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The authors of the article 'Perceived Causes of Prescribing Errors by
Junior Doctors in Hospitals' published in the BMJ Quality & Safety on
30 October 2012 report that "the main task factor identified was poor
availability of drug information on admission (often out of hours)" and
"Systems which should aid prescribers were not always available (e.g. the
Emergency Care Summary was available, but the doctor did not have...
The authors of the article 'Perceived Causes of Prescribing Errors by
Junior Doctors in Hospitals' published in the BMJ Quality & Safety on
30 October 2012 report that "the main task factor identified was poor
availability of drug information on admission (often out of hours)" and
"Systems which should aid prescribers were not always available (e.g. the
Emergency Care Summary was available, but the doctor did not have a
password for it)". The article postulates that had the information
contained in the Emergency Care Summary (ECS) been available, it would
have led to a decrease in errors.
The ECS is a national system of shared electronic records in Scotland
which enables up to date prescribing information from Primary Care systems
to be available to clinicians working in unscheduled care i.e. Out of
Hours, Ambulance, Emergency Rooms and Acute Receiving Units(1). It was
designed to improve the information available when GP practices are
closed. At the time of the study, in 2011, ECS was not available for
junior doctors dealing with scheduled admissions in secondary care.
The lack of access to ECS in secondary care has been identified as a
critical patient safety gap and plans have been made to address this. New
developments to make the medication information in ECS available for all
patients in hospitals and out patients are underway. In 2011, a pilot
project in Lanarkshire reported(2) that the use of ECS for medicines
reconciliation in Medicine for the Elderly, Orthopaedic admissions and
Surgical day cases was found to be helpful by all users. A review of 31
cases found 119 discrepancies, between medicines information in ECS and
the referral letter, an average of 5 per patient, as the average length of
time between referral and pre-assessment was 110 days. The ECS records
were accessed by nursing staff and pharmacists carrying out medicines
reconciliation and was felt to be so beneficial that it was agreed to
extend the use of ECS within secondary care using the Clinical Portals(3)
to provide secure identity and event based governance(4).
The article states that "problems with inadequate quality medicines
information at admission to hospital were highlighted. It is
disappointing to see that measures such as the ECS which have been
designed to tackle this very issue by providing an up to date list of
patient's medicines are not working (many doctors said that they did not
have access to the Emergency Care Summary)" and we would like to correct
this statement as since it's inception the ECS was specifically designed
to improve care Out of Hours and was not available to hospital doctors for
planned admissions. Medicines reconciliation (a process by which the most
recent and accurate sources of information are used to create a full list
of medicines for a patient) has been a major priority for the Scottish
Patient Safety Programme and they have helped to make the case for
extending use of ECS for this purpose.
Significant developments are underway to extend access to ECS for all
clinical users and eHealth developments such as the Clinical Portals will
mean that ECS accounts and separate passwords will not be required in the
longer term.
Dr Libby Morris, eHealth Clinical Lead, Scottish Government Health
and Social Care Directorate and GP, Hermitage Medical Practices, 5
Hermitage Terrace, Edinburgh, EH10 4RP
Dr Ian M Thompson, Chair, Emergency Care Summary Service Board and
GP, East Linton Surgery, Station Road, East Linton, East Lothian, EH40 3DP
Jonathan Cameron, Programme Manager/ Interim Head of Project
Management, National Information Systems Group, NHS National Services
Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB
Conflict of Interest:
LM and JC were responsible for managing the ECS as a development project. IMT is the clinical chair for ECS as a business as usual service.
I appreciated Shearer et al's recent article in BMJQS[1], it brings
to light the debilitating effects of ill-placed social and cultural
influences, and the professional hierarchies evident in all hospitals. The
issues identified from the research further validate the necessity for a
systems approach when dealing with clinical risk management[2]. That said,
mandating rapid response systems (RRS) as part of hospital protocol...
I appreciated Shearer et al's recent article in BMJQS[1], it brings
to light the debilitating effects of ill-placed social and cultural
influences, and the professional hierarchies evident in all hospitals. The
issues identified from the research further validate the necessity for a
systems approach when dealing with clinical risk management[2]. That said,
mandating rapid response systems (RRS) as part of hospital protocols
should not be so quickly dismissed as an ineffective avenue to improving
RRS effectiveness. It is not a new concept that workplace culture has much
to do with clinical efficacy and patient safety; in fact, Leape and
Berwick[3] pinpoint culture as a significant barrier to progress in
patient safety and highlight the necessity for dramatic changes to occur
as the next step to achieving higher standards. Unequal relationships
exist within the healthcare team, and inter-occupational hierarchies
between doctors and nurses impede the flow of information[4], as does the
seniority of doctors over their junior staff[5]. This element of fear that
is created by an institution's structure - fear of reprimand by senior
staff, fear of failure to meet expectations, and fear of judgement from
others, acts alongside a clinician's medical knowledge in determining
whether or not to call for help in poorly defined clinical situations, or
to activate the RRS protocol, even when the patient fulfils the defined
criteria. Standardisation of processes is an acceptable and widely
employed mechanism for the prevention of errors[6]. Sliding scale insulin
dosing and perioperative antibiotic protocols were adopted by institutions
to produce significant improvements in patient safety, much of which
younger clinicians, like myself, take for granted these days. Following
the successful establishment of a rapid response team, it speaks for
itself that an effective way to ensure that patients are receiving a high
standard of care when their status is deteriorating is, not only to
educate and train staff on the RRS, but also to make such a protocol
compulsory.
At present, readily available and easily identifiable criteria exist
to guide the management of specific diseases, and to minimise variations
in clinical judgement within an institution. A mandated RRS protocol would
provide a similar opportunity to remove the pressure of judging the risk
involved in tricky clinical situations and the fear of repercussions
associated with initiating the call. I imagine, like those sliding scales
and antibiotic protocols, once implemented, a compulsory RRS protocol
would seem like second nature. Explicit criteria for determining when one
needs help and how to access that help, may serve as a means to
effectively overcome the negative implications of workplace culture, as
well as inter- and intra- professional hierarchies[4].
1. Shearer B, Marshall S, Buist MD, et al. What stops hospital
clinical staff from following protocols? An analysis of the incidence and
factors behind the failure of bedside clinical staff to activate the rapid
response system in a multi-campus Australian metropolitan healthcare
service. BMJ Qual. Saf.2012;21:569-75.
2. Kohn CT, Corrigan JM, Donaldson MS. Chapter 8: creating safety
systems in health care organizations. To err is human: building a safer
health system. Washington, DC: National Academy Press 1999:134-174.
3. Leape LL, Berwick DM. Five years after To Err Is Human, what have
we learned? JAMA. 2005;293(19):2384-90
4. Mackintosh N, Sandall J. Overcoming gendered and professional
hierarchies in order to facilitate escalation of care in emergency
situations: the role of standardised communication protocols. Soc Sci Med.
2010;71(9):1683-6
5. Stewart J. To call or not to call: a judgement of risk by pre-
registration house officers. Med Educ. 2008;42(9):938-44
6. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-7
We read the article on discharge summaries by Mohta et al with
interest. We passionately believe that we must keep trying innovative
methods to improve the quality of this most important handover document of
care. Earlier this month, our audit to evaluate the extent to which
contents of all fields in the electronic discharge summary template are
completed with relevant information, revealed that the trainees had failed
to...
We read the article on discharge summaries by Mohta et al with
interest. We passionately believe that we must keep trying innovative
methods to improve the quality of this most important handover document of
care. Earlier this month, our audit to evaluate the extent to which
contents of all fields in the electronic discharge summary template are
completed with relevant information, revealed that the trainees had failed
to complete some of the most important fields in the template. We then
interviewed doctors at different seniority in our hospital to find the
reasons for such practice. We also interviewed GPs to confirm what they
want in these summaries. Based on the results, we now intend to implement
three interventions (1) Trainees will print random summaries completed by
them to do CbD (Case-based discussion) with their supervisors for their e-
portfolio. This will give them an opportunity for feedback from senior
consultants (2) We intend to put a large sticker on the top of the case
record for the clinicians to make note of any important clinical event as
it happens which should become part of the discharge summary at the time
of the patient discharge. Person completing the discharge summary will
make sure that all events on the sticker form part of the summary (3)
Formal training module on discharge summaries at the time of induction on
the first day when the trainee joins the Department. It will be
interesting to find the results of the closing loop results of this audit.
I appreciated seeing an introduction of analysis of means (ANOM) by
Mohammed and Holder. As stated in their article, the technique is not well
known, but nonetheless I would like to encourage people to learn this
useful graphical display to compare groups. I have been using this method
in healthcare improvement work (1,2) and would like to share a couple of
lessons learned over the years.
The proportion ANOM chart should...
I appreciated seeing an introduction of analysis of means (ANOM) by
Mohammed and Holder. As stated in their article, the technique is not well
known, but nonetheless I would like to encourage people to learn this
useful graphical display to compare groups. I have been using this method
in healthcare improvement work (1,2) and would like to share a couple of
lessons learned over the years.
The proportion ANOM chart should meet most of your needs, since first
continuous type data can be converted to a proportion. For example, length
of stay (LOS) greater than 2 days can be used in the proportion ANOM chart
to compare groups (such as hospitals or providers) versus using LOS in the
continuous ANOM chart. Secondly, the proportion ANOM chart is easier to
use since it is the p-chart (a statistical process control chart), which
people may be familiar with. The only difference between the ANOM for
proportions and the p-chart is the control limits on the ANOM are not set
at 3 sigma - they are adjusted to account for number of groups being
compared. The best reference I have seen on ANOM is in a book by
Balestracci & Barlow.(3)
Another issue with the ANOM chart is the denominator size - you need the
right size for these charts to be most helpful. A good rule of thumb is 5. If you are comparing LOS greater than 2 days across hospitals and
25% is the overall rate then each hospital will need to have 21 or more
patients (5/.25 = 20). If there were only 10 patients in each group, then
the control limits will be too wide and may not yield useful information.
Besides too few patients in the denominator, another issue is too many
patients. If your subpopulation of patients is 1,000, then you have 50
times more patients than needed and you may have many groups crossing the
limits, which most likely contains Type 1 errors and is also useless
information. The primary purpose of the ANOM chart is to find the hospital
(or whatever you are comparing) that is performing outside the system
result because there will be opportunity to learn from the hospital that
is performing beyond the others.
One last lesson to keep in mind is the ANOM chart can be somewhat useless
if you are analyzing rare events or a proportion that is less than 10%.
For example, mortality rate (MR) for a specific procedure is 1.5% and you
want to see if there is a difference across 15 hospitals; however, there
are on average 100 patients per year that have the procedure. Using the 5 rule, you would need 334 or more patients in the denominator so
you will need 3.3 years of data. You may have the data, but most likely
you will only find a low performer, which can be motivating information
for the low performing hospital but more useful information is finding a
hospital that is doing this well. If a hospital had 0% MR, then the ANOM
chart will not show the 0% crossing the lower limit with 334 patients in
the denominator. The hospital would need to have 2.5 times more patients
(835 with 0% MR) and then the result would be significantly different.
If ANOM is not in your analytical tool box, I would highly suggest
learning more about this method, since the graphical display does so
effectively what statistical process charts are suppose to do - point out
the difference between common and special cause variation.
1. Homa K. Analysis of means used to compare providers' referral
patterns. Quality Management in Health Care 16(3): 256-264, July/September
2007.
2. Homa K, Kirkland KB. Determining next steps in a hand hygiene
improvement initiative by examining variation in hand hygiene compliance
rates. Quality Management in Health Care 20(2):116-121, April - June 2011
3. Balestracci D, Jr., Barlow JL. Quality Improvement. Practical
Applications for Medical Group Practice. 2nd ed. Englewood, CO: Center for
Research in Ambulatory Health Care Adminstration; 1998.
There is a paucity of papers focused on the sustainability of
improvement projects. In addition, the authors and the VA are to be
congratulated on sharing what are less-than-positive results so we can all
learn.
The quality improvement collaborative (QIC) process is excellent in
raising awareness of issues, training staff in QI techniques and in
mobilising action to improve. With all methods there are some gain...
There is a paucity of papers focused on the sustainability of
improvement projects. In addition, the authors and the VA are to be
congratulated on sharing what are less-than-positive results so we can all
learn.
The quality improvement collaborative (QIC) process is excellent in
raising awareness of issues, training staff in QI techniques and in
mobilising action to improve. With all methods there are some gains and
losses. The positive contribution of the QIC process needs to be balanced
with the lack of deep behavioural or system change - and this matters when
it comes to sustainability. The continual focus on technical measurements
in QIC allows participants to displace the need for behavioural changes.
Also, because the process is team focused, rather than organisational
focused, system changes are difficult to make.
Just because sustainability drops off after the program, doesn't mean
it isn't a good program. It may, however, mean that to gain sustainability
additional parallel support is required or the QIC needs to be redesigned
in content and structure.
We welcome the recent Original Viewpoint paper by Foy et al1, titled
The role of theory in research to develop and evaluate the implementation
of patient safety practices. We strongly support the recommendations in
this paper, and in particular, the application of behavioural change
theory in the design, implementation and evaluation of Patient Safety
Practices (PSPs).
We welcome the recent Original Viewpoint paper by Foy et al1, titled
The role of theory in research to develop and evaluate the implementation
of patient safety practices. We strongly support the recommendations in
this paper, and in particular, the application of behavioural change
theory in the design, implementation and evaluation of Patient Safety
Practices (PSPs).
However, on reading this paper, one could be forgiven for believing
that the use of such behavioural theory as the basis for the design,
implementation and evaluation of PSPs is novel. Reference to the
application of the Theory of Planned Behaviour (TPB) in the paper, was
restricted to taking intra-oral radiographs, managing upper respiratory
tract infections with antibiotics and disclosure of dementia: hardly
mainstream PSPs.
We are therefore perplexed at the apparent 'blind spot' of the
authors for citing relevant research in this area. Pubmed and even a
simple Google search using search string "TPB and patient safety
behaviours" will produce original published work which has been omitted.
The first article in this Google search is a paper which explored the
use of TPB in understanding hand hygiene behaviour and design of
interventions to improve compliance2. We have been using such theory for
more than ten years, to design, implement and evaluate important PSPs
including the recent pivotal PSP of hand hygiene.2,3 As hand hygiene was
used as a core example of PSP by Foy et al1, we were left wondering why
such relevant and highly cited3 research was not included.
Another citation on page one of the Google search related to an
original research paper published in 2010 in Quality and Safety in Health
Care (the same journal now called BMJ Quality and Safety). This paper
titled Patient Safety Culture: factors that influence clinician
involvement in patient safety behaviours4, applied TPB to a range of
patient safety behaviours including incident reporting and speaking up
when witnessing a colleague making a mistake. This paper has for the
first time in the literature identified predictive factors for these PSPs,
establishing unique models for differing professional sub-groups such as
junior and senior doctors; junior and senior nurses; and, allied health
practitioners. Again, it is hard to understand why such research,
published in the same journal, was not cited.
For the past decade behavioural theory has been successful in
predicting patients' non compliant antiviral therapy to prevent wide-
spread resistance8 as well as other central public safety issues of the
time.5-9
Perhaps the root cause of the issues identified by Foy et al, is that
the focus has been on identifying an evidence base for what PSPs to
implement, rather than how best to change behaviour and practice. The
former, is founded in traditional biosciences, reductionist research
paradigms and pedagogy, wheras the latter is far more the domain of public
health, behavioural and social sciences. Perhaps if we were to re-state
the problem of patient safety as public health, then we would start to
employ the appropriate scientific endeavours to design, implement and
evaluate interventions.
Finally, we welcome the increased focus on behavioural theory driven
interventions in patient safety, and congratulate the authors and journal
for shining a light on this important issue. However, we believe that the
authors have been selective in their review of the relevant literature on
the use of behavioural theory applied to PSPs, both at a general level,
and in relation to specific examples in the paper.
1. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. BMJ Qual Saf bmjqs.2010.047993Published Online First: 11 February 2011 doi:10.1136/bmjqs.2010.047993.
2. Whitby M, McLaws ML, Ross MW. Why healthcare workers don't wash their hands: a behavioural explanation. Infect Control Hosp Epidemiol 2006; 27:
484-492.
3. Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax H, Larson E, Seto WH, Donaldson L, Pittet D. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2006; 65(1):1-8.
4. Wakefield J, McLaws ML, Whitby M, Patton L, Blake S. Patient Safety Culture: Factors that influence clinician involvement in patient safety behaviour. Quality and Safety in Healthcare 2010 Aug 19 (6): 585-91.
5. Begely K, McLaws ML, Ross MW, Gold J. Adherence behavior of patients on long term protease inhibitor therapy: insight for the treating clinician.
Clinical Psychologist 2008;12(1):9-17.
6. McLaws ML, Irwig LM, Oldenburg B, Mock P, Ross MW. Predicting intention to use condoms in homosexual men: an application and extension of the theory of reasoned action. Psychol Health 1996;11(5):745-55.
7. McLaws ML, Oldenburg B, Ross MW. Application of the Theory of Reasoned Action to measurement of condom use among gay men. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ,
Gallois C, McCamish M (Eds). Chapter 10. Pergamon Press. Oxford, 1993.
8. Ross MW, McLaws ML. Attitudes towards condoms and the Theory of Reasoned Action. In: The Theory of Reasoned Action: Its Application to AIDS-Preventive Behaviour. Terry DJ, Gallois C, McCamish M (Eds). Chapter 5. Pergamon Press. Oxford, 1993.
9. Ross MW, McLaws ML. Subjective norms about condoms are better predictors of use and intention to use than attitudes. Health Educ Research 1992; 7 (3): 335-339.
Travaglia et al's recent paper in BMJQS[1] alongside their earlier
work[2] provides some valuable insights into research which has been carried
out on large-scale disasters and accidents. This type of work has the
potential to move patient safety away from a focus on individual error and
towards the adoption of a wider and more inclusive perspective on the
failure of whole health care systems such as hospital.[3] That sa...
Travaglia et al's recent paper in BMJQS[1] alongside their earlier
work[2] provides some valuable insights into research which has been carried
out on large-scale disasters and accidents. This type of work has the
potential to move patient safety away from a focus on individual error and
towards the adoption of a wider and more inclusive perspective on the
failure of whole health care systems such as hospital.[3] That said, it
is perhaps all the more surprising that their work appears to have
overlooked the contribution of one of the landmark studies of the origins
and preconditions of disaster, namely the late Barry Turner's work on Man-
Made Disasters.[4-6] Turner carried out a detailed analysis of 84
British accident inquiry reports from 1965-1975 across a range of
industries. One outcome from his analysis was a stage model of the factors
underlying failure and a description of the preconditions for disaster in
what Turner called the "incubation period" immediately prior to the
disaster. During the "incubation period" a chain of discrepant events, or
several chains of discrepant events, develop and accumulate unnoticed.
These types of events might include oversights, failure to follow safety
procedures or errors which go unnoticed. In combination these events raise
the potential for an accident or disaster to occur. Turner's work is also
important in terms of the stress it placed upon adopting a systemic
approach towards accidents and disasters. The systems approach emphasizes
the need to understand in fine detail the nature of organisational
processes and the how connections between these processes and other system
levels (e.g., individual, group) emerge, interact and consolidate over
time. A comparison between the generic disaster model described by
Travalgia et al. with Turner's work, both in terms of his stage model and
focus on causality across system levels would be a worthwhile future
undertaking and might help us go further towards learning from patient
safety disasters.
Competing interests
None.
References
(1) Travaglia JF, Hughes C, Braithwaite J. Learning from disasters to
improve patient safety: applying the generic disaster pathway to health
system errors. BMJQS 2011; 20:1-8.
(2) Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding
lights? Learning from disasters to improve patient safety. Qual Saf Health
Care 2010;19: 332-336
(3) Weick KE, Sutcliffe KM, Hospitals as cultures of re-enactment: a
re-analysis of the Bristol Royal Infirmary. California Management Review,
2003; 45:2, 73-84.
The authors of the article 'Perceived Causes of Prescribing Errors by Junior Doctors in Hospitals' published in the BMJ Quality & Safety on 30 October 2012 report that "the main task factor identified was poor availability of drug information on admission (often out of hours)" and "Systems which should aid prescribers were not always available (e.g. the Emergency Care Summary was available, but the doctor did not have...
I appreciated Shearer et al's recent article in BMJQS[1], it brings to light the debilitating effects of ill-placed social and cultural influences, and the professional hierarchies evident in all hospitals. The issues identified from the research further validate the necessity for a systems approach when dealing with clinical risk management[2]. That said, mandating rapid response systems (RRS) as part of hospital protocol...
We read the article on discharge summaries by Mohta et al with interest. We passionately believe that we must keep trying innovative methods to improve the quality of this most important handover document of care. Earlier this month, our audit to evaluate the extent to which contents of all fields in the electronic discharge summary template are completed with relevant information, revealed that the trainees had failed to...
I appreciated seeing an introduction of analysis of means (ANOM) by Mohammed and Holder. As stated in their article, the technique is not well known, but nonetheless I would like to encourage people to learn this useful graphical display to compare groups. I have been using this method in healthcare improvement work (1,2) and would like to share a couple of lessons learned over the years. The proportion ANOM chart should...
There is a paucity of papers focused on the sustainability of improvement projects. In addition, the authors and the VA are to be congratulated on sharing what are less-than-positive results so we can all learn.
The quality improvement collaborative (QIC) process is excellent in raising awareness of issues, training staff in QI techniques and in mobilising action to improve. With all methods there are some gain...
Dear Editor,
We welcome the recent Original Viewpoint paper by Foy et al1, titled The role of theory in research to develop and evaluate the implementation of patient safety practices. We strongly support the recommendations in this paper, and in particular, the application of behavioural change theory in the design, implementation and evaluation of Patient Safety Practices (PSPs).
However, on rea...
Travaglia et al's recent paper in BMJQS[1] alongside their earlier work[2] provides some valuable insights into research which has been carried out on large-scale disasters and accidents. This type of work has the potential to move patient safety away from a focus on individual error and towards the adoption of a wider and more inclusive perspective on the failure of whole health care systems such as hospital.[3] That sa...