I read with interest the article on what role the patient and public
should play in healthcare improvement (1) as this is a question that my
organisation has long grappled with and is now required to achieve
accreditation against the mandatory National Safety and Quality Health
Service Standards (2).
For many years we had a strong Community Advisory Committee and
consumers on all key quality and safety committe...
I read with interest the article on what role the patient and public
should play in healthcare improvement (1) as this is a question that my
organisation has long grappled with and is now required to achieve
accreditation against the mandatory National Safety and Quality Health
Service Standards (2).
For many years we had a strong Community Advisory Committee and
consumers on all key quality and safety committees but it sometimes felt
more like we were ticking a box rather than properly engaging with our
consumers. We did enjoy some notable successes such as training consumers
to participate in our Root Cause Analysis investigation teams and while
this garnered national and international interest we didn't feel that we
were partnering with our consumers in a meaningful way that acknowledged
sufficiently that consumers no longer play a passive role in their
healthcare experience.
Following extensive consultation a Partnerships in Care Strategy (3)
was developed which examined partnership at the individual (i.e. person
centred care), program/department and organisational levels with four key
focus areas: Leadership and staff; Empowerment; Feedback and
responsiveness; and Environment. Partnering with and empowering our
patients and consumers is also one of the six strategic priorities of the
organisational strategic plan (4).
The past two years have seen our consumers engaged in many new and
exciting ways and also some reinvigoration of existing processes (e.g.
evidence based co-design and patient stories). We now have a program that
trains managers to interview staff with consumers on the interview panel
which has been very successful in the Outpatient and Allied Health
setting. Programs/departments are developing strong relationships with the
consumers who work with them on quality improvement projects or sit with
them on committees and a number are now invited to annual planning days
and are considered to be part of the team.
There has also been a large investment in developing electronic tools
to capture patient experience information and feedback in the inpatient
and outpatient settings which is used to measure the performance of units
and inform changes to our processes.
Our ultimate goal is to develop a culture that places patient
experience at the heart of everything that we do and where partnering with
patients, consumers and carers is the norm (3). Are we there yet? No but
the journey is underway and we really are enjoying the ride.
References
1. Ocloo J and Matthews R. From tokenism to empowerment: progressing
patient and public involvement in healthcare improvement. BMJ Qual Saf
2016;25: 626-632
2. Australian Commission on Safety and Quality in Health Care. Standard 2:
Partnering with Consumers - Safety and Quality Improvement Guide. ACSQHC.
2012
3. Melbourne Health. Partnerships in Care: Working together to improve
your experience and outcomes. 2014
4. Melbourne Health. Transforming Health - Melbourne Health Strategic Plan
2015-2020. 2015
In the important editorial of the Grant, is underlined the overuse of
thromboprophylaxis in patients hospitalized in the medical field.
We agree in emphasizing the difficulty of proper patient assessment that
must be carefully evaluated, considering comorbidity and various risk
factors,and using the main scores currently in use to assess the start of
tromboprofilattica therapy.
For this reason we carried out a study where...
In the important editorial of the Grant, is underlined the overuse of
thromboprophylaxis in patients hospitalized in the medical field.
We agree in emphasizing the difficulty of proper patient assessment that
must be carefully evaluated, considering comorbidity and various risk
factors,and using the main scores currently in use to assess the start of
tromboprofilattica therapy.
For this reason we carried out a study where we evaluated 279 patients
hospitalized in 21 hospitals in Italy. All patients were negative for the
risk of thrombosis to the main risk scales (padua score, Chopard score,
Kuscher score). We assessed the frequency of thromboprophylaxis in acutely
ill medical patients hospitalized in emergency and internal medicine
wards.The results were surprising.Forty-seven patients (16.5%) with
negative risk scores were given thromboprophylaxis during hospitalization.
On backward stepwise logistic regression analysis, severe infection (odds
ratio [OR] 2.31; 95% confidence interval [CI] 1:25 to 4:35) and chronic
venous insufficiency (OR 2.3; 95% CI 1.96-4.67) were found to be the
strongest predictors of the use of thromboprophylactic treatment with
heparin. The subgroup of patients who did not exhibit risk factors was
analyzed also, and age was found to be the main factor in the decision-
making process Regarding heparin administration in the absence of other
risk factors (74.9 ? 11.8 vs 63.7 ? 18.1, p = 0.002).
In conclusion, we agree with Grant about the difficulty of identifying
patients at moderate risk.
We stress also how even patients with low risk then carried out a
thromboprophylaxis is not necessary and nd for that reason turns out to be
even more 'important to perform a correct stratification of the risk of
thromboembolism.
Best regards
1 Monti M, Monti A, Bertazzoni G, Pugliese FR, Ciammaichella M,
Landolfi R. The overuse of thromboprophylaxis in medical patients: main
clinical aspects.G Ital Cardiol (Rome). 2015;16(11):639-43.
Vermeulen et al [1] provides further insight into the effect of
emergency department (ED) crowding and length of stay (LOS) on several
quality indicators. This piece of work not only adds to the body of
literature which suggests ED crowding delays timeliness of interventions,
but importantly highlights that government initiatives targeting LOS alone
are not enough to enhance other aspects of true, q...
Vermeulen et al [1] provides further insight into the effect of
emergency department (ED) crowding and length of stay (LOS) on several
quality indicators. This piece of work not only adds to the body of
literature which suggests ED crowding delays timeliness of interventions,
but importantly highlights that government initiatives targeting LOS alone
are not enough to enhance other aspects of true, quality care delivery.
Donabedian [2] originally explored the various dimensions of quality,
using a measurement framework recognising structural, procedural and
outcome indicators. These have since been refined by various authors but
are widely recognised to include efficacy, access, efficiency, safety,
equitability, appropriateness and acceptability - the full spectrum of
which must be considered when assessing the quality of care in emergency
departments and hospitals.
Like the Ontario ER Wait Time Strategy, Australia has adopted a
National Emergency Access Target (NEAT) as a way of addressing crowding,
patient flow and access to emergency care. Overcrowding and prolonged LOS
in ED for admitted patients is certainly associated with poorer outcomes,
and the introduction of a 4-hour rule can reduce hospital mortality [3].
As is well demonstrated by Vermeulen et al, LOS targets measure when
you arrive and when you leave ED - nothing in between. While seen as a
quality access target, it in no way measures what actually happens within
this time gap. Extended wait times for medical assessment and intervention
have been associated with higher mortality rates and hospital admissions
[4], but this only looks at one part of the patient's overall emergency
experience. So although it is acknowledged that access is important,
having LOS targets may also create unintended, negative consequences. ED
doctors have less time to spend with complex patients, potentially
resulting in diagnostic error and avoidable admissions. The results of
this study show a lack of improvement in most quality indicators measured,
suggesting that perhaps purely targeting LOS can in fact compromise
effectiveness. The push to get patients through the system faster has also
resulted in sick patients being transferred to ill-equipped medical
assessment units - this I have experienced first-hand.
Quality of care is of upmost importance but is complex and difficult
to measure. Performance indicators such as NEAT are easily monitored but
are, at best, only surrogate markers of quality. As Vermeulen highlights,
strategies aimed at reducing ED LOS do not necessarily result in
improvements to the other dimensions of excellent care provision. Whilst
no detrimental effects to safety are demonstrated in this research, other
measures such as adverse events, medication errors or changes in hospital
admission rates were not captured to support this conclusion.
LOS targets may have been an appropriate first step to tackle the
issue of crowding, but there is now a need to look deeper into the quality
of care being delivered in our ED's. Interestingly, the UK has lowered its
performance threshold on the 4 hour rule, now placing emphasis on a number
of other quality indicators [5]. Quality of patient care must be
prioritised while ensuring access is maintained. This requires more
sophisticated measurements of the quality of emergency medical care.
Tess Baker
References:
1. Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti M, Rowe BH et
al. Are reductions in emergency department length of stay associated with
improvements in quality of care? A difference-in-difference analysis. BMJ
Qual Saf 2015;0:1-10
2. Donabedian A. The quality of care. How can it be assessed? JAMA
1988; 260(12):1743-1748
3. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The
association between hospital overcrowding and mortality among patients
admitted via Western Australian emergency departments. MJA 2006, 184;208-
212
4. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association
between waiting times and short term mortality and hospital admission
after departure from emergency department: population based cohort study
from Ontario, Canada. BMJ 2011;342:D2983
5. Department of Health. Accident and emergency provisional quality
indicators [internet] UK: Department of Health; August 2010 [cited 2015
Sept 7]. Available from https://www.gov.uk/government/news/accident-and-
emergency-provisional-quality-indicators
I commend Vermeulen et al for addressing a fundamental question: Is
ED length of stay (ED LOS), a globally used key performance indicator,
actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with
one of three acute conditions (high acuity asthma, upper
arm/forearm/shoulder fracture and acute myocardial infarct) at hosp...
I commend Vermeulen et al for addressing a fundamental question: Is
ED length of stay (ED LOS), a globally used key performance indicator,
actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with
one of three acute conditions (high acuity asthma, upper
arm/forearm/shoulder fracture and acute myocardial infarct) at hospitals
with reduced ED LOS following the introduction of the Ontario Emergency
Room Wait time strategy were also likely to experience improvements in
other measures of quality of care; i.e. is evidence based treatment more
likely given and if so, is it done in a timely fashion [1]?
Interestingly, the study did not reveal an association between
reduced ED LOS and improvement of other quality indicators, surprisingly
not even for measures involving timely delivery of care [1]. Nevertheless,
they did find that shift-level crowding is inversely associated with
quality indicators related to timeliness of care: timeliness of
reperfusion in AMI, splinting and analgesia in adult patients with
fractures and steroid, bronchodilator within 60 minutes of presentation
with acute asthma[1]. This supports prior studies reporting a correlation
between ED crowding and increased short-term or in patient mortality [2,
3] and failure to administer timely care [4]. In my view, this study
confirms that both quality initiatives and assessment of quality of care
ought to be multidimensional and not focussed on one quality indicator.
The association with shift-level crowding emphasises that we must
concentrate on mapping trends in ED crowding over time to allow for
appropriate ED staffing and institute systems that aid efficiency while
assuring safety during those times. This may prove to be a more effective
system to improve overall quality of care that encompasses safety,
efficiency, timeliness and patient centredness [5] rather than focussing
on reducing ED LOS in isolation, which appears to be a poor measure of
quality of care[1]. Furthermore, reducing ED LOS equals time pressure, a
known major contributing factor to error in human performance, which is
likely to predominantly affect the diagnosis and treatment in complex
patients due to performance degradation[6]. Finally, though it seems
obvious that reduced ED LOS improves patient satisfaction, if it is
associated with abrupt staff and contributes to human error[6], this is
unlikely to be the case. I applaud Vermeulen et al for highlighting the
critical issue with using one-dimensional measures to assess quality of
healthcare.
Word count: 394.
References.
1. Vermeulen, M.J., et al., Are reductions in emergency department
length of stay associated with improvements in quality of care? A
difference-in-differences analysis. BMJ Qual Saf, 2015.
2. Guttmann, A., M.J. Schull, and M.J. Vermeulen, Association between
waiting times and short term mortality and hospital admission after
departure from emergency department: population based cohort study from
Ontario, Canada. BMJ, 2011. 342.
3. Sun, B., R. Hsia, and R. Weiss, Effect of emergency department crowding
on outcomes of admitted patients. Ann Emerg Med, 2013. 61: p. 605-611.
4. Pines, J., J. Hollander, and A. Localio, The association between
emergency department crowding and hospital performance on antibiotic
timing for pneumonia and percutaneous intervention for myocardial
infarction. Acad Emerg Med, 2006. 13: p. 873-878.
5. Pronovost, P., et al., How can clinicians measure safety and quality in
acute care? Lancet, 2004. 363: p. 1061-1067.
6. Suzuki, T., T.L. Von Thaden, and W. Geibel Influence of time pressure
on aircraft maintenance errors. 2008.
To the Editor: I was a little surprised to see Buljac-Samardzic et
al. in their recent article on safety culture in long-term care state that
few tools are available to evaluate the effectiveness of initiatives to
improve safety culture in nursing and residential homes. While there may
be fewer tools available for nursing and residential homes than inpatient
settings, there are several safety climate instruments that are...
To the Editor: I was a little surprised to see Buljac-Samardzic et
al. in their recent article on safety culture in long-term care state that
few tools are available to evaluate the effectiveness of initiatives to
improve safety culture in nursing and residential homes. While there may
be fewer tools available for nursing and residential homes than inpatient
settings, there are several safety climate instruments that are worthy of
note [1-5]. Additionally, the authors provide weak support for their
reliance on their instrument of choice. To conclude that one survey is the
best available general climate measure based on a review from 2005seems
incomplete. While I agree with the authors that we need more instruments
for measurement in nursing and residential homes and believe the authors
selected a fine measure of safety climate, the authors do themselves and
their study a disservice by not providing a more thorough acknowledgement
of previous research.
References
1 Handler SM, Castle NG, Studenski SA, et al. Patient safety culture
assessment in the nursing home. Quality and Safety in Health Care
2006; 15:400-4. doi:10.1136/qshc.2006.018408
2 Hughes CM, Lapane KL. Nurses"and nursing assistants" perceptions of
patient safety culture in nursing homes. Int J Qual Health Care 2006;
18:281-6. doi:10.1093/intqhc/mzl020
3 Singer SJ, Kitch BT, Rao SR, et al. An Exploration of Safety
Climate in Nursing Homes. J Patient Saf 2012; 8:104-24.
doi:10.1097/PTS.0b013e31824badce
4 Hartmann CW, Meterko M, Zhao S, et al.Validation of a novel safety
climate instrument in VHA nursing homes. Medical Care Research and Review
2013; 70:400-17. doi:10.1177/1077558712474349
5 Bonner AF, Castle NG, Perera S, et al. Patient Safety Culture: A
Review of the Nursing Home Literature and Recommendations for Practice.
Ann Longterm Care 2008; 16:18-22.
We appreciate Dr. Singer's point about a more thorough discussion of
the large literature on safety climate and tools for assessing it.
Although we did include two of the articles she refers to; not all were
included. While acknowledging and discussing other instruments for
measuring Patient Safety Climate (PSC), would have made our article more
complete, the findings and conclusions of the study would not have
changed....
We appreciate Dr. Singer's point about a more thorough discussion of
the large literature on safety climate and tools for assessing it.
Although we did include two of the articles she refers to; not all were
included. While acknowledging and discussing other instruments for
measuring Patient Safety Climate (PSC), would have made our article more
complete, the findings and conclusions of the study would not have
changed. For instance, we would have still chosen the Safety Attitude
Questionnaire (SAQ) to measure PSC in nursing and residential homes, as
we aimed to benchmark our findings with other health care settings
(inpatient, ICU, ambulatory care) in the Netherlands and abroad. The
results for benchmarking constitute a substantial part of our findings and
discussion. The SAQ is a frequently used survey in multiple healthcare
settings and is often used as a foundation for other PSC surveys. Thus, we
chose the SAQ so that our assessment of PSC in nursing and residential
homes in The Netherlands would not stand in isolation, but could be
considered in the context of international results. In conclusion, we
should have discussed more recent literature on other possible PSC surveys
and explained better why we chose the SAQ. But, we believe this oversight
does not affect the substance of our findings--nor apparently does Dr
Singer.
Dear Editor,
we would like to congratulate Russ et al. on their paper on the patients'
views of surgical checklists (SC). In their elegant work, the above
authors underlined that assessing the fidelity of the SC remains a
challenge, but demonstrated a high level of patient support for use of
checklists. They found that patients were surprised that SC was only a
recent introduction to surgical care. Moreover, the authors...
Dear Editor,
we would like to congratulate Russ et al. on their paper on the patients'
views of surgical checklists (SC). In their elegant work, the above
authors underlined that assessing the fidelity of the SC remains a
challenge, but demonstrated a high level of patient support for use of
checklists. They found that patients were surprised that SC was only a
recent introduction to surgical care. Moreover, the authors stressed that
the majority of patients agreed that they would like the SC to be used if
they were having an operation.
In our experience, we confirm that the value of SC does not lie in the so-
called Hawthorne effect, but in changing (improving!) the mental model. As
also documented in the field of aviation, most accidents tend to involve
non-technical skills (NTS) such as communications, leadership, conflict,
and flawed decision-making. The relationship between NTS and human error
has been extensively demonstrated.
In Aviation it is mandatory for pilots to read a checklist for every single
phase of flight.
Of course they know the checklists by heart, but what if....you are
stressed, the last leg of the day, distracted, with family problems?
Of course it may be that you don't need any checklist, but will you risk it?
Will you risk to take off from Toronto under snow knowing that pilots
didn't read any checklist because they know procedures by heart and
because statistics say it doesn't matter, and results are the same..?
We would like conclude that one of the effective barriers to error is
the surgery safety checklist and, believe it or not, we are sure that
pilots if going under surgery they would like to know that surgeon uses
appropriate checklists that day!
____________________________________________________________
Fabrizio Dal Moro is an Assistant Professor at the University of Padova,
expert on NTS.
Gianluigi Zanovello and Fabio Cassan are airline pilots in Italy:
Zanovello is a former "Frecce Tricolori" (italian acrobatic team) leader;
Cassan was fighter squadron commander (51' Stormo Aeronautica Militare
Italiana).
They teach at Practice simulation center in the medicine University
of Verona - Italy. There, surgeons can practice exactly like the pilots
and run-through not only the anatomy before the real procedure. There is
something else: get familiar with NTS and understand that communication,
decision making, teamwork, situation awareness are important as the
professional, and technical.
The authors (1) have raised a very important issue relating to
recognition and management of a deteriorating patient. Over the years,
cases have been reported where outcome may have been better if
deterioration was recognized in time. Once recognized, an urgent response
by a qualified team could instigate immediate investigations and
management as warranted, possibly averting a poor outcome.
The authors (1) have raised a very important issue relating to
recognition and management of a deteriorating patient. Over the years,
cases have been reported where outcome may have been better if
deterioration was recognized in time. Once recognized, an urgent response
by a qualified team could instigate immediate investigations and
management as warranted, possibly averting a poor outcome.
Code blue calls or cardiac arrest teams (2) were first introduced in
1970, with the motive of initiating an urgent response to a deteriorating
patient. By definition, activation of this system occurred after an arrest
had occurred, so patient had no recordable pulse, blood pressure,
respiration and did not respond to noxious stimuli.
However, more gains were to be made by initiating this response
before the patient had reached a terminal stage. Based on research showing
that cardiac arrest usually follows a series of events, attempts were made
to identify these events so as to preempt an arrest before it actually
occurred. Medical emergency teams (MET) were a culmination of these
efforts.
MET responses, introduced circa 2000 include a critical care
registrar and nurse, among others. Any clinician caring for a
deteriorating patient is encouraged to activate the response though a
rapid response system and can expect help within minutes. Whilst the
concept of MET response is similar to that of cardiac arrest teams, a
fundamental difference is in the timing of initiating the response.
However, the MET response is also activated after a level of
deterioration has occurred. The quest continued to find alarm signs or
signals that indicate deterioration is likely to occur. Once again, the
presumption is that an earlier response, before deterioration has
occurred, should result in a better outcome.
Analysis of hospital admissions suggests an adverse outcome is likely
in about 10% of admitted patients (3). Improving the outcome further,
particularly for these 10%, has triggered a nationally coordinated
approach that is being overseen by the Australian Commission on Safety and
Quality in Health Care (ACSQHC).
A new paradigm as suggested by Jones et al (4) would be required to
drive this further improvement. The focus is now on early detection and
prediction of clinical deterioration, so urgent help can be sought even
before the situation actually worsens. Eight essential elements have been
identified and compiled into a package that is the effort of ACSQHC.
Despite differences, it was encouraging that this consensus statement was
ratified by all state health ministers in Australia (5). The package,
widely distributed throughout Australian hospitals, is hoped to improve
outcomes by encouraging early detection of deterioration, and calling for
help early.
These strategies, in addition to the "swimming between the flags"
observation chart and rapid response systems include many other
initiatives with focus on education as one of the essential elements.
Different educational programs and packages such as COMPASS and DETECT (5)
have been developed in Australia specifically to improve practice
regarding the recognition and response to clinical deterioration amongst
all staff.
References:
1. Hughes C, Pain C, Braithwaite J, Hillman K. 'Between the flags':
implementing a rapid response system at scale. BMJ Qual Saf 2014;23:714-
717
2. McGrath RB. In-hospital cardiopulmonary resuscitation -- after a
quarter of a century. Ann Emerg Med 1987; 16: 1365-1368.
3. Runciman W and Moller J. Iatrogenic Injury in Australia, A Report
prepared by the Australian Patient Safety Foundation for the National
Health Priorities and Quality Branch of the Department of Health and Aged
Care of the Commonwealth of Australia (2001) available from:
http://www.apsf.net.au/dbfiles/Iatrogenic_Injury.pdf (accessed September
2014)
4. Jones AD, Dunbar NJ and Bellomo R. Clinical deterioration in
hospital inpatients: the need for another paradigm shift. Med J Aust 2012;
196 (2): 97-100
5. Australian Commission on Safety and Quality in Health Care.
National consensus statement: essential elements for recognising and
responding to clinical deterioration. Sydney: ACSQHC, 2010. Available
from: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/Nat-
Consensus-Statement-PDF-Complete-Guide.pdf (accessed Sept 2014)
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (U...
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (UKPDS and DCCT studies).[1][2][3] But few patients are aware of this information, fewer still know their own levels, and fewer still know how to achieve such levels. By providing such information, regarding the importance of the levels and finding them out and the need for medical care to reach the required targets, patients would not only be screened but an intervention would have been carried out that would enable many patients to avoid retinopathy and other complications.
Surely it is time to consider that retinopathy screening visits provide the opportunity for vastly improved quality of care, not simply a check up. Indeed, the authors note the success of foot intervention programs in preventing amputations, whilst it is only a very small further step to prevent many diabetic complications by informing patients of the need for good control of their diabetes, and the need to check control with HbA1c and blood pressure checks.
References
(1) Diabetes Control and Complications Trial (DCCT) Research Group. The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long Term Complication in Insulin-Dependant Diabetes Mellitus. N Engl J Med 1993;329:977-86.
(2) Adler, AI, et al, on behalf of the UK Prospective Diabetes Study Group. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36). BMJ 2000;321:412-19.
(3) Stratton, IM, et al, on behalf of the UK Prospective Diabetes Study Group. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35). BMJ 2000;321:405-12.
We wish to congratulate Russ SJ et al. (1) for their excellent survey
investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the
checklist has encountered some difficulties. Specifically, barriers
including checklist fatigue and difficulties in assembling the theatre
team are mentioned. Whilst we certainly agree with this, we wish to amend
the a...
We wish to congratulate Russ SJ et al. (1) for their excellent survey
investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the
checklist has encountered some difficulties. Specifically, barriers
including checklist fatigue and difficulties in assembling the theatre
team are mentioned. Whilst we certainly agree with this, we wish to amend
the authors' catalogue of concerns by sharing our experience at Queen
Alexandra Hospital (QAH).
At QAH we operate a modified WHO safer surgery checklist to suit
local practice. The checklist is applied to every patient passing through
the theatre complex. During a routine audit we identified how an
apparently minor communication error fundamentally undermined the
checklist's safety function and placed our patients at risk.
Our venous thromboembolism (VTE) prophylaxis checkpoint reads 'VTE
prophylaxis considered?'. In practice however, this question is frequently
altered to 'Flowtron's on?' (Flowtron refers to the intermittent pneumatic
calf compression devices (IPCCD) used at QAH). The multiple meanings of
the word 'on' (either interpreted as 'on the patient' or 'switched on')
introduced ambiguity and a communication error. This incorrect use of the
checklist resulted in multiple patients having IPCCDs applied to their
calfs, yet the devices were never switched on and our patients were placed
at risk.
Our experience illustrates two important communication errors that
may undermine the checklist's safety function. Firstly, accurate and
unambiguous wording of each component of the checklist is essential. Words
with homonymous meanings should be avoided where possible. Secondly, each
checklist question must be verbalised accurately during the patient check
to avoid introducing errors.
The original WHO safer surgery checklist (2009) (2) limits such
potential error, as most questions are yes/no answerable. Any local
checklist modifications should aim to maintain this format. Introducing
words with homonymous meanings may lead to communication errors; undermine
the checklist's safety function and place patients at risk.
Reference:
1. BMJ Qual Saf. 2014 Jul 18. The WHO surgical safety checklist:
survey of patients' views. Russ SJ, Rout S, Caris J, Moorthy K, Mayer E,
Darzi A, Sevdalis N, Vincent C.
I read with interest the article on what role the patient and public should play in healthcare improvement (1) as this is a question that my organisation has long grappled with and is now required to achieve accreditation against the mandatory National Safety and Quality Health Service Standards (2).
For many years we had a strong Community Advisory Committee and consumers on all key quality and safety committe...
In the important editorial of the Grant, is underlined the overuse of thromboprophylaxis in patients hospitalized in the medical field. We agree in emphasizing the difficulty of proper patient assessment that must be carefully evaluated, considering comorbidity and various risk factors,and using the main scores currently in use to assess the start of tromboprofilattica therapy. For this reason we carried out a study where...
Dear Editor,
Vermeulen et al [1] provides further insight into the effect of emergency department (ED) crowding and length of stay (LOS) on several quality indicators. This piece of work not only adds to the body of literature which suggests ED crowding delays timeliness of interventions, but importantly highlights that government initiatives targeting LOS alone are not enough to enhance other aspects of true, q...
Dear Editor,
I commend Vermeulen et al for addressing a fundamental question: Is ED length of stay (ED LOS), a globally used key performance indicator, actually associated with improvement in quality of care[1]?
Vermeulen et al set out to compare whether patients presenting with one of three acute conditions (high acuity asthma, upper arm/forearm/shoulder fracture and acute myocardial infarct) at hosp...
To the Editor: I was a little surprised to see Buljac-Samardzic et al. in their recent article on safety culture in long-term care state that few tools are available to evaluate the effectiveness of initiatives to improve safety culture in nursing and residential homes. While there may be fewer tools available for nursing and residential homes than inpatient settings, there are several safety climate instruments that are...
We appreciate Dr. Singer's point about a more thorough discussion of the large literature on safety climate and tools for assessing it. Although we did include two of the articles she refers to; not all were included. While acknowledging and discussing other instruments for measuring Patient Safety Climate (PSC), would have made our article more complete, the findings and conclusions of the study would not have changed....
Dear Editor, we would like to congratulate Russ et al. on their paper on the patients' views of surgical checklists (SC). In their elegant work, the above authors underlined that assessing the fidelity of the SC remains a challenge, but demonstrated a high level of patient support for use of checklists. They found that patients were surprised that SC was only a recent introduction to surgical care. Moreover, the authors...
The authors (1) have raised a very important issue relating to recognition and management of a deteriorating patient. Over the years, cases have been reported where outcome may have been better if deterioration was recognized in time. Once recognized, an urgent response by a qualified team could instigate immediate investigations and management as warranted, possibly averting a poor outcome.
Code blue calls or...
The authors point out the effectiveness and need for retinopathy screening and foot care in diabetes. However, as in much of the "screening" literature, the opportunity for intervention during the screening visit is not ephasised.
We know that by achieving an HbA1c of 6% and blood pressure of 130/80 or below, not smoking, and having a hyperlipidaemia treated, most retinopathy could be avoided or delayed (U...
We wish to congratulate Russ SJ et al. (1) for their excellent survey investigating patients' views of the WHO safer surgery checklist.
The authors point out that the UK wide implementation of the checklist has encountered some difficulties. Specifically, barriers including checklist fatigue and difficulties in assembling the theatre team are mentioned. Whilst we certainly agree with this, we wish to amend the a...
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