, allows this analysis to occur.

Bates DW. Frequency, consequences and prevention of adverse drug events . J Qual Clin Pract 1999 Mar; 19 :13–7.

Abstract reproduced from the original article.

Iatrogenic injuries are important because they are frequent and many may be preventable; those caused by therapeutic drugs are among the most frequent. Although medication errors are common, most have little potential for harm. Some errors, however, such as giving a patient a drug to which they have a known allergy, are more likely to cause injury. Error theory provides insights into the changes required to reduce medication error injury rates. Data from the Adverse Drug Event Prevention Study suggest that most serious errors occur at the ordering and dispensing stages, while another, smaller, proportion occur at the administration stage. These data suggest that physician computer-order entry, where physicians write orders on line with decision support, including patient specific information and alerts about potential problems, has the potential to significantly reduce the number of serious medication errors.

Clark RB, Graham JD, Williamson JA. Towards system-wide strategies for reducing adverse drug events . J Qual Clin Pract 1999 Mar; 19 :37-40.

Abstract reproduced from the original article.

Despite the best efforts of committed healthcare workers, there are many adverse drug events (ADEs). A large proportion of ADEs arise from system factors, either directly (for example, poor equipment design) or indirectly (for example, inappropriate staff rosters). This article represents the proceedings of a workshop focus group that deliberated on priority health system issues identified as requiring action to minimise the risks of ADEs. Major issues canvassed were the gathering of appropriate and useful data about ADEs, the dissemination of information to professionals and consumers, and effective communication across groups of professionals and between professionals and consumers. Various recommendations were put forward as important first steps in addressing these issues.

Thornton PD, Simon S, Mathew TH. Towards safer drug prescribing, dispensing and administration in hospitals . J Qual Clin Pract 1999 Mar; 19 :41–5.

Abstract reproduced from the original article.

A multidisciplinary workshop was held to identify strategies likely to produce a reduction in adverse drug events, by targeting hospital systems involved in drug prescribing, dispensin, and administration. Strategies identified at the workshop included: (a) improving the education and practice development of medical and nursing staff in drug treatment and safe prescribing principles; (b) introducing and using information technology and electronic prescribing processes; (c) implementing the Australian Pharmaceutical Advisory Council (APAC) national guidelines to achieve the continuum of quality use of medicines between hospitals and the community; (d) enhancing the importance of medication history taking as a routine part of the admission process; (e) instituting individual patient supply as the standard method of drug distribution in hospitals; and (f) stimulating the hospital based clinical pharmacy workforce.

Wakefield DS, Wakefield BJ, Uden-Holman T, et al. Understanding why medication administration errors may not be reported . Am J Med Qual 1999 Mar-Apr; 14 :81–8.

Abstract reproduced from the original article.

Because the identification and reporting of medication administration errors (MAEs) is a non-automated and voluntary process, it is important to understand potential barriers to MAE reporting. This paper describes and analyses a survey instrument designed to assist in evaluating the relative importance of 15 different potential MAE reporting barriers. Based on the responses of over 1300 nurses and a confirmatory LISREL analysis, the 15 potential barriers are combined into 4 subscales: disagreement over error, reporting effort, fear, and administrative response. The psychometric properties of this instrument and descriptive profiles are presented. Specific suggestions for enhancing MAE reporting are discussed.

Wakefield DS, Wakefield BJ, Borders T, et al . Understanding and comparing differences in reported medication and administration error rates . Am J Med Qual 1999 Mar-Apr; 14 :73–80.

Abstract reproduced from the original article.

The prevention of medication administration errors (MAEs) represents a central focus of hospitals' quality improvement and risk management initiatives. Because the identification and reporting of MAEs is a non-automated and voluntary process, it is essential to understand the extent to which errors may not be reported. This study reports the results of 2 multi-hospital surveys in which over 1300 staff nurses in each survey estimated the extent to which various types of non-intravenous and intravenous related MAEs are actually being reported in their nursing units. Overall, respondents estimated that about 60% of MAEs are actually being reported. Considerable differences in estimated rates of MAE reporting were found between staff and supervisors working on the same patient care units. A simulation based on actual and perceived rates of MAE reporting is presented to estimate the range of errors not being reported. Implications about the reliability, validity, and completeness of MAEs actually being reported are discussed.

Internet search: sentinel event alert from the Joint Commission on Accreditation of Healthcare Organisations

A search using the search engine Alta Vista was done in October 1999. The search terms “sentinel event” listed the material from the Joint Commission on Accreditation of Health care Organisations (JCAHO). This is called Sentinel Event Alert” (wwwb.jcaho.org/edu_pub/sealert/se_alert.html) and lists bulletins from February 1998 to August 1999.

The sentinel events cover a range of issues including medication errors involving potassium chloride, wrong site surgery, infant abductions, and blood transfusion errors. Each issue covers risk factors, root causes identified, suggested strategies for reducing risk, and expert recommendations.

ROSS SCRIVENER

Clinical Effectiveness Information Manager, Dynamic Quality Improvement Programme, Royal College of Nursing, 20 Cavendish Square, London W1M 0AB

## Quality in practice

The following abstracted papers encourage healthcare providers to reflect on their practice and consider alternative approaches that have quantified benefits for the patient and the organisation.

The first study indicates that primary angioplasty compared with intravenous streptokinase results in lower mortality rates and lower re-infarction rates. Furthermore, from a financial perspective, the angioplasty method also proved to be more cost effective than using intravenous streptokinase.

Zijlstra F, Hoorntje JCA, De Boer M-J, et al. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1999; 341 :1413–19.

Abstract reproduced from the original.

Background

As compared with thrombolytic therapy, primary coronary angioplasty results in a higher rate of patency of the infarct related coronary artery, lower rates of stroke re-infarction, and higher inhospital or 30 day survival rates. However, the comparative long term efficacy of these two approaches has not been carefully studied.

Methods

A total of 395 patients with acute myocardial infarction were assigned randomly to treatment with angioplasty or intravenous streptokinase. Clinical information was collected for a mean (SD) of 5(2) years and medical charges associated with the two treatments were compared.

Results

A total of 194 patients were assigned to undergo angioplasty and 201 to receive streptokinase. Mortality was 13% in the angioplasty group as compared with 24% in the streptoki-nase group (relative risk 0.54; 95% confidence interval, 0.36 to 0.87). Non-fatal re-infarction occurred in 6% and 22% of the two groups, respectively (relative risk, 0.27; 95% CI 0.15 to 0.52). The combined incidence of death and non-fatal re-infarction was also lower among patients assigned to angioplasty than among those assigned to streptokinase, with a relative risk of 0.13 (95% CI 0.05 to 0.37) for early events (within the first 30 days) and a relative risk of 0.62 (95% CI 0.43 to 0.91 for late events (after 30 days). The rates of readmission for heart failure and ischaemia were also lower in the angioplasty group than in the streptokinase group. In addition, total medical charges per patient were lower in the angioplasty group ($16 090) than in the streptokinase group ($16 813, p=0.05).

Conclusions

As compared with thrombolytic therapy with streptokinase, primary coronary angioplasty is associated with better clinical outcomes over five years.

## Central venous catheterisation

Central venous catheterisation is often required for the intensive medical and surgical management of patients. Complications, such as catheter related bloodstream infection, are associated with its use. The most commonly used method for diagnosing these infections generally necessitates the removal of the catheter so that it can be cultured, and results are not available for at least 24 hours. The following study describes a more rapid, cost effective, and patient friendly alternative.

Kite P, Dobbins B, Wilcox M, et al. Rapid diagnosis of central-venous-catheter -related bloodstream infection without catheter removal. Lancet 1999; 354 :1504–7.

Background

Current methods for the diagnosis of bloodstream infection related to central venous catheters (CVC) are slow and in many cases require catheter removal. Because most CVCs that are removed on suspicion of causing infection prove not to be infected, removal of catheters unnecessarily exposes patients to the risks associated with reinsertion. The aim of the study was to explore a rapid diagnostic method for catheter related bloodstream infection.

Methods

The gram stain and acridine-orange leucocyte cytospin test (AOLC) is rapid (30 minutes), inexpensive, and requires only 100 μl catheter blood (treated with edetic acid) and the use of light and ultraviolet microscopy. Blood was withdrawn through a CVC lumen and subjected to these tests. These results were compared with two other methods—namely, catheter removal (tip roll and tip flush) and an in situ endoluminal brush, in conjunction with quantitative peripheral blood cultures. Catheter related bloodstream infection was defined as a positive culture by one or more of the three CVC culture techniques and validation by positive quantitative peripheral blood culture caused by the same micro-organism.

Results

128 cases of suspected catheter related bloodstream infection were assessed in 124 surgical patients. In 112 (88%) cases CVC blood was obtainable. Catheter related bloodstream infection was diagnosed in 50 cases. The sensitivity of the gram stain and AOLC test was 96% and the specificity was 92% with a positive predictive value of 91% and a negative predictive value of 97%. Comparatively, the tip roll, tip flush, and endoluminal brush methods had sensitivities of 90%, 95%, and 92% and specificities of 55%, 76%, and 98%, respectively.

Conclusions

The gram stain and AOLC test is a simple, non-invasive, and rapid method for the diagnosis of catheter related bloodstream infection. This diagnostic method compares favourably with other diagnostic methods such as catheter removal.

## Tube feeding of patients with dementia

The issue of tube feeding patients with dementia is commonly debated, mostly from an ethical stance. The following article reviews existing clinical research and finds few positive outcomes to support its use with these types of patients. This article will stimulate debate and encourage clinicians to reconsider their practice in this area.

Finucane TE, Christmas C, Travis K . Tube feeding in patients with advanced dementia, a review of the evidence. JAMA 1999; 282 :1365–70.

Background

Patients with advanced dementia frequently develop eating difficulties and weight loss. Enteral feeding is intended to prevent aspiration pneumonia and malnutrition and its sequealae, including death by starvation. It is also used to provide comfort. Although tube feeding is commonly used with patients who have dementia, the benefits and risks of this treatment are unclear.

Methods

The authors searched and reviewed Medline (1966–99) to identify data about the efficacy of this treatment. Studies pertaining to patients with cancer, burns, trauma, dysphagic stroke mechanical obstruction, critical illness, paediatrics, or ventilated patients were not considered. The focus of the review was maintained on the clinical evidence of enteral tube feeding. The data gathered were assessed on whether or not tube feeding could prevent aspiration pneumonia, prolong survival, reduce the risk of pressure sores or infection, improve function, or provide palliation.

Results

No randomised trial studies were found that compared tube feeding with oral feeding. The reviewed studies were based on retrospective or observational studies, or were not based on those with dementia. As regards aspiration pneumonia, an enteral tube cannot prevent regurgitated gastric contents/oral secretions entering the lungs. No research to date would suggest that tube feeding could reduce the risk of aspiration pneumonia. Tube feeding does not appear to prevent the consequences of malnutrition despite administration of adequate nutrients and calories. Furthermore, the authors could not substantiate the view that enteral feeding improves patients' survival. In fact it was discovered that its use is associated with significant adverse effects and mortality rates. No evidence linking tube feeding to positive outcomes for pressure sores was found. Also, the delivery of nutrients via an enteral tube has not been shown to reduce infection. Instead it has been shown to cause serious local and systemic infection. It is widely believed that providing an emaciated patient with artificial feeding is thought to improve strength, function, or self care. No clinical evidence exists to support this stance, however. There are also no published reports of patients with dementia being made more comfortable by the use of a tube. Enteral feeding denies the individual the pleasure of eating as well as subjecting the person to discomfort of the tube and to regular repositioning of same. In addition, patients with an enteral tube in situ may have the added imposition of a physical/chemical restraint.

Conclusions

The authors could not identify any data to support the use of tube feeding patients with dementia. The authors reflect on possible reasoning behind this form of treatment, for example convenience and misunderstanding of healthcare providers and families.

## Ethnicity, tuberculosis, and poverty

This article provides an analysis of the differences in ethnicity in relation to tuberculosis and poverty. The findings have repercussions for planners and deliverers of public health and environmental policies.

Hawker JI, Bakshshi SS, Ali S, et al . Ecological analysis of ethnic differences in relation between tuberculosis and poverty . BMJ 1999; 319 :1031–4.

Background

The epidemiology of tuberculosis differs considerably with ethnicity. For example, in the main, Asian people acquire new infection from infected people in the same community or when visiting the Indian subcontinent. Comparatively, white people generally have reactivation of endogenous latent infection. This distinction is reflected in the differences in the age distribution of cases and in the type of disease between ethnic groups. It can not be assumed that social factors that affect tuberculosis incidence in one group will affect another group. This study explored the effect of ethnicity on the relation between tuberculosis and deprivation.

Methods

1991 census data (which includes demographic profiles) were used from 39 electoral wards in Birmingham, UK. A retrospective ecological approach was used to compare the incidence of tuberculosis in white and south Asian residents in these wards. During the study period (1989–93), 1516 cases of tuberculosis were notified in Birmingham. Of these 995 (66%) were in Asians and 332 (22%) in white people. The crude annual notification rates were 153/100 000 population for Asian people and 8.8/100 000 for white people, a 17-fold difference.

Results

Univariate analysis showed significant associations of tuberculosis rates for the whole population with several indices of deprivation (p>0.01) and with the proportion of the population of south Asian origin (p<0.01). All deprivation covariates were associated positively with each other, but on multiple regression a higher level of overcrowding was independently associated with high tuberculosis rates. For the white population, overcrowding was associated with tuberculosis rates independently of other variables (p=0.0036). No relation with deprivation was found for the south Asian population in either single or multivariate analyses.

Conclusions

Social factors such as poverty, which influence the likelihood of developing (predominantly reactivated) tuberculosis in white people, are likely to be different from those influencing the risk of contracting (predominately new infection) tuberculosis in the Asian population. Potential interventions such as public health measures need to reflect these differences.

RÓISÍN GALLINAGH

Lecturer/Practitioner in Nursing, Whiteabbey Hospital and University of Ulster, Jordanstown, Co Antrim, UK

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