Quality & Safety in Health Care最新文献

{"title":"Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care.","authors":"Claire Friedemann Smith, Hannah Lunn, Geoff Wong, Brian D Nicholson","doi":"10.1136/bmjqs-2021-014529","DOIUrl":"10.1136/bmjqs-2021-014529","url":null,"abstract":"<p><strong>Background: </strong>Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.</p><p><strong>Objective: </strong>To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.</p><p><strong>Methods: </strong>Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.</p><p><strong>Results: </strong>95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.</p><p><strong>Conclusions: </strong>We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.</p>","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"541-554"},"PeriodicalIF":0.0,"publicationDate":"2022-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9234415/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42217429","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"High reliability organising in healthcare: still a long way left to go","authors":"Christopher G. Myers, K. Sutcliffe","doi":"10.1136/bmjqs-2021-014141","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014141","url":null,"abstract":"","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"845 - 848"},"PeriodicalIF":0.0,"publicationDate":"2022-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49024261","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme","authors":"Leahora Rotteau, J. Goldman, Kaveh G. Shojania, Timothy J. Vogus, Marlys K. Christianson, G. Baker, P. Rowland, M. Coffey","doi":"10.1136/bmjqs-2021-013938","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-013938","url":null,"abstract":"Background Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts. Objective This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme. Methods We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data. Results Participants reported enactment of the HRO principles ‘preoccupation with failure’, ‘reluctance to simplify interpretations’ and ‘sensitivity to operations’, and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles ‘commitment to resilience’ and ‘deference to expertise’ and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability. Conclusion Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"867 - 877"},"PeriodicalIF":0.0,"publicationDate":"2022-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46819921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnosing diagnostic errors: it’s time to evolve the patient safety research paradigm","authors":"D. Stockwell, P. Sharek","doi":"10.1136/bmjqs-2021-014517","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014517","url":null,"abstract":"","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"701 - 703"},"PeriodicalIF":0.0,"publicationDate":"2022-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46952174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transition of care from adult intensive care settings – implementing interventions to improve medication safety and patient outcomes","authors":"S. McCarthy, R. Laaksonen, V. Silvari","doi":"10.1136/bmjqs-2021-014443","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014443","url":null,"abstract":"© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. On admission to an intensive care unit (ICU), patients’ regular longterm medications may be withheld while they are being stabilised. Such medications are sometimes not restarted during the rest of their hospital stay, even when transferred to a lower acuity ward or discharged from hospital. This puts patients discharged from an ICU at higher risk of unintentional medication discontinuation, which could lead to future exacerbation of chronic conditions. Additionally, ICU patients may have medications commenced in the acute stage of their ICU admission (eg, gastric acid secretion inhibitors) that might inadvertently be continued following transfer from the ICU. There is a growing body of evidence that care transitions, whether from inpatient to outpatient settings, or within a hospital stay between different specialties or departments, pose an elevated risk of patients experiencing negative outcomes such as medication errors or adverse events. 4 A systematic review suggests that across five studies, the median rate of medication errors following hospital discharge is 53% per adult discharged patient. However, less is known about medication errors in adults transferred from ICU to general hospital wards; the limited research available suggests high levels of medication errors associated with this transition point with 46%–74% of patients experiencing a medication error. 7 Commonly occurring errors include continuation of medication indicated only in the ICU, untreated indications and medications without an indication. There is a need to understand what interventions can be used to reduce medication errors, and the effectiveness of these interventions, when transitioning patients from the ICU setting.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"565 - 568"},"PeriodicalIF":0.0,"publicationDate":"2022-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45404211","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Epidemiology of adverse drug events and medication errors in four nursing homes in Japan: the Japan Adverse Drug Events (JADE) Study","authors":"Nobutaka Ayani, N. Oya, Riki Kitaoka, Akiko Kuwahara, T. Morimoto, M. Sakuma, J. Narumoto","doi":"10.1136/bmjqs-2021-014280","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014280","url":null,"abstract":"Background Worldwide, the emergence of super-ageing societies has increased the number of older people requiring support for daily activities. Many elderly residents of nursing homes (NHs) take drugs to treat chronic conditions; however, there are few reports of medication safety in NHs, especially from non-western countries. Objective We examined the incidence and nature of adverse drug events (ADEs) and medication errors (MEs) in NHs for the elderly in Japan. Design, setting, and participants The Japan Adverse Drug Events Study for NHs is a prospective cohort study that was conducted among all residents, except for short-term admissions, at four NHs for older people in Japan for 1 year. Measurements Trained physicians and psychologists, five and six in number, respectively, reviewed all charts of the residents to identify suspected ADEs and MEs, which were then classified by the physicians into ADEs, potential ADEs and other MEs after the exclusion of ineligible events, for the assessment of their severity and preventability. The kappa score for presence of an ADE and preventability were 0.89 and 0.79, respectively. Results We enrolled 459 residents, and this yielded 3315 resident-months of observation time. We identified 1207 ADEs and 600 MEs (incidence: 36.4 and 18.1 per 100 resident-months, respectively) during the study period. About one-third of ADEs were preventable, and MEs were most frequently observed in the monitoring stage (72%, 433/600), with 71% of the MEs occurring due to inadequate observation following the physician’s prescription. Conclusion In Japan, ADEs and MEs are common among elderly residents of NHs. The assessment and appropriate adjustment of medication preadmission and postadmission to NHs are needed to improve medication safety, especially when a single physician is responsible for prescribing most medications for the residents, as is usually the case in Japan.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"878 - 887"},"PeriodicalIF":0.0,"publicationDate":"2022-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48066293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Replicating and publishing research in different countries and different settings: advice for authors","authors":"B. Franklin, E. Thomas","doi":"10.1136/bmjqs-2021-014431","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014431","url":null,"abstract":"","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"627 - 630"},"PeriodicalIF":0.0,"publicationDate":"2022-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46978958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study","authors":"Emilie J Braun, Siddhartha Singh, Annie C. Penlesky, Erin A Strong, Jeana M. Holt, K. Fletcher, Michael E. Stadler, A. Nattinger, Bradley H. Crotty","doi":"10.1136/bmjqs-2021-014498","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014498","url":null,"abstract":"Background Unrecognised changes in a hospitalised patient’s clinical course may lead to a preventable adverse event. Early warning systems (EWS) use patient data, such as vital signs, nursing assessments and laboratory values, to aid in the detection of early clinical deterioration. In 2018, an EWS programme was deployed at an academic hospital that consisted of a commercially available EWS algorithm and a centralised virtual nurse team to monitor alerts. Our objective was to understand the nursing perspective on the use of an EWS programme with centralised monitoring. Methods We conducted and audio-recorded semistructured focus groups during nurse staff meetings on six inpatient units, stratified by alert frequency (high: >100 alerts/month; medium: 50–100 alerts/month; low: <50 alerts/month). Discussion topics included EWS programme experiences, perception of EWS programme utility and EWS programme implementation. Investigators analysed the focus group transcripts using a grounded theory approach. Results We conducted 28 focus groups with 227 bedside nurses across all shifts. We identified six principal themes: (1) Alert timeliness, nurses reported being aware of the patient’s deterioration before the EWS alert, (2) Lack of accuracy, nurses perceived most alerts as false positives, (3) Workflow interruptions caused by EWS alerts, (4) Questions of actionability of alerts, nurses were often uncertain about next steps, (5) Concerns around an underappreciation of core nursing skills via reliance on the EWS programme and (6) The opportunity cost of deploying the EWS programme. Conclusion This qualitative study of nurses demonstrates the importance of earning user trust, ensuring timeliness and outlining actionable next steps when implementing an EWS. Careful attention to user workflow is required to maximise EWS impact on improving hospital quality and patient safety.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"716 - 724"},"PeriodicalIF":0.0,"publicationDate":"2022-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43290591","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg","authors":"E. Bamberger, Peter A. Bamberger","doi":"10.1136/bmjqs-2021-014157","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014157","url":null,"abstract":"© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. Since the publication of the 1999 ‘To Err is Human’ report by the Institute of Medicine, healthcare researchers have been attentive to factors potentially associated with iatrogenic risk, or in other words medical care that exacerbates or complicates an existing patient condition. While studies have explored a variety of patient factors (eg, age and weight of neonates) and situational constraints (eg, staffing ratios and healthcare worker (HCW) sleep deprivation ), the risks posed by negative interpersonal interactions in healthcare contexts remain understudied and poorly understood. It is therefore timely that in BMJ Quality & Safety, Guo and colleagues present a systematic review of research examining the effects of unacceptable behaviours between HCWs on clinical performance and patient outcomes. Guo and colleagues’ findings present an important step in raising awareness of the risks posed by negative interpersonal interactions among HCWs, shedding light on how and when such behaviour may indeed serve as a significant iatrogenic risk factor. However, as troubling as their findings may be, they may understate the magnitude and complexity of the challenge that unacceptable behaviours present to HCWs. In this editorial, we begin by commenting on the magnitude of impact that such behaviour has on clinical performance and patient safety, arguing that its true impact is most apparent when considered relative to the magnitude of impact of other iatrogenic risk factors. We then argue that other, largely unexplored, aspects of HCW exposure to unacceptable behaviour may impact clinical performance and patient safety no less than those aspects examined in Guo and colleagues’ review, highlighting (1) the collateral effects of unacceptable HCW behaviour on witnesses and HCW teams, and (2) the effects of unacceptable behaviour directed at HCWs by patients or their families.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"638 - 641"},"PeriodicalIF":0.0,"publicationDate":"2022-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45676174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity","authors":"C. Davidson, S. Denning, Kristin Thorp, L. Tyer‐Viola, M. Belfort, H. Sangi-Haghpeykar, M. Gandhi","doi":"10.1136/bmjqs-2021-014225","DOIUrl":"https://doi.org/10.1136/bmjqs-2021-014225","url":null,"abstract":"The objective of this study was to evaluate the impact of quality improvement (QI) and patient safety initiatives and data disaggregation on racial disparities in severe maternal morbidity from hemorrhage (SMM-H). Our hospital began monitoring and reporting on SMM-overall and SMM-H rates in 2018 using administrative data. In March 2019, we began stratifying data by race and ethnicity and noted a disparity in rates, with non-Hispanic Black women having the highest SMM rates. The data was presented as run charts at monthly department meetings. During this time, our hospital implemented several QI and patient safety initiatives around obstetric hemorrhage and used the stratified data to inform guideline development to reduce racial disparity. The initiatives included implementation of a hemorrhage patient safety bundle and in-depth case reviews of adverse patient outcomes with a health equity focus. We then retrospectively analyzed our data. Our outcome of interest was SMM-H prior to data stratification (pre-intervention: June 2018-February 2019) as compared to after data stratification (post-intervention: March 2019-June 2020). During our study time period, there were 13,659 deliveries: 37% Hispanic, 35% White, 20% Black, 7% Asian and 1% Other. Pre-intervention, there was a statistically significant difference between Black and White women for SMM-H rates (p<0.001). This disparity was no longer significant post-intervention (p=0.138). The rate of SMM-H in Black women decreased from 45.5% to 31.6% (p=0.011). Our findings suggest that QI and patient safety efforts that incorporate race and ethnicity data stratification to identify disparities and use the information to target interventions have the potential to reduce disparities in SMM.","PeriodicalId":49653,"journal":{"name":"Quality & Safety in Health Care","volume":"31 1","pages":"670 - 678"},"PeriodicalIF":0.0,"publicationDate":"2022-04-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"63896282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}