141 e-Letters

  • General, Logistical, Red Flag and Risk (GLRR) approach to safety netting

    Smith et al (2022) present an excellent review of the current state of safety netting theory and practice in Primary Care. In relation to the education of paramedics working in primary care, the General, Logistical, Red Flag and Risk approach has been suggested as a means of implementing the theory of safety netting into a clinician’s practice (Mallinson, 2023). It reminds clinicians to always give a General worsening statement, meeting Smith et al’s Recommendation No. 1. The second point is to provide clear Logistical advice to patients on how to seek help; the specifics of what phone number to call to seek or summon help. This perhaps aligns to Recommendation 9; “including a specific safety-netting plan”. Red Flag safety netting reinforces the importance of patient education in relation to possible serious deterioration which aligns to Recommendation 4 in terms of “specific situations that should be cause for concern”. The final component of Risk based safety netting relates to shared decision making and specifically situations where there is disagreement and a patient is not following medical advice. The Risk component seeks to ensure that patients are fully aware of the potential risks inherent in their chosen course to action. This is vital in relation to ensuring patients are making informed decisions about their care. There is definitely more work to be done on improving education around Safety Netting, and Smith et al’s work provides us with clear recommendati...

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  • Telehealth advances in enhancing paediatric asthma care through safe remote consultations

    Dear Editor,

    We were interested to read the recent article on patient safety in remote primary care encounters by Payne et al. We have been reviewing the use of remote consultations specifically for paediatric asthma patients and would like to thank the authors for their work.

    Firstly, we agree with the authors’ findings that a remote environment may exacerbate existing inequalities such as economic and language barriers. We would add that an additional factor that must be assessed is a patient’s ability to use technology. Pinnock et al. highlight the risk of virtual consultations to those who lack “e-literacy (or digital healthcare literacy)” (2). These patients must be identified and offered additional support or alternative methods of consultation to maintain the utmost level of care.

    Payne et al. highlight the need for a more definitive approach to escalating care rather than a “rule of thumb” or “if in doubt, put it down as urgent” approach (1). We would echo that there need to be clear guidelines and more specific thresholds for escalating care from remote to in-person visits. One suggestion by Galway et al. is having a lower threshold for seeing younger children face to face (3). Galway et al. also suggest having alternative “red-flag” signs that are unique to the remote setting. For example, multiple calls from a patient may indicate the need to escalate their care to face-to-face. More of these red-flag signs unique to this setting need to be...

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  • Acute frailty in the community

    I work in a hospital at home (H@H) service and have found the AFN website a very useful learning resource and regularly recommend it to my Clinical practitioners and nurses. Read the paper with interest and tend to agree with the conclusion reached by the authors.
    Given that the flow of patients to hospital are from the community the way we deal with an acute frailty crisis in the community needs to be looked at. The atypical presentation of acute illness in the frail older person coupled with the move to virtual consultations ( due to work pressure on GPs) has led to a delay in the diagnosis and treatment of acute illness in this group of patients. We often come across the scenario of patients being prescribed multiple courses of antibiotics when the underlying diagnosis is not an infection. The consequence is that the patients become deconditioned even before they enter an Acute frailty unit (AFU) making them less responsive to all the interventions prescribed. I am sure a proportion of patients on an AFU do not need to be there if their acute illness was dealt with promptly in the community.
    A H@H service is well placed to deal with acute frailty crisis in the community but needs to be able to respond in a timely way to the high risk frail older population which are care home residents, the housebound older patient and the frail older person on the ambulance stack waiting a paramedic response. If this service is well resourced it will enable an AFU to...

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  • A Poor Statistical Approach is Better than Not Having an Approach

    Dear BMJ Quality and Safety,

    Having perused the article titled "Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review," I found it captivating and of great significance. The notion behind this study is quite innovative, as it tackles the concerns of policymakers who worry about the potential to erroneously misdiagnose emergency patients, who indeed are in the most need of care. I firmly believe that this article will provide invaluable insights into a topic that greatly interests a wide audience.

    Given my keen interest in this study, and to enhance its quality and the reliability of the final findings, I would like to offer a few suggestions.

    I find that the authors have stated that they dropped the chance for a quantitative meta-analysis as they found substantial heterogeneity. I agree with them on decreased reliability of a pooled estimate with high heterogeneity. However, I believe that a quantitative estimate, even accompanied by considerable heterogeneity, is still much more convenient for readers to infer and relate. In fact, having a high heterogeneity is a good chance for authors to investigate the factors and covariates, providing a more precise insight into the complex relationships, and substantially improving the quality of the study. Therefore, I suggest an appendix that provides such data. Providing the limitation...

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  • Prescribing medications with indications: the script has been flipped

    In the editorial authored by G.D. Schiff, B. L. Lambert, and A. Wright, the concept of "indication-based prescribing" is explored. This involves clearly documenting the reason, or indication, for prescribing a medication and linking it to the prescription itself. Despite recommendations and evidence supporting its potential to enhance medication safety and patient comprehension, this essential piece of information is frequently absent from current practices.

    The authors advocate for a drastic reimagining of the prescription process. Rather than treating the indication as a supplementary detail, it should serve as the inception point. Under this proposed model, the prescriber would initially enter the medical condition to be addressed. The electronic prescribing system would then recommend the most appropriate and evidence-based medication for the patient. This suggestion, although raising issues about autonomy and trust, is posited to elevate prescription safety, patient education, medication reconciliation, deprescribing, and efficiency in prior authorization processes.

    A further innovative proposal places the prescriber in full control. We have developed clinical decision support software enabling the prescriber to begin with either a) an indication, b) a medication, or c) the administration route. The software then filters the remaining pertinent options. As the combination of these three elements, along with the patient's specific context,...

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  • Does CPOE use result in significant decreases to patient harm? A word of caution

    We are writing in response to Abraham et al.’s recent review of systematic reviews (SR) targeting the impact of computerised provider order entry (CPOE) on clinical and safety outcomes [1]. We commend the authors’ inclusion of medication errors and adverse drug events (ADE) among the outcomes assessed. This is particularly timely given the World Health Organisation’s 2017 announcement of the third Global Patient Safety Challenge to motivate actions to reduce medication errors causing actual patient harm by half in five years [2]. Abraham et al. concluded that, based on the evidence reported by three SR of inpatient populations, pooled studies showed significant reduction in ADEs with CPOE use, with considerable variation in the magnitude of relative risk reduction [1]. However, there are significant limitations to the studies on which this conclusion is based, and we believe a more cautious approach should be taken when assessing the current evidence.

    Firstly, as the authors acknowledged, there was variation in the definitions of ADE across the three SR and the 18 studies they included. We agree that these are significant limitations when trying to summarise the impact of CPOE on ADE. To be clear, the included studies assessed preventable ADEs (10 studies) and/or potential ADEs (15 studies), and three studies did not specify the type of ADE. An ADE can be preventable, non-preventable, or potential [3]. A preventable ADE refers to a medication error which reached the...

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  • Inadequate limitations

    We feel that this article and accompanying press release have failed to fully acknowledge some significant limitations of the study. We feel these limitations are important when making the conclusion that following guidelines by earlier referral would be associated with earlier cancer diagnosis.
    1. There is no recognition that the cancer diagnosed in the year following index consultation may not have any association with the index consultation. For example a non-urgent referral for breast lump who developed bladder carcinoma in the following year would be included as someone who could have benefitted from earlier referral.
    2. There is no attempt to acknowledge screening cancer diagnoses. Again these would be included despite them being unrelated to any previous “red flag” symptoms.
    3. Most significantly, there is no acknowledgement that not “following guidelines” is often an important part of shared decision-making that prevents morbidity related to diagnostic processes and treatment. Although the article explains that co-morbidities and age greater than 85 are associated with lower referral rates; it fails to recognise that any delay in cancer diagnosis in this group would often not be considered a “missed opportunity”,. There is sometimes no clinical benefit to the patient of earlier diagnosis. In relation to this It also fails to recognise that many local 2ww guidelines include severe frailty as an exclusion criteria for an urgent or 2w...

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  • Better consistency and quality with the use of CDSS (Clinical Decision Support Systems)

    The authors of this paper describe GP decision-making as ‘good but not good enough’. Their paper also highlights considerable variation among clinicians with the highest referrers being more than two times more likely to refer patients with red flag symptoms for cancer investigation than the lowest referrers. When we consider this wide disparity among individual doctors, we must look at how we can objectively and consistently reduce this. How can we make the diagnostic process in primary care ‘reliable, not heroic’ [1]?

    Previous papers have considered interventions that can reduce the global burden of diagnostic errors in primary care [2], including the use of information technology tools. Perhaps we can consider that better use of technology such as Clinical Decision Support Systems (CDSS) could improve clinical diagnostics especially in those areas with clear guideline-based practice such as in the decision to refer urgently for suspected cancer [3]. These tools can be used to provide appropriate suggestions for differentials at any point in the clinical consultation or offer ‘alerts’ at the end of the consultation if there are important diagnoses that haven’t been considered [4].

    Uptake of CDSS has been poor [5] and clinician response to these tools when they have been implemented are mixed [6] despite them showing that they increase physician’s diagnostic accuracy [7, 8]. At present, clinical work mostly only uses inconsistently implemented ‘alerts’. Some...

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  • Overuse of diagnostic testing: possible explanations and solutions

    The recent article by Muskens et al "Overuse of diagnostic testing in healthcare: a systematic review" published online on May 10, 2021, admirably describes the prevalence and overuse of low-value diagnostic tests in multiple healthcare settings, but does not offer possible explanations or solutions. Some salient reasons are (1): 1. Physicians do not consider healthcare costs during a diagnostic workup; 2. Malpractice concerns; 3. An excessive fee-for-service mentality--more tests and consultations generate more income; 4. Lack of trust in clinical skills versus high technology testing; 5. Believing that diagnostic workups should eliminate all conceivable etiologies; and 6. Patients may experience greater satisfaction with more testing.

    Underlying these last three possibilities is the failure to appreciate that in science, especially after Darwin, Einstein and Heisenberg, absolute certainty is considered unachievable. Facts and theories, and clinical diagnoses, are now rated on the probability that they are true. A diagnosis is more probable than not, or more probable than another, based on degrees of evidence. Hence recent interest in Bayesianism, which analyses evidence in terms of probability. When determining the efficacy of additional tests, Bayesianism requires a pre-test (a priori) probability estimate of the diagnosis. The more probable a diagnosis is clinically (a priori) and the greater the diagnostician's clinical confidence, the less nec...

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  • Professor Julian Bion

    We thank Professors Marang-van de Mheen and Vincent for their comments [1] on our examination of variations in weekend and weekday admission care quality during the introduction of seven day services in England [2]. Their analysis and logic models demonstrate with admirable simplicity the complexity of these causal pathways.
    One of the pathways which is not highlighted in the literature is how quality of pre-hospital care may impact on the post-admission phase in hospital. Using exploratory data from the 20 hospitals in our data set, we have shown that while in-hospital care quality did not vary between weekend and weekday admissions, and had improved over time, there was a concurrent deterioration in performance indicators related to care in the community preceding hospital admission. Weekend admissions were much less likely to have been referred by family doctors, and more likely to attend hospital by emergency ambulance, to be dependent on others for activities of daily living, and to be candidates for palliative care. These differences became more marked with the passage of time. In a separate single-centre study we have shown that patients admitted at weekends are sicker than those admitted on weekdays [3]. We therefore contend that while there may be opportunities to improve hospital care across all days of the week, the cause for the weekend effect may reside in community healthcare services. As the weekend effect is a global phenomenon [4], policy makers a...

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