"There's something happening here
What it is ain't exactly clear..."
—Buffalo Springfield
Improving the efficiency and quality of care that hospitalised patients receive is clearly important. The study by Glasgow and colleagues in this issue of BMJ Quality and Safety provides interesting insights into the summative outcomes of a large, national quality collaborative focused on reducing length of stay and discharging hospitalised patients before noon. Additionally, the authors included mortality and 30-day readmissions as secondary outcomes as part of their robust evaluation of a large mandatory collaborative (termed ‘FIX’) that occurred within the 130 hospitals that are part of the Veterans Health Administration (VHA). The findings of this ambitious study extend the literature evaluating quality-improvement projects. We applaud the authors on their achievement in reporting short-term outcomes of this large-scale initiative, and in going further to assess how any gains achieved in the initiative endured. Their innovative approach to measuring sustainability is an...]]>
High-quality discharge summaries are a key component of a safe transition in care. The purpose of this study was to determine the effects of standardised feedback and a ‘discharge time-out’ (DTO) on the quality of discharge summaries.
During 2006–2007, the authors trained hospitalists to provide two interventions at their discretion: (1) feedback on one discharge summary to each intern using a standardised form and (2) a DTO, modelled after the surgical time-out, in which key questions about the patient's hospital course and discharge plan are answered verbally by the intern during rounds on the day of discharge. To evaluate these interventions, trained clinicians, blinded to group assignment, performed an explicit review of two discharge summaries before and after intervention implementation. The authors used a mixed linear model to evaluate relative improvement over time.
The authors compared 14 interns who only received a 1-h lecture and a small-group resident-led training session with 13 interns who also received feedback and 12 interns who received feedback and a DTO. Save greater improvement in the documentation of tasks to be completed after discharge (39% vs 8% absolute improvement, p=0.05) by interns receiving an intervention, most domains were unaffected by having received a DTO and/or feedback.
These results suggest that standardised feedback and a DTO integrated into attending rounds have limited potential to improve discharge summaries as currently designed. This study stresses the need for developing and refining interventions that can improve the narrative flow of discharge summaries.
To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture.
All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure.
The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05).
The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.
Enhancing competency in patient safety at entry to practice requires introduction and integration of patient safety into health professional education. As efforts to include patient safety in health professional education increase, it is important to capture new health professionals' perspectives of their own patient safety competence at entry to practice. Existing instruments to measure patient safety knowledge, skills and attitudes have been developed largely to examine the impact of specific patient safety curricular initiatives and the psychometric analyses of the instruments used thus far have been exploratory in nature.
Confirmatory factor analytic approaches are used to extensively test the Health Professional Education in Patient Safety Survey (H-PEPSS), a newly designed survey rooted in a patient safety competency framework and designed to measure health professionals' self-reported patient safety competence around the time of entry to practice. The H-PEPSS focuses primarily on the socio-cultural aspects of patient safety including culture, teamwork, communication, managing risk and understanding human factors.
Results support a parsimonious six-factor measurement model of health professionals' perceptions of patient safety competency. These results support the validity of a reduced version of the H-PEPSS and suggest it can be appropriately used at or near training completion with a variety of health professional groups.
Given increased demands for patient safety competency among health professionals at entry to practice and slow, but emerging changes in health professional education, ongoing research to understand the extent of patient safety competency among health professionals around the time of entry to practice will be important.
Patients are increasingly being thought of as central to patient safety. A small but growing body of work suggests that patients may have a role in reporting patient safety problems within a hospital setting. This review considers this disparate body of work, aiming to establish a collective view on hospital-based patient reporting.
This review asks: (a) What can patients report? (b) In what settings can they report? (c) At what times have patients been asked to report? (d) How have patients been asked to report?
5 databases (MEDLINE, EMBASE, CINAHL, (Kings Fund) HMIC and PsycINFO) were searched for published literature on patient reporting of patient safety ‘problems’ (a number of search terms were utilised) within a hospital setting. In addition, reference lists of all included papers were checked for relevant literature.
13 papers were included within this review. All included papers were quality assessed using a framework for comparing both qualitative and quantitative designs, and reviewed in line with the study objectives.
Patients are clearly in a position to report on patient safety, but included papers varied considerably in focus, design and analysis, with all papers lacking a theoretical underpinning. In all papers, reports were actively solicited from patients, with no evidence currently supporting spontaneous reporting. The impact of timing upon accuracy of information has yet to be established, and many vulnerable patients are not currently being included in patient reporting studies, potentially introducing bias and underestimating the scale of patient reporting. The future of patient reporting may well be as part of an ‘error detection jigsaw’ used alongside other methods as part of a quality improvement toolkit.
The study had two specific objectives: (1) To analyse change in a survey measure of organisational patient safety climate and capability (SCC) resulting from participation in the UK Safer Patients Initiative and (2) To investigate the role of a range of programme and contextual factors in predicting change in SCC scores.
Single group longitudinal design with repeated measurement at 12-month follow-up.
Multiple service areas within NHS hospital sites across England, Wales, Scotland and Northern Ireland.
Stratified sample of 284 respondents representing programme teams at 19 hospital sites.
A complex intervention comprising a multi-component quality improvement collaborative focused upon patient safety and designed to impact upon hospital leadership, communication, organisation and safety climate.
A survey including a 31-item SCC scale was administered at two time-points.
Modest but significant positive movement in SCC score was observed between the study time-points. Individual programme responsibility, availability of early adopters, multi-professional collaboration and extent of process measurement were significant predictors of change in SCC. Hospital type and size, along with a range of programme preconditions, were not found to be significant.
A range of social, cultural and organisational factors may be sensitive to this type of intervention but the measurable effect is small. Supporting critical local programme implementation factors may be an effective strategy in achieving development in organisational patient SCC, regardless of contextual factors and organisational preconditions.
Cardiac surgery is a complex, high-risk procedure with potential vulnerabilities for patient safety. The evidence base describing safety hazards in the cardiovascular operating room is underdeveloped but is essential to guide future safety improvement efforts.
To identify and categorise hazards (anything that has the potential to cause a preventable adverse patient safety event) in the cardiovascular operating room.
An interdisciplinary team of researchers used prospective methods, including direct observations, contextual inquiry and photographs to collect hazard data pertaining to the cardiac surgery perioperative period, which started immediately before the patient was transferred to the operating room and ended immediately after patient handoff to the post-anaesthesia/intensive care unit. Data were collected between February and September 2008 in five hospitals. An interdisciplinary approach that included a human factors and systems engineering framework was used to guide the study.
Twenty cardiac surgeries including the corresponding handoff processes from operating room to post-anaesthesia/intensive care unit were observed. A total of 58 categories of hazards related to care providers (eg, practice variations), tasks (eg, high workload), tools and technologies (eg, poor usability), physical environment (eg, cluttered workspace), organisation (eg, hierarchical culture) and processes (eg, non-compliance with guidelines) were identified.
Hazards in cardiac surgery services are ubiquitous, indicating numerous opportunities to improve safety. Future efforts should focus on creating a stronger culture of safety in the cardiovascular operating room, increasing compliance with evidence-based infection control practices, improving communication and teamwork, and developing a partnership among all stakeholders to improve the design of tools and technologies.
Timely reporting and acknowledgement are crucial steps in critical laboratory results (CLR) management. The authors previously showed that an automated pathway incorporating short messaging system (SMS) texts, auto-escalation, and manual telephone back-up improved the rate and speed of physician acknowledgement compared with manual telephone calling alone. This study investigated if it also improved the rate and speed of physician intervention to CLR and whether utilising the manual back-up affected intervention rates.
Data from seven audits between November 2007 and January 2011 were analysed. These audits were carried out to assess the robustness of CLR reporting process in the authors' institution. Comparisons were made in the rate and speed of acknowledgement and intervention between the audits performed before and after automation. Using the automation audits, the authors compared intervention data between communication with SMS only and when manual intervention was required.
1680 CLR were reported during the audit periods. Automation improved the rate (100% vs 84.2%; p<0.001) and speed (median 12 min vs 23 min; p<0.001) of CLR acknowledgement. It also improved the rate (93.7% vs 84.0%, p<0.001) and speed (median 21 min vs 109 min; p<0.001) of CLR intervention. From the automation audits, the use of SMS only did not improve physician intervention rates.
The automated communication pathway improved physician intervention rate and time in tandem with improved acknowledgement rate and time when compared with manual telephone calling. The use of manual intervention to augment automation did not adversely affect physician intervention rate, implying that an end-to-end pathway was more important than automation alone.
Study goals were to assess older veterans' understanding of their emergency department (ED) discharge information and to determine the association between understanding discharge information and patient assessment of overall quality of care.
Telephone interviews were conducted with 305 patients aged 65 or older (or their proxies) within 48 h of discharge from a Veterans Affairs Medical Center ED. Patients were asked about their perceived understanding (at the time of ED discharge) of information about their ED diagnosis, expected course of illness, contingency plan (ie, return precautions, who to call if it got worse, potential medication side effects) and follow-up care. Overall quality of ED care was rated on a four-point scale of poor, fair, good or excellent.
Patients or their proxies reported not understanding information about their ED diagnosis (21%), expected course of illness (50%), contingency plan (43%), and how soon they needed to follow-up with their primary care provider (25%). In models adjusted for age and race, a positive association was observed between perceived understanding of the cause of the problem (OR 2.3; 95% CI 1.3 to 4.0), expected duration of symptoms (OR 1.6; 95% CI 1.0 to 2.5) and the contingency plan (OR 2.2; CI 1.3 to 3.4), and rating overall ED care as excellent.
Older veterans may not understand key items of information at the time ED discharge, and this may have an impact on how they view the quality of ED care. Strategies are needed to improve communication of ED discharge information to older veterans and their families.
National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety.
To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members.
The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance.
M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.
Research has demonstrated a knowledge and practice gap in the identification and management of chronic kidney disease (CKD). In 2009, published data showed that general practices in Greater Manchester had a low detection rate for CKD.
A 12-month improvement collaborative, supported by an evidence-informed implementation framework and financial incentives.
19 general practices from four primary care trusts within Greater Manchester.
Number of recorded patients with CKD on practice registers; percentage of patients on registers achieving nationally agreed blood pressure targets.
The collaborative commenced in September 2009 and involved three joint learning sessions, interspersed with practice level rapid improvement cycles, and supported by an implementation team from the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Greater Manchester.
At baseline, the 19 collaborative practices had 4185 patients on their CKD registers. At final data collection in September 2010, this figure had increased by 1324 to 5509. Blood pressure improved from 34% to 74% of patients on practice registers having a recorded blood pressure within recommended guidelines.
Evidence-based improvement can be implemented in practice for chronic disease management. A collaborative approach has been successful in enabling teams to test and apply changes to identify patients and improve care. The model has proved to be more successful for some practices, suggesting a need to develop more context-sensitive approaches to implementation and actively manage the factors that influence the success of the collaborative.
Formal evaluations of programmes are an important source of learning about the challenges faced in improving quality in healthcare and how they can be addressed. The authors aimed to integrate lessons from evaluations of the Health Foundation's improvement programmes with relevant literature.
The authors analysed evaluation reports relating to five Health Foundation improvement programmes using a form of ‘best fit’ synthesis, where a pre-existing framework was used for initial coding and then updated in response to the emerging analysis. A rapid narrative review of relevant literature was also undertaken.
The authors identified ten key challenges: convincing people that there is a problem that is relevant to them; convincing them that the solution chosen is the right one; getting data collection and monitoring systems right; excess ambitions and ‘projectness’; organisational cultures, capacities and contexts; tribalism and lack of staff engagement; leadership; incentivising participation and ‘hard edges’; securing sustainability; and risk of unintended consequences. The authors identified a range of tactics that may be used to respond to these challenges.
Securing improvement may be hard and slow and faces many challenges. Formal evaluations assist in recognising the nature of these challenges and help in addressing them.
Errors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review was to identify interventions that might reduce the likelihood of these cognitive errors.
We searched PubMed and other medical and non-medical databases and identified additional literature through references from the initial data set and suggestions from subject matter experts. Articles were included if they either suggested a possible intervention or formally evaluated an intervention and excluded if they focused solely on improving diagnostic tests or provider satisfaction.
We identified 141 articles for full review, 42 reporting tested interventions to reduce the likelihood of cognitive errors, 100 containing suggestions, and one article with both suggested and tested interventions. Articles were classified into three categories: (1) Interventions to improve knowledge and experience, such as simulation-based training, improved feedback and education focused on a single disease; (2) Interventions to improve clinical reasoning and decision-making skills, such as reflective practice and active metacognitive review; and (3) Interventions that provide cognitive ‘help’ that included use of electronic records and integrated decision support, informaticians and facilitating access to information, second opinions and specialists.
We identified a wide range of possible approaches to reduce cognitive errors in diagnosis. Not all the suggestions have been tested, and of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice. Future progress in this area will require methodological refinements in outcome evaluation and rigorously evaluating interventions already suggested, many of which are well conceptualised and widely endorsed.
The objective was to systematically review comparative economic analyses of patient safety improvements in the acute care setting.
A systematic review of 15 patient safety target conditions and six improvement strategies was conducted. The authors searched the published literature through Medline (2000–November 2011) using the following search terms for costs: ‘costs and cost analysis’, ‘cost-effectiveness’, ‘cost’ and ‘financial management, hospital’. The methodological quality of potentially relevant studies was appraised using Cochrane rules of evidence for clinical effectiveness in quality improvement, and standard economic methods.
The authors screened 2151 abstracts, reviewed 212 potentially eligible studies, and identified five comparative economic analyses that reported a total of seven comparisons based on at least one clinical effectiveness study of adequate methodological quality. Pharmacist-led medication reconciliation to prevent potential adverse drug events dominated (lower costs, better safety) a strategy of no reconciliation. Chlorhexidine for vascular catheter site care to prevent catheter-related bloodstream infections dominated a strategy of povidone-iodine for catheter site care. The Keystone ICU initiative to prevent central line-associated bloodstream infections was economically dominant over usual care. Detecting surgical foreign bodies using standard counting compared with a strategy of no counting had an incremental cost of US$1500 (CAN$1676) for each surgical foreign body detected. Several safety improvement strategies were less economically attractive, such as bar-coded sponges for reducing retained surgical sponges compared with standard surgical counting, and giving erythropoietin to reduce transfusion requirements in critically ill patients to avoid one transfusion-related adverse event.
Five comparative economic analyses were found that reported a total of seven comparisons based on at least one effectiveness study of adequate methodological quality. On the basis of these limited studies, pharmacist-led medication reconciliation, the Keystone ICU intervention for central line-associated bloodstream infections, chlorhexidine for vascular catheter site care, and standard surgical sponge counts were economically attractive strategies for improving patient safety. More comparative economic analyses of such strategies are needed.
Unsolicited web-based comments by patients regarding their healthcare are increasing, but controversial. The relationship between such online patient reports and conventional measures of patient experience (obtained via survey) is not known. The authors examined hospital level associations between web-based patient ratings on the National Health Service (NHS) Choices website, introduced in England during 2008, and paper-based survey measures of patient experience. The authors also aimed to compare these two methods of measuring patient experience.
The authors performed a cross-sectional observational study of all (n=146) acute general NHS hospital trusts in England using data from 9997 patient web-based ratings posted on the NHS Choices website during 2009/2010. Hospital trust level indicators of patient experience from a paper-based survey (five measures) were compared with web-based patient ratings using Spearman's rank correlation coefficient. The authors compared the strength of associations among clinical outcomes, patient experience survey results and NHS Choices ratings.
Web-based ratings of patient experience were associated with ratings derived from a national paper-based patient survey (Spearman =0.31–0.49, p<0.001 for all). Associations with clinical outcomes were at least as strong for online ratings as for traditional survey measures of patient experience.
Unsolicited web-based patient ratings of their care, though potentially prone to many biases, are correlated with survey measures of patient experience. They may be useful tools for patients when choosing healthcare providers and for clinicians to improve the quality of their services.
It is well known that many healthcare systems have poor reliability; however, the size and pervasiveness of this problem and its impact has not been systematically established in the UK. The authors studied four clinical systems: clinical information in surgical outpatient clinics, prescribing for hospital inpatients, equipment in theatres, and insertion of peripheral intravenous lines. The aim was to describe the nature, extent and variation in reliability of these four systems in a sample of UK hospitals, and to explore the reasons for poor reliability.
Seven UK hospital organisations were involved; each system was studied in three of these. The authors took delivery of the systems' intended outputs to be a proxy for the reliability of the system as a whole. For example, for clinical information, 100% reliability was defined as all patients having an agreed list of clinical information available when needed during their appointment. Systems factors were explored using semi-structured interviews with key informants. Common themes across the systems were identified.
Overall reliability was found to be between 81% and 87% for the systems studied, with significant variation between organisations for some systems: clinical information in outpatient clinics ranged from 73% to 96%; prescribing for hospital inpatients 82–88%; equipment availability in theatres 63–88%; and availability of equipment for insertion of peripheral intravenous lines 80–88%. One in five reliability failures were associated with perceived threats to patient safety. Common factors causing poor reliability included lack of feedback, lack of standardisation, and issues such as access to information out of working hours.
Reported reliability was low for the four systems studied, with some common factors behind each. However, this hides significant variation between organisations for some processes, suggesting that some organisations have managed to create more reliable systems. Standardisation of processes would be expected to have significant benefit.
To examine the reliability and predictive validity of two patient safety culture surveys—Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPS)—when administered to the same participants. Also to determine the ability to convert HSOPS scores to SAQ scores.
Employees working in intensive care units in 12 hospitals within a large hospital system in the southern United States were invited to anonymously complete both safety culture surveys electronically.
All safety culture dimensions from both surveys (with the exception of HSOPS's Staffing) had adequate levels of reliability. Three of HSOPS's outcomes—frequency of event reporting, overall perceptions of patient safety, and overall patient safety grade—were significantly correlated with SAQ and HSOPS dimensions of culture at the individual level, with correlations ranging from r=0.41 to 0.65 for the SAQ dimensions and from r=0.22 to 0.72 for the HSOPS dimensions. Neither the SAQ dimensions nor the HSOPS dimensions predicted the fourth HSOPS outcome—number of events reported within the last 12 months. Regression analyses indicated that HSOPS safety culture dimensions were the best predictors of frequency of event reporting and overall perceptions of patient safety while SAQ and HSOPS dimensions both predicted patient safety grade. Unit-level analyses were not conducted because indices did not indicate that aggregation was appropriate. Scores were converted between the surveys, although much variance remained unexplained.
Given that the SAQ and HSOPS had similar reliability and predictive validity, investigators and quality and safety leaders should consider survey length, content, sensitivity to change and the ability to benchmark when selecting a patient safety culture survey.
The paper by Gillespie et al
We feel that what is required in studies such as the one reported by Gillespie et al
Despite considerable efforts to improve healthcare quality and patient safety, broad measures of patient outcomes show little improvement. Many factors, including limited programme evaluations and understanding of whether quality improvement (QI) efforts are sustained, potentially contribute to the lack of widespread improvements in quality. This study examines whether hospitals participating in a Veterans Health Affairs QI collaborative have made and then sustained improvements.
Separate patient-level risk-adjusted time-series models for two primary outcomes (hospital length of stay (LOS) and rate of discharges before noon) as well as three secondary outcomes (30-day all-cause hospital readmission, in-hospital mortality and 30-day mortality). The models considered 2 years of pre-intervention data, 1 year of data to measure improvements and then 2 years of post-intervention data to see whether improvements were sustained.
Among 130 Veterans Affairs hospitals, 35% and 46% exhibited improvements beyond baseline trends on LOS and discharges before noon, respectively. 60% of improving LOS hospitals exhibited sustained improvements, but only 32% for discharges by noon. Additional subgroup analyses by hospital size and region found a similar performance across most groups.
This quasi-experimental evaluation found lower rates of improvements than normally reported in studies of QI collaboratives. The most striking observation was that a majority of hospitals increased their rates of discharges before noon, but after completing the collaborative their performance declined. Future work needs to qualitatively and quantitatively assess what organisational features distinguish those hospitals that can improve and sustain quality.
To determine if composite measures based on process indicators are consistent with short-term outcome indicators in surgical colorectal cancer care.
Longitudinal analysis of consistency between composite measures based on process indicators and outcome indicators for 85 Dutch hospitals.
The Dutch Surgical Colorectal Audit database, the Netherlands.
4732 elective patients with colon carcinoma and 2239 with rectum carcinoma treated in 85 hospitals were included in the analyses.
All available process indicators were aggregated into five different composite measures. The association of the different composite measures with risk-adjusted postoperative mortality and morbidity was analysed at the patient and hospital level.
At the patient level, only one of the composite measures was negatively associated with morbidity for rectum carcinoma. At the hospital level, a strong negative association was found between composite measures and hospital mortality and morbidity rates for rectum carcinoma (p<0.05), and hospital morbidity rates for colon carcinoma.
For individual patients, a high score on the composite measures based on process indicators is not associated with better short-term outcome. However, at the hospital level, a good score on the composite measures based on process indicators was consistent with more favourable risk-adjusted short-term outcome rates.
This issue of the journal contains a descriptive study by Ott and colleagues that highlights how medical emergencies in medical imaging departments are neither rare nor benign.
A variety of quality measurement schemes exist in many countries, including confidential reporting directed at healthcare organisations, public reporting of performance, policies tying performance to funding, such as ‘pay for performance’.
More than half of in-hospital adverse events can be attributed to a surgical discipline. Checklists can effectively decrease errors and adverse events. However, the mechanisms by which checklists lead to increased safety are unclear. This study aimed to assess the number, nature and timing of incidents intercepted by use of the Surgical Patient Safety System (SURPASS) checklist, a patient-specific multidisciplinary checklist that covers the entire surgical patient pathway.
The checklist was implemented in two academic hospitals and four teaching hospitals in the Netherlands. Users of the checklist had three options for each item that was checked: ‘not applicable’, ‘yes’ and ‘intercepted by checklist’. In each hospital, the first 1000 completed checklists were entered into an online central database.
In six participating hospitals, 6313 checklists were collected. One or more incidents were intercepted in 2562 checklists (40.6%). In total, 6312 incidents were intercepted. After correction for the number of items and the extent of adherence in each part of the checklist, the number of intercepted incidents was highest in the preoperative and postoperative stages.
The checklist intercepts many potentially harmful incidents across all stages of the surgical patient pathway. The majority of incidents were intercepted in the preoperative and postoperative stages of the pathway. The degree to which these incidents would have been intercepted by a single checklist in the operating room only, compared with a checklist for the entire surgical pathway, remains a subject for future study.
To demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital microsystems and macrosystems.
Ordinary least squares and panel data regression of retrospective hospital billing data, and SPC charts of prospective patient records for a US tertiary-care facility (2004–2007). A prospective cohort of hospital inpatients at risk for HAPUs was the study population.
There were 337 HAPU incidences hospital wide among 43 844 inpatients. A probit regression model predicted the correlation of age, gender and length of stay on HAPU incidence (pseudo R2=0.096). Panel data analysis determined that for each additional day in the hospital, there was a 0.28% increase in the likelihood of HAPU incidence. A p-chart of HAPU incidence showed a mean incidence rate of 1.17% remaining in statistical control. A t-chart showed the average time between events for the last 25 HAPUs was 13.25 days. There was one 57-day period between two incidences during the observation period. A p-chart addressing Braden scale assessments showed that 40.5% of all patients were risk stratified for HAPUs upon admission.
SPC charts complement standard regression analysis. SPC amplifies patient outcomes at the microsystem level and is useful for guiding quality improvement. Macrosystems should monitor effective quality improvement initiatives in microsystems and aid the spread of successful initiatives to other microsystems, followed by system-wide analysis with regression. Although HAPU incidence in this study is below the national mean, there is still room to improve HAPU incidence in this hospital setting since 0% incidence is theoretically achievable. Further assessment of pressure ulcer incidence could illustrate improvement in the quality of care and prevent HAPUs.
We sought to identify the characteristics of patients who experience medical emergency team calls in the radiology department (MET-RD) and the relationship between these characteristics and patient outcomes.
Retrospective review of 111 inpatient MET-RD calls (May 2008–April 2010).
Academic medical centre with a well established MET system.
The characteristics of patients before, during and after transport to radiology were extracted from medical records and administrative databases. These characteristics were compared between patients with good and poor outcomes.
The majority of patients who experience MET-RD calls had a Charlson Comorbidity Index ≥4 and were from non-intensive care units (60%). Almost half (43%) of MET-RD calls occurred during patients' first day in hospital. Patients commonly arrived with nasal cannula oxygen (38%), recent tachypnoea (28%) and tachycardia (34%). A minority (16%) fulfilled MET call criteria in the 12 h before the MET-RD. MET-RD etiologies were cardiac (41%), respiratory (29%) or neurological (25%), and occurred most frequently during CT (44%) and MRI (22%) testing. Post MET-RD, the majority of patients (70%) required a higher level of care. Death before discharge (25%) was associated with need for cardiovascular support prior to RD transport (p=0.02), need for RD monitoring (p=0.02) and need for heightened RD surveillance (p=0.04).
The majority of patients who experienced MET-RD calls came from non-intensive care units, with comorbidities and vital sign alterations prior to arrival at the RD. Risk appeared to be increased for those requiring CT and MRI. These findings suggest that prior identification of a subset of patients at risk of instability in the RD may be possible.
Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence.
Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physician's HH compliance.
718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p<0.001). Similar results were seen on exiting the room. The effects of the first person were not driven solely by the attending physician's HH behaviour because the attending physician was first or second to enter 57% of the encounters and exit 44% of the encounters.
If the first person entering a patient room performs HH, then others were more likely to perform HH too, implying that peer pressure impacts team member HH compliance. The attending physician's behaviour also influenced team members regardless of whether the attending physician was the first to enter or exit an encounter, implying that role modelling impacts the HH behaviour of learners. These findings should be used when designing HH improvement programmes targeting physicians.
Communication breakdowns have been identified as a source of problems in complex work settings such as hospital-based healthcare.
The authors conducted a multi-method study of change of shift handoffs between nurses, including interviews, survey, audio taping and direct observation of handoffs, posthandoff questionnaires, and archival coding of clinical records.
The authors found considerable variability across units, nurses and, surprisingly, roles. Incoming and outgoing nurses had different expectations for a good handoff: incoming nurses wanted a conversation with questions and eye contact, whereas outgoing nurses wanted to tell their story without interruptions. More experienced nurses abbreviated their reports when incoming nurses knew the patient, but the incoming nurses responded with a large number of questions, creating a contest for control. Nurses' ratings did not correspond to expert ratings of information adequacy, suggesting that nurses consider other functions of handoffs beyond information processing, such as social interaction and learning.
These results suggest that variability across roles as information provider versus receiver and experience level (as well as across individual and organisational contexts) are reasons why improvement efforts directed at standardising and improving handoffs have been challenging in nursing and in other healthcare professions as well.
Korne et al used co-creation between surgical staff and tarmac operators at Schiphol airport and a work analysis to develop a design solution to an issue that had traditionally been approached through training and technical issues. This is an approach firmly rooted in human factors. Many people in healthcare will now be familiar with the term ‘human factors’, but how far have we come in applying this approach in healthcare?
One of the earliest references to human factors in the healthcare literature dates back to 1957 and calls for...]]>
One in seven pages are sent to the wrong physician and may result in unnecessary delays that potentially threaten patient safety. The authors aimed to implement a new team-based paging process to reduce pages sent to the wrong physician.
The authors redesigned the paging process on general internal medicine (GIM) wards at a Canadian academic medical centre by implementing a standardised team-based paging process (pages directed to one physician responsible for receiving pages on behalf of the entire physician team) using rapid-cycle change methods. The authors evaluated the intervention using a controlled before–after study design by measuring pages sent to the wrong physician before and after implementation of the redesigned paging process.
Pages sent to the wrong physician from the GIM (intervention) wards decreased from 14% to 3% (11% reduction), while pages sent to the wrong physician from control wards fell from 13% to 7% (6% reduction). The difference between the intervention wards and the control wards was significant (5% greater reduction in the intervention group compared with the control group, p=0.008). Nurses were more satisfied with team-based paging than the existing paging process. Team-based paging may, however, introduce changes in communication workflow that lead to increased paging interruptions for certain members of the physician team.
The authors successfully redesigned the hospital's paging process to decrease pages sent to the wrong physician. They recommend that the frequency of pages sent to the wrong physician is measured and changes be implemented to paging processes to reduce this error.
The role of time management in safe and efficient medicine is important but poorly incorporated into the taxonomies of error in primary care. This paper addresses the lack of time management, presenting a framework integrating five time scales termed ‘Tempos’ requiring parallel processing by GPs: the disease's tempo (unexpected rapid evolutions, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. The art of medicine is to control all of these tempos in parallel and simultaneously.
Two qualified physicians reviewed a sample of 1046 malpractice claims from one liability insurer to determine whether a medical injury had occurred and, if so, whether it was due to one or more tempo-related problems. 623 of these reports were analysed in greater detail to identify the prevalence and characteristics of claims and related time management errors.
The percentages of contributing factors were as follows: disease tempo, 37.9%; office tempo, 13.2%; patient tempo, 13.8%; out-of-office coordination tempo, 22.6%; and GP's access to knowledge tempo, 33.2%.
Although not conceptualised in most error taxonomies, the disease and patient tempos are cornerstones in risk management in primary care. Traditional taxonomies describe events from an analytical perspective of care at the system level and offer opportunities to improve organisation, process, and evidence-based medicine. The suggested classification describes events in terms of (unsafe) dynamic control of parallel constraints from the carer's perspective, namely the GP, and offers improvement on how to self manage and coordinate different contradictory tempos and day-to-day activities. Further work is needed to test the validity and usefulness of this approach.
To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned.
The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics.
Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR.
OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.
Oncology nurses in ambulatory settings are at increased risk for unintentional chemotherapy exposure due to the large volumes of agents delivered and the absence of regulatory enforcement. Given the limited data regarding the correlates of exposure, the authors sought to identify the relationship between the organisational structures and processes of care in ambulatory oncology settings associated with increased risk of unintentional chemotherapy.
Between April 2010 and June 2010, a state-wide sample of oncology nurses were surveyed who reported their employment outside of hospital inpatient units (n=1339). The survey examined the likelihood of self-reported exposure to chemotherapy as a function of perceived quality of the practice environment, nursing workload, and seven ambulatory chemotherapy administration safety standards.
The response rate was 30.4%, with minimal demographic differences observed between respondents and non-respondents. The overall rate of exposure to the skin or eyes in the past year was 16.9%. In multivariable logistic regression models that controlled for demographic characteristics and clustering of nurses in practices, the likelihood of exposure decreased when nurses reported adequate staffing and resources (OR 0.35, 95% CI 0.17 to 0.73; p=0.001), and when nurses reported that chemotherapy doses were verified by two nurses frequently or very frequently (OR 0.17, 95% CI 0.05 to 0.59; p=0.001).
Oncology nurses in the ambulatory setting report substantial unintentional skin and eye exposure to chemotherapy. Ensuring adequate staffing and resources and adherence to recognised practice standards may protect oncology nurses from harm.
Use of sedation protocols is associated with fewer mechanical ventilation days in critically ill patients. Canadian intensive care units (ICUs) often have a higher nurse–patient ratio and more specialised training of ICU nurses than French ICUs. Considering these differences, the purpose of this study was to compare implementation of sedation protocols as indicated by frequency of sedation assessment and response to levels of sedation between a Canadian and a French ICU.
This was a retrospective observational study of 30 patients who were mechanically ventilated for at least 24 h in each of two tertiary care ICUs in Vancouver, Canada and Montpellier, France. The authors tabulated all Richmond Agitation–Sedation Scale scores, frequency of score measurement, target scores, frequency and magnitude of scores that were out of target range, and the response to these scores within 1 h of measurement. Practices between the two hospitals were compared using regression modelling, adjusting for patient age, sex, and Acute Physiology and Chronic Health Evaluation (APACHE) II score.
Although sedation scores were measured more frequently in the Canadian ICU, there were fewer appropriate adjustments in medications in response to scores that were outside the target range in this ICU than in the French ICU, which had a lower nurse–patient ratio and no specialised training of nurses (OR 0.26 (95% CI 0.13 to 0.50) for scores that were higher than target, and OR 0.14 (95% CI 0.07 to 0.28) for scores that were lower than target).
Differences in sedation management between these ICUs are likely related to factors other than nurse–patient ratio or specialised training of ICU nurses.
The safety-and-quality movement is now two decades old. Errors persist despite best efforts, indicating that there are entrenched overt and perhaps less explicit barriers limiting the success of improvement efforts.
To examine the perspectives of five groups of healthcare workers (administrative staff, nurses, medical practitioners, allied health and managers) and to compare and contrast their descriptions of quality-and-safety activities within their organisation. Differences in perspectives can be an indicator of divergence in the conceptualisation of, and impetus for, quality-improvement strategies which are intended to engage healthcare professions and staff.
Study data were collected in a defined geographical healthcare jurisdiction in Australia, via individual and group interviews held across four service streams (aged care and rehabilitation; mental health; community health; and cancer services). Data were collected in 2008 and analysed, using data-mining software, in 2009.
Clear differences in the perspectives of professional groups were evident, suggesting variations in the perceptions of, and priorities for, quality and safety.
The visual representation of quality and safety perspectives provides insights into the conceptual maps currently utilised by healthcare workers. Understanding the similarity and differences in these maps may enable more effective targeting of interprofessional improvement strategies.
To measure patient safety culture in Belgian hospitals and to examine the homogeneous grouping of underlying safety culture dimensions.
The Hospital Survey on Patient Safety Culture was distributed organisation-wide in 180 Belgian hospitals participating in the federal program on quality and safety between 2007 and 2009. Participating hospitals were invited to submit their data to a comparative database. Homogeneous groups of underlying safety culture dimensions were sought by hierarchical cluster analysis.
90 acute, 42 psychiatric and 11 long-term care hospitals submitted their data for comparison to other hospitals. The benchmark database included 55 225 completed questionnaires (53.7% response rate). Overall dimensional scores were low, although scores were found to be higher for psychiatric and long-term care hospitals than for acute hospitals. The overall perception of patient safety was lower in French-speaking hospitals. Hierarchical clustering of dimensions resulted in two distinct clusters. Cluster I grouped supervisor/manager expectations and actions promoting safety, organisational learning–continuous improvement, teamwork within units and communication openness, while Cluster II included feedback and communication about error, overall perceptions of patient safety, non-punitive response to error, frequency of events reported, teamwork across units, handoffs and transitions, staffing and management support for patient safety.
The nationwide safety culture assessment confirms the need for a long-term national initiative to improve patient safety culture and provides each hospital with a baseline patient safety culture profile to direct an intervention plan. The identification of clusters of safety culture dimensions indicates the need for a different approach and context towards the implementation of interventions aimed at improving the safety culture. Certain clusters require unit level improvements, whereas others demand a hospital-wide policy.
Physicians should be engaged in quality-improvement activities to make the systems in which they work safer and more reliable. However, many physicians are still unable to contribute to patient safety initiatives that lead to safer, high-quality care for their patients.
To survey 10 high-performing hospitals in the USA to determine how they engage their physicians in quality and safety.
Qualitative study that used site visits and a semistructured 20-question interview.
Ten high-performing US hospitals were chosen from the 2010 US News and World Report Best Hospitals and the Leapfrog Group on Patient Safety.
Forty two interviews were conducted with forty-six quality leaders including CEO's, Chief Medical Officers, Vice Presidents for Quality and Safety and physicians.
Site visits and in-person interviews were conducted during 2010–2011. The interviews were transcribed and coded using the constant comparative method for further analysis by the team.
The authors developed a six-point framework for physician engagement in quality and safety as a constellation of the best strategies being used across the country. The framework consists of engaged leadership, a physician compact, appropriate compensation, realignment of financial incentives, data plus enablers and promotion.
The qualitative design and the small number of hospitals surveyed mean that the results may not be generalisable.
There remain many ongoing barriers to physician engagement in quality and safety. Some high-performing hospitals in the USA have made significant improvements in engaging their physicians in quality and safety. The proposed framework can assist organisations in the development of strategies to engage physicians in quality-and-safety activities.
Medical-error analyses have been conducted to determine the root cause of adverse events and near misses. More precise determination of the cause-and-effect relationship likely will require a prospective design path analysis including both direct and indirect effects.
The authors performed a 6-month prospective cohort study using structural-equation modelling (SEM). Of the 879 nurses approached, 789 (89.8%) were included in the final analysis. Potential predictors provided for analysis included age, years of nursing experience, mean frequency of night shifts per month, nursing-specific job stressors, degree of depression, frequency of feeling unskilled, feeling time pressure, feeling a lack of communication between self and other hospital staff members, frequency of suffering from sleep disturbance and frequency of feeling a decrease in attention. The authors regarded a latent variable composed of frequencies for near misses and adverse events as an outcome.
The SEM model constructed in this study suggested that potential root causes (exogenous variables directly or indirectly connected to the outcome which are not affected by other variables) were years of nursing experience, feeling unskilled, job stressors and sleep disturbance, with estimated standardised total (direct and indirect) effects of –0.22, 0.21, 0.008 and 0.005, respectively. A prospective design path analysis using the SEM model for both direct and indirect effects enabled a statistical exploration of root causes and estimation of their impact on the outcome. Our findings suggested such an analysis to be useful in devising countermeasures against medical errors.
To assess the effect of participatory healthcare-provider orientation in enhancing patient knowledge, appropriate prescribing and dispensing of artemether-lumefantrine, during drug treatment of uncomplicated malaria.
A cluster quasi-experimental study. The authors developed strategies to address challenges encountered by healthcare providers during clinical management of malaria. The primary outcome was patient knowledge on prescribed malaria drug treatment. Secondary outcomes were appropriate prescribing and provision of adequate drug dispensing information. The authors used generalised estimating equation logistic regression to investigate correlates of appropriate use of artemether-lumefantrine.
The proportion of patients or caretakers of paediatric patients sufficiently knowledgeable about malaria treatment increased from 16/85 (18.8%) at baseline to 33/96 (34.4%) at evaluation, OR 2.26 (95% CI 1.13 to 4.49), p=0.020, in the intervention, and fell slightly from 49/134 (36.6%) to 35/114 (30.7%), OR 0.77, (95% CI 0.45 to 1.31), p=0.331 in the control district. This was enhanced by the existence of drug-dispensing standard operating procedures (adjusted OR 1.85, 95% CI 0.98 to 3.50; p=0.057). The proportion of appropriate prescriptions increased from 61/87 (70.1%) to 94/112 (83.9%) in the intervention district, OR 2.23 (95% CI 1.13 to 4.40), p=0.020 and reduced from 91/115 (79.1%) to 75/112 (67.0%) in the control district, OR 0.53, (95% CI 0.29 to 0.97), p=0.040. The frequency of adequately dispensed prescriptions increased in the intervention district (34(32.4%) to 53(45.3%), OR 1.73 (95% CI 1.00 to 2.99), p=0.050) but decreased in the control location (94 (69.6%) to 71 (52.6%), OR 0.48 (95% CI 0.29 to 0.80), p=0.004).
Participatory healthcare-provider orientation enhanced patient knowledge, healthcare provider prescribing and dispensing of artemether-lumefantrine, bolstered by adequate medication counselling and use of drug-dispensing standard operating procedures.
Despite widespread emphasis on promoting ‘assertive communication’ by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care.
The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units.
The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7±11 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2–10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations.
This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.