BMJ Open Quality最新文献

{"title":"Effectiveness of motivational messages on nurses' professional quality of life: a systematic review.","authors":"Amal M T Ababneh, Ruqayya Zeilani","doi":"10.1136/bmjoq-2024-003100","DOIUrl":"10.1136/bmjoq-2024-003100","url":null,"abstract":"<p><strong>Objectives: </strong>To assess the efficacy of motivational messages on nurses' professional quality of life and well-being.</p><p><strong>Design: </strong>The present systematic review was conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a widely accepted framework for conducting systematic reviews. The researchers used specific keywords to search for eligible studies in several databases. This review covered articles written in English and published between the years 2014 and 2024. Eventually, five articles were included in this review study; in particular, four articles were trial studies and one was a cross-sectional study. The risk of bias and risk of methodological quality of the included studies were assessed using the Joanna Briggs Institute Critical Appraisal methods.</p><p><strong>Results: </strong>The results of the review demonstrate how motivational messages may be an effective strategy for reducing work-related stress among healthcare employees.</p><p><strong>Conclusion: </strong>By using technological platforms and employing motivational messages during regular work tasks, healthcare organisations may foster a positive work environment which, in turn, promotes nurses' resilience and enhances their well-being.</p><p><strong>Prospero registration number: </strong>CRD42024576029.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12421170/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145022755","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":"Impact of a 24/7 on-site percutaneous coronary intervention team strategy on door-to-wire time.","authors":"Liang Wang, Xinglin Yang, Wei Wu, Ran Tian, Ming Yang, Yechen Han, Jianzhong Shen, Hao Qian, Fan Guo, Tengyue Zhang, Xueqing Zhu, Xiaofeng Jin, Chonghui Wang, Hongzhi Xie, Zhongjie Fan, Zhujun Shen, Jihai Liu, Zhanjie Zhang, Xiaojun Ma, Zhenyu Liu, Huadong Zhu","doi":"10.1136/bmjoq-2025-003386","DOIUrl":"10.1136/bmjoq-2025-003386","url":null,"abstract":"<p><strong>Background: </strong>Current guidelines recommend that the door-to-wire (D2W) time should be <90 min in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). This study evaluated the effect of a 24/7 on-site PCI team strategy on the D2W time.</p><p><strong>Methods: </strong>In this single-centre, retrospective study, patients with STEMI undergoing primary PCI within 1 year before (control group, n=143) and 1 year after (intervention group, n=96) implementing a 24/7 on-site PCI team strategy were enrolled. This strategy required that the PCI team was always available in hospital to minimise the time required to make the catheterisation laboratory ready for PCI. The primary endpoint was the D2W time, and the secondary endpoints were the rate of delayed PCI (D2W time ≥90 min) and the on-site time of the PCI team members. Multivariate analysis was conducted to determine the independent predictors of delayed PCI in the intervention group.</p><p><strong>Results: </strong>The D2W time was shorter (52 vs 97 min, p<0.001), the rate of delayed PCI was lower (19.8% vs 55.2%, p<0.001), but the on-site time of the PCI team members (35 040 vs 9960 hours) was longer in the intervention group than in the control group. Time-to-obtain electrocardiogram >10 min (p=0.027) and time-to-make STEMI diagnosis >9 min (p<i>=</i>0.001) were independent predictors of delayed PCI after implementing the strategy.</p><p><strong>Conclusions: </strong>Implementing a 24/7 on-site PCI team strategy was associated with reductions in the D2W time and the rate of delayed PCI but an increase in the on-site time of the PCI team members.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12421147/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145022741","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":"Artificial intelligence approach to optimise safety for hospitalised patients with dementia.","authors":"Lauren Bangerter, Allan Fong, Garrett Zabala, Yijung K Kim, Azade Tabaie, Nicole E Werner, Karl Eric De Jonge, Raj M Ratwani","doi":"10.1136/bmjoq-2024-003270","DOIUrl":"10.1136/bmjoq-2024-003270","url":null,"abstract":"<p><strong>Background: </strong>The aim of the study is to develop a machine learning (ML) model to identify contributing factors to dementia-related safety events using patient safety event report data.</p><p><strong>Method: </strong>This study uses dementia-related safety event reports from a patient safety reporting system of a 10-hospital health system in the USA. Contributing factors to safety events were coded using the Yorkshire contributory factors framework based on free-text descriptions in the reports. The coded event reports were used to develop two ML models using eXtreme Gradient Boosting (XGBoost), one to classify situational patient factors and another to classify active failures relating to human error.</p><p><strong>Results: </strong>We used 1387 safety event reports for model development, 989 (71.3%) reports related to situational factors and 119 (8.6%) reports related to active failures. The model for situational factors achieved a precision of 0.843 and a recall of 0.826. The F1 score was 0.834, indicating a balance of precision and recall performance. The specificity of the model was 0.639 and the area under the receiver operating characteristic curve (ROC AUC) was 0.833. The final model for active failure achieved a precision of 0.333 and a recall of 0.056. The F1 score was 0.095, reflective of imbalanced precision and recall performance. The specificity of the model was 0.992, indicating a strong ability to identify negative cases, and the ROC AUC was 0.817.</p><p><strong>Conclusion: </strong>ML techniques can provide insights into situational factors and active failures that drive dementia-related safety events. These insights can inform targeted interventions such as specialised staff training for behavioural symptoms management and pharmacist-led medication optimisation, to enhance care and safety for hospitalised people living with dementia.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12414173/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991482","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":"Nationwide data-driven quality improvement in ultrasound medicine: insights from an indicator-based initiative in China.","authors":"Aiping Zeng, Rui Zhang, Li Ma, Xixi Tao, Luying Gao, Jianchu Li, Hongyan Wang, Yuxin Jiang","doi":"10.1136/bmjoq-2025-003349","DOIUrl":"10.1136/bmjoq-2025-003349","url":null,"abstract":"<p><strong>Background: </strong>There are only a limited number of countries systematically tracking the quality of ultrasound at the national and institutional levels. Our study presents an example of a national, data-driven approach to ultrasound medicine quality measurement and improvement through indicators.</p><p><strong>Aim: </strong>This study aims to establish a nationwide, indicator-based framework for measuring and improving the quality of ultrasound medicine in China. By developing and applying quality indicators, we seek to systematically evaluate performance, identify areas for improvement and guide data-driven quality enhancement efforts across institutions.</p><p><strong>Methods: </strong>To enhance ultrasound quality and improve quality management, a leadership team was established. Pertinent quality indicators were developed as evaluation metrics. Quality improvement programmes were designed following the identification of key causes of suboptimal performance. A Plan-Do-Study-Act method was applied. Nationwide sample surveys were conducted annually to collect and document the relevant quality data. 10 ultrasound quality indicators were selected and comparisons of data from 2020 to 2023 were made. χ² tests were used to evaluate statistical differences.</p><p><strong>Results: </strong>The ultrasound instruments quality inspection rate, the completion rate of notification of ultrasound critical findings within 10 min, the qualification rate of ultrasound reports remained and the completion rate of inpatient ultrasound examinations within 48 hours remained consistently high. The Breast Imaging Reporting and Data System utilisation rate of breast lesions in ultrasound reports, the concordance rate of ultrasound diagnoses, the accuracy rate of ultrasound diagnosis of breast lesions and the concordance rate of ultrasound diagnosis of ≥50% carotid stenosis all improved and showed an upward trend.</p><p><strong>Conclusions: </strong>Indicator-based data can drive nationwide measurement, improvement and monitoring of ultrasound medicine quality. The use of indicators supports sustained efforts to improve quality and safety in ultrasound services.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12410611/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991560","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":"Restraint reduction during psychiatric intensive care: a controlled bi-phasic time series evaluation of a culture change intervention.","authors":"Eleanor Green, Stephen Kellett, Chris Gaskell, Martin Hobbs","doi":"10.1136/bmjoq-2024-002956","DOIUrl":"10.1136/bmjoq-2024-002956","url":null,"abstract":"<p><strong>Background: </strong>Restrictive practices (ie, physical restraint, rapid tranquilisation and seclusion) are used to manage risk of harm to self and/or others during inpatient psychiatric admissions. Restrictive practices can be physically and psychologically hazardous for both patients and staff, but there have been few well-controlled evaluations of interventions to reduce restrictive practices.</p><p><strong>Objective: </strong>To conduct a controlled evaluation of the implementation of a culture change intervention on a psychiatric intensive care unit (PICU) compared with a control PICU on use of restraint.</p><p><strong>Methods: </strong>A new staff role was created on the intervention PICU (ie, the <i>reducing restrictive interventions advocate</i>; RRIA). The RRIA met with patients/carers and advised, trained, supervised and debriefed the multidisciplinary team concerning restraint. Mixed methods evaluated the effectiveness of the RRIA role. Restraint outcomes on the intervention and the control PICU were compared pre (19 months) and post intervention (19 months). Qualitative interviews were conducted with the RRIA, the PICU ward manager and the RRI organisational lead.</p><p><strong>Results: </strong>On the intervention PICU, there were significant reductions in the use of seclusion, full restraint and use of standing holds. Qualitatively, positive changes to the safety culture of the intervention PICU were reported, and these were consistently rated as important, impactful and unlikely without the RRIA role.</p><p><strong>Conclusions: </strong>PICU safety culture can improve when specific roles focused on changing ward practices around restraints are implemented. More controlled evaluations of reducing restraint interventions on PICUs are needed.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12406904/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144941281","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":"Evaluating the implementation of the Saving Babies Lives Care Bundle Version 2 from service user and healthcare professionals' perspectives: a questionnaire study.","authors":"Kate Widdows, Holly Reid, Debbie M Smith, Rebecca Wood-Harper, Elizabeth Camacho, Stephen A Roberts, Alexander E P Heazell","doi":"10.1136/bmjoq-2025-003456","DOIUrl":"10.1136/bmjoq-2025-003456","url":null,"abstract":"<p><strong>Introduction: </strong>The Saving Babies' Lives Care Bundle (SBLCB) was introduced in England in 2015 and was updated in 2019 (SBLCBv2). This study aimed to describe the degree to which SBLCBv2 was implemented in practice and describe contemporary experiences of receiving and delivering antenatal and intrapartum care informed by the recommendations of SBLCBv2.</p><p><strong>Methods: </strong>This cross-sectional questionnaire study was conducted in 28 National Health Service maternity units across England between October and December 2023. The study had two arms, one for maternity service users and one for healthcare professionals. Maternity service users aged ≥16 years who had given birth in the last 12 months were invited to participate in an online survey which contained closed questions about elements of the SBLCBv2, and two free-text questions about their experiences of receiving antenatal and intrapartum care. Maternity healthcare professionals from participating sites were invited to complete a separate questionnaire about delivering care. Responses were summarised by descriptive statistics.</p><p><strong>Results: </strong>1140 women and 633 healthcare professionals participated. The majority of staff reported implementing all five elements of SBLCBv2, though this varied from 57% (prevention of preterm birth) to 99% (smoking cessation). Service users frequently reported receiving interventions that were part of SBLCBv2: 26% were offered Aspirin and 97% monitored fetal movement. Staff generally reported positive experiences of implementing the SBLCBv2, feeling that it supported clinical decision making. 89% and 86% of service users reported a positive experience in pregnancy and labour, respectively. This was underpinned by positive staff attitudes, behaviours and communication, and being listened to and involved in decisions about care.</p><p><strong>Conclusions: </strong>SBLCBv2 has been integrated into clinical practice, though some elements require additional focus to increase implementation (e.g., preterm birth). Maternity staff may benefit from additional training to discuss the reasons for and results of interventions to reduce the risk of pregnancy complications.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12410671/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144942211","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":"Rapid access microscopy and real-time case discussion via a secure messaging app improves diagnostic accuracy and management of acute hot swollen joints.","authors":"Anouchka Lewis, Geraldine M McCarthy, Sharon Cowley, Callum Swift, Oisin Corish, Khaled Taha, Abuelmagd Abdalla, Tomas Breslin, Frank Lyons, Eavan Muldoon, Cian McDermott, Helina Alemayehu, Oliver Boughton, John Stack","doi":"10.1136/bmjoq-2025-003417","DOIUrl":"10.1136/bmjoq-2025-003417","url":null,"abstract":"<p><p>Patients with acute swollen joints are often presumed to have septic arthritis, leading to intravenous antibiotics and arthroscopic washout. Previously at our centre, joint fluid aspirates often lacked crystal analysis, resulting in excess culture-negative septic arthritis diagnoses. We developed a 'Hot Joint Pathway', hypothesising that since acute crystal arthropathy can be misdiagnosed as 'culture-negative septic arthritis', introducing the pathway would improve diagnostic accuracy.This pathway provides a structured approach for investigating acutely swollen joints, distinguishing septic arthritis from crystal arthritis. Key features include a secure messaging app for multidisciplinary discussion and rheumatology-led point-of-care polarised light microscopy (POC PLM) <24 hours 6 days per week. A service evaluation of hospital inpatient data identified patients labelled with septic arthritis admitted between two periods: before (1 January 2019-30 November 2020) and after (27 September 2022-29 February 2024) pathway implementation. Emergency department (ED) patients discussed via the app were also analysed (27 September 2022-25 September 2023).Among ED patients, 92% received rheumatology input, and 100% underwent joint aspiration with rheumatologist-led crystal analysis in <24 hours. 68% avoided hospital admission, receiving same-day discharge. Of these, 53% were diagnosed with crystal arthropathy and were discharged with planned outpatient follow-up.Diagnostic accuracy increased for inpatients following pathway introduction. Joint aspirates increased from 50% to 76% (p=0.034). Culture-negative cases of septic arthritis reduced from 34% to 17% and culture positive cases increased from 41% to 76% (p<0.005). Crystal analysis increased from 19% to 28%. Positive blood cultures increased from 28% to 41%. Mean length of stay decreased from 26 to 23 days.A structured care pathway combining rheumatology-led POC PLM and multidisciplinary discussion increases diagnostic accuracy, facilitates admission avoidance and reduces hospital stay for patients with acute swollen joints. Rheumatology-led PLM is essential for the success of this pathway.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12406939/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144942368","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":"Pharmacist-led guideline-directed medical therapy in heart failure: impact analysis in primary care.","authors":"Markus Schichtel, Stephen Barclay, Helena Papworth, Leila Mills, Ben Bowers","doi":"10.1136/bmjoq-2025-003401","DOIUrl":"10.1136/bmjoq-2025-003401","url":null,"abstract":"<p><p>Optimal guideline-directed medical therapy (GDMT) can reduce mortality, unplanned hospital admissions and improve quality of life for patients suffering from heart failure (HF). However, GDMT remains underused in primary care. Only a minority of patients on HF registers receive optimal GDMT in the UK. This suboptimal care is compounded by a mounting lack of GP capacity and the growing burden of HF.A multisite, quantitative impact analysis was undertaken to evaluate the optimisation of HF patients by a novel pharmacist-led GDMT model in UK primary care.We identified low-risk HF patients suitable for pharmacists' input, including a community validated risk stratification tool-the HF Event STrengthening Score. The primary outcome was to compare the proportion of patients on optimal HF GDMT at 6 months and 2 years with baseline. Secondary outcomes were direct personnel healthcare costs and GP workload. A subgroup analysis was modelled to estimate effect on mortality, hospitalisation and quality of life.A total of 237 patients were included. Pharmacist-led GDMT contributed to the increase of optimal GDMT from 17.7% at baseline to 76.5% at 6 months and 94.5% at 2 years follow-up. The novel approach reduced GPs' HF GDMT workload by 36.6% at 6 months and 42.1% at 2 years and healthcare costs by 18.4% at 6 months and 20.3% at 2 years. Patients with combined angiotensin receptor neprilysin inhibitor/sodium glucose co-transporter 2 inhibitor treatment indicated a reduction of 20.8% in cardiovascular mortality, a reduction of 34.8% in hospitalisations and a 5.31 Kansas City Cardiomyopathy Questionnaire Score for improved quality of life at 2 years.For low-risk HF patients, pharmacist-led optimisation achieved significantly higher GDMT rates, reduced personnel healthcare costs, reduced GPs' workload, contributed to reduced cardiovascular mortality, reduced hospitalisations and improved quality of life. In the context of current workload pressures, this approach should be considered for widespread implementation in general practice.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12406906/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144942344","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":"'Alone on our NF1 island': a patient-led mixed-method survey study to understand the care pathway for neurofibromatosis type 1 (NF1) patients in the UK.","authors":"Shaowen Ju, Laura Cowley, Ishan Jain, Vanessa Martin, Ellie Day, Rona Smith, Tessa Morgan","doi":"10.1136/bmjoq-2025-003383","DOIUrl":"10.1136/bmjoq-2025-003383","url":null,"abstract":"<p><strong>Background: </strong>Neurofibromatosis type 1 (NF1), a rare genetic disorder characterised by neurofibroma growth, affects approximately 25 000 individuals in the UK. Its wide range of clinical manifestations presents significant challenges in providing comprehensive care for patients. In agreement with National Health Service England's Commissioners, Childhood Tumour Trust initiated a patient-led service evaluation to understand existing care pathways and identify factors influencing patient satisfaction.</p><p><strong>Methods: </strong>The study was coproduced with patient charities, clinicians and the Patient Led Research Hub. Online surveys were composed for patients, families, carers (PFCs) and healthcare professionals (HCPs) and disseminated through charity and healthcare networks. Structured features were analysed using descriptive statistics to review pathways and examine correlations with care satisfaction. Free-text responses were coded and analysed thematically to explore PFCs' and HPCs' experiences.</p><p><strong>Results: </strong>A total of 1083 PFC and 94 HCP responses were received from across the UK (783 and 49 were complete, respectively). Overall, 54% PFCs expressed dissatisfaction with NF1 care. While London had a significantly higher satisfaction rate (64%; p=0.01) than the national average, Scotland (30%, p=0.01) and Northern Ireland (16%, p=0.01) had significantly lower rates. Influencing factors included poor care coordination, long specialist wait times and insufficient signposting to charities. Regarding diagnosis and management, 46 HCP roles, 35 referral routes and 16 sources of management guidelines were identified, indicating a lack of clear pathways and care standardisation. Free-text data revealed additional challenges, including limited education and information for families, low NF1 awareness among professionals, inequitable access to specialists and a desire for holistic care.</p><p><strong>Conclusions: </strong>This evaluation revealed UK-wide dissatisfaction with NF1 care and a pressing need for system-level changes to improve regional disparities and care coordination, enhance patient education and HCP training and establish standardised pathways with a holistic model to enable high-quality equitable care for all NF1 patients.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12410633/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144942264","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":"Fatal anaphylactic shock following cefoperazone-sulbactam re-exposure: a short report on systemic gaps in adverse drug reaction management.","authors":"Xiaomei Mo, Guanhua Liang, Wenhui Gan, Lili Xu, Meixing Yan","doi":"10.1136/bmjoq-2025-003392","DOIUrl":"10.1136/bmjoq-2025-003392","url":null,"abstract":"<p><p>This report presents a case of fatal anaphylactic shock following re-exposure to cefoperazone-sulbactam, highlighting systemic gaps in adverse drug reaction (ADR) management. The patient initially tolerated the drug without immediate adverse effects but developed severe hypersensitivity reactions upon subsequent exposures, ultimately leading to death. Analysis revealed that the healthcare team underestimated the risk of delayed IgE-mediated sensitization, and critical allergy information was not documented in the emergency department (ED). Additionally, the electronic health record (EHR) system lacked real-time allergy alerts. Fragmented communication during care transitions and technological deficiencies further exacerbated the risks.</p>","PeriodicalId":9052,"journal":{"name":"BMJ Open Quality","volume":"14 3","pages":""},"PeriodicalIF":1.6,"publicationDate":"2025-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12410647/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144942363","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}