Q: WHAT DO YOU LEARN WHEN YOU DO A SECOND AUDIT FIVE YEARS AFTER THE FIRST?

A team of investigators were able to compare audits on treatment for hip fractures carried out in seven hospitals in East Anglia, UK in 1992 and 1997. They found a number of changes. Pharmaceutical thromboembolic prophylaxis had gone up from 45% to 81% and early mobilisation from 56% to 70%. Cases of pneumonia, wound infection, pressure sores, and fatal pulmonary embolism had gone down. Functional outcomes (at 3 months) and mortality had not improved. Some hospitals were doing better in some areas, but others were doing worse. “This highlights the need for continuous quality improvement by repeating the audit cycle to reach and then improve standards”, write the authors. They identify rehabilitation and long term support as key areas for future research.

See page 239

“ . . . the performance of individuals and organisations should be continuously measured, not in a desire to reprimand or punish but to enhance and celebrate” (commentary, Kazandjian, page 212)

▸ACTION POINT

Keep doing audits!

Q: DOES PUBLISHING A SET OF NATIONAL GUIDELINES HAVE ANY IMPACT ON PRACTICE?

Researchers in the Netherlands set out to test whether the national guidelines on treatment for depression were being met. They compiled 22 case studies and sent them to 150 GPs, 100 psychiatrists, 123 psychotherapists and 100 clinical psychologists, asking them to state what treatment they would have given. They then compared their answers with nationally agreed guidelines. Seven out of every 10 decisions met the guidelines and were considered appropriate. Two out of 10 were considered undertreatment and one out of 10 overtreatment. The authors conclude that “ . . . many treatment choices made by the care providers were inappropriate . . . Education of care providers alone certainly is not sufficient but in view of the slow diffusion of scientific knowledge it seems necessary in order to improve outcomes in depression.”

See page 214

▸ACTION POINT

Just publishing a set of guidelines is not in itself going to be enough.

Q: IS THERE A RELATIONSHIP BETWEEN QUALITY OF CARE AND LENGTH OF STAY IN HOSPITAL?

In this Swiss study, researchers examined the records of 371 patients who had been treated in hospital for congestive heart failure. They used published criteria, developed at the Baylor College of Medicine in Houston, Texas, to look at quality in three phases of care. They found no relationship between length of stay and administrative work up, but they did find positive relationships between quality scores at the evaluation and treatment stage and at the readiness for discharge stage. The authors write: “Our data suggest that careful reorganisation of the process of care should accompany any attempt to reduce length of stay to avoid detrimental effects on quality of care”. They also report that they are considering introducing a critical pathway and developing a tool to identify unnecessary process delays.

See page 219 (commentary page 209)

▸ACTION POINT

If you want to reduce length of stay, you must first reappraise and, if necessary, redesign existing procedures.

Q: HOW MUCH DO WE KNOW ABOUT MEDICAL ERRORS IN PRIMARY CARE?

There have been many studies on medical errors in hospitals, but very few on errors in family practice. Researchers took reports from 42 family physicians and used qualitative analysis to develop a preliminary taxonomy of medical errors. Out of 344 reports, 83% were “process errors” and 13% “knowledge and skills errors” (the other 4% were considered “adverse events” and not errors). The process errors included administrative failures (31%), investigation failures (25%), treatment delivery lapses (23%), miscommunication (6%), and payment systems problems (1%). The knowledge and skills errors included wrong execution of a clinical task (6%), wrong treatment decision (4%), and wrong diagnosis (4%). “Practising family practitioners report a spectrum of medical errors that is different from the types of medical errors previously identified in hospital based care”, write the authors.

See page 233

▸ACTION POINT

We need to look more at process errors in primary care.