Table 2

Published examples of trade-offs and pleasant and unpleasant surprises in the improvement literature

StudyImprovement goalsOther consequencesExamples of balancing measures prior, during and postimplementation
Kavanagh et al 35 To improve the timeliness of management of vaso-occlusive pain events in children with sickle cell disease in paediatric emergency departmentsExpected undesirable consequences
Mean time from triage to the second intravenous opioid dose was introduced as a balancing measure because of concern that the use of intranasal fentanyl as the first-line intervention might delay subsequent intravenous dosing. Other trade-offs measured included readmission rates within 24 hours of discharge, episodes of respiratory depression and inpatient length of stay.
Dewan et al 36 To decrease unnecessary routine complete blood count testing in a low-risk cohort of postoperative patients in the paediatric intensive care unitsExpected undesirable consequences
Balancing measures were implemented for haemoglobin level below 8g/dL in patients for whom complete blood counts were actually sent and blood transfusions up to 7 days postoperatively for any patients in the cohort.
Duvoisin et al 37 To reduce the number of unnecessary diagnostic tests such as complete blood count and C-reactive protein in infants with risk factors for early-onset neonatal sepsisUnexpected desirable consequences
(pleasant surprises)
There was preintervention concern that reduction in the use of diagnostic tests would delay the initiation of antibiotic treatment, but unexpectedly the intervention resulted in earlier treatment of infection on average.
Bell et al 38 To reduce the preoperative use of antimicrobials associated with Clostridium difficile infectionUnexpected undesirable consequences
(unpleasant surprises)
The new surgical prophylaxis regimen of four doses of flucloxacillin 1 g plus single-dose gentamicin 4 mg/kg unexpectedly led to increased rates of postoperative acute kidney injury in orthopaedic patients, large enough to lead to the termination of the intervention through a change in the national antibiotic policy recommendation for orthopaedic surgical prophylaxis.
Strom et al 39 To evaluate the effectiveness of a customised nearly hard stop alert in reducing concomitant orders for warfarin and trimethoprim- sulfamethoxazole compared with the standard practice of a pharmacist intervention programmeUnexpected undesirable consequences
(unpleasant surprises)
Unexpected delays in indicated anticoagulant and/or antimicrobial treatment initiation were deemed sufficiently serious to warrant discontinuation of the improvement intervention.