BMJ Quality & Safety最新文献

{"title":"Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine.","authors":"Jane Jomy, Ke Xin Lin, Ryan S Huang, Alisia Chen, Aleena Malik, Michelle Hwang, Tahara D Bhate, Nazia Sharfuddin","doi":"10.1136/bmjqs-2023-017022","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-017022","url":null,"abstract":"<p><strong>Introduction: </strong>Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.</p><p><strong>Methods: </strong>In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.</p><p><strong>Results: </strong>Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.</p><p><strong>Discussion: </strong>EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141310027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Global, regional and national time trends in incidence of adverse effects of medical treatment, 1990-2019: an age-period-cohort analysis from the Global Burden of Disease 2019 study.","authors":"Liangquan Lin","doi":"10.1136/bmjqs-2023-016971","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016971","url":null,"abstract":"<p><strong>Background: </strong>Current adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework.</p><p><strong>Methods: </strong>AEMT was defined as harm resulting from a procedure, treatment or other contact with the healthcare system. The overall crude incidence rate, age-standardised incidence rate and their changes over time were analysed to evaluate temporal trends. Data were stratified by sociodemographic index (SDI) quintiles, age groups and sex to address heterogeneity across and within nations. An age-period-cohort model framework was used to differentiate the contributions of age, period and cohort effects on AEMT incidence changes. The model estimated overall and age-specific annual percentage changes in incidence rates.</p><p><strong>Findings: </strong>Although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950.</p><p><strong>Conclusion: </strong>As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141305394","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementation factors, activities and outcomes.","authors":"Jonas Torp Ohlsen, Eirik Søfteland, Per Espen Akselsen, Jörg Assmus, Stig Harthug, Regina Küfner Lein, Nick Sevdalis, Hilde Valen Wæhle, John Øvretveit, Miriam Hartveit","doi":"10.1136/bmjqs-2024-017185","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017185","url":null,"abstract":"<p><strong>Introduction: </strong>Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted.</p><p><strong>Objective: </strong>The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research.</p><p><strong>Methods: </strong>We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed.</p><p><strong>Results: </strong>From the 159 included studies, eight categories of implementation activities were identified: <i>education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training;</i> and <i>patient involvement</i>. Most studies reported activities from multiple categories. Implementation factors included: c<i>linical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence;</i> and <i>feasibility of innovation</i>. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: <i>fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability;</i> and <i>spread</i>. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities.</p><p><strong>Conclusions: </strong>The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-06-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141282906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality, safety and artificial intelligence.","authors":"Tayana Soukup, Bryony Dean Franklin","doi":"10.1136/bmjqs-2024-017382","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017382","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":"33 6","pages":"406-410"},"PeriodicalIF":5.4,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140956094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pragmatic trials are needed to assess the effectiveness of enhanced recovery after surgery protocols on patient safety.","authors":"Antoine Duclos","doi":"10.1136/bmjqs-2023-016966","DOIUrl":"10.1136/bmjqs-2023-016966","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"348-350"},"PeriodicalIF":5.6,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140012104","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study.","authors":"Yukinori Harada, Yumi Otaka, Shinichi Katsukura, Taro Shimizu","doi":"10.1136/bmjqs-2022-015436","DOIUrl":"10.1136/bmjqs-2022-015436","url":null,"abstract":"<p><strong>Background: </strong>There has been growing recognition that contextual factors influence the physician's cognitive processes. However, given that cognitive processes may depend on the physicians' specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians.</p><p><strong>Objective: </strong>This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy.</p><p><strong>Methods: </strong>We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis.</p><p><strong>Results: </strong>Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively.</p><p><strong>Conclusion: </strong>Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"386-394"},"PeriodicalIF":5.6,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10598818","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial.","authors":"Eva Pagano, Luca Pellegrino, Manuela Robella, Anna Castiglione, Francesco Brunetti, Lisa Giacometti, Monica Rolfo, Alessio Rizzo, Sarah Palmisano, Maurizio Meineri, Ilaria Bachini, Mario Morino, Marco Ettore Allaix, Alfredo Mellano, Paolo Massucco, Paola Bellomo, Roberto Polastri, Giovannino Ciccone, Felice Borghi","doi":"10.1136/bmjqs-2023-016594","DOIUrl":"10.1136/bmjqs-2023-016594","url":null,"abstract":"<p><strong>Background: </strong>Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention.</p><p><strong>Methods: </strong>A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items.</p><p><strong>Results: </strong>Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of -0.58 days (95% CI -1.07, -0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68).</p><p><strong>Conclusion: </strong>Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications. <b>Trial registration number</b> NCT04037787.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"363-374"},"PeriodicalIF":5.6,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11103294/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139995556","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"‘This time is different’: physician knowledge in the age of artificial intelligence","authors":"Gurpreet Dhaliwal","doi":"10.1136/bmjqs-2024-017141","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017141","url":null,"abstract":"Great diagnosticians are often portrayed as recognising rare diseases that evade the efforts of mere mortals. This makes for great TV and local legends, but does not reflect daily practice, where the most common diagnostic challenge is discriminating between common conditions like pneumonia and heart failure or appendicitis and gastroenteritis. Questions about how to train the brain to make those distinctions are central to the efforts of many clinician educators. An unresolved issue is whether the structure of knowledge (about diseases and diagnostic pathways) in the physician’s long-term memory or the clinician’s mode of cognition (intuitive or analytical thinking) is more deterministic of diagnostic success. A study1 in this issue of BMJQS sheds light on this issue, but also invites a broader question: is physician cognition still essential for this task at all? In a two-phase experiment, Mamede et al 1 asked 68 internal medicine residents to recall from memory the key clinical features of six conditions (vitamin B12 deficiency, inflammatory bowel disease, hyperthyroidism, adrenal insufficiency, appendicitis, endocarditis). Physicians were categorised as high knowledge (HK) or low knowledge (LK) based on their recall of discriminating features, which are essential to differentiate one condition from common competing diagnoses. One week later, the residents were given related clinical vignettes and asked to render a diagnosis. Half of the vignettes had a salient distracting feature (SDF), a clinical finding that may prompt the physician to suspect a condition other than the correct diagnosis. For example, a vignette of a confused patient included a family history of dementia, which was irrelevant in the face of strong evidence for vitamin B12 deficiency. The authors used the SDF as a model for activating the anchoring heuristic , which is a tendency to adhere to an early judgement triggered by a data point. Essentially, …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":"16 1","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Checking all the boxes: a checklist for when and how to use checklists effectively","authors":"Myrtede Alfred, Laura H Barg-Walkow, Joseph R Keebler, Alex Chaparro","doi":"10.1136/bmjqs-2023-016934","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016934","url":null,"abstract":"Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts’ feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users’ expertise.","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":"150 1","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-05-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Taking action on inequities: a structural paradigm for quality and safety","authors":"Tara A Burra, Christine Soong, Brian M Wong","doi":"10.1136/bmjqs-2023-017027","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-017027","url":null,"abstract":"As quality improvement and patient safety (QIPS) practitioners, we aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. Should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement? Inattention to the equity domain in improvement efforts ignores systemic biases and can worsen inequities in health outcomes. How to measure inequity, and growing calls to reframe health equity data measurement, presentation and analysis are central to this discourse. In this issue of BMJ Quality and Safety , Arrington and colleagues1 offer strategies to collect, share and interpret quality data using a racial equity lens. The authors first describe the problems with stratifying quality data by race and ethnicity, which can perpetuate the false notion that race or ethnicity is responsible for differences in health outcomes and inhibit teams from identifying embedded structural or systemic root causes of health inequities. They provide concrete examples of reimagining data collection and presentation that are actionable and feasible. These include considering root causes beyond describing differences among racial groups, choosing reference points equitably (eg, avoiding using outcomes of white patients as reference points), presenting the most specific level of aggregation (eg, identifying race as ‘Chinese’ rather than ‘Asian’), collecting data on strengths (eg, describing groups with positive outcomes) rather than deficits, measuring racism instead of race and collaborating with community partners. Using this framework, the narrative shifts away from race and ethnicity to a focus on unjust systems, structures and practices responsible for health inequities. As articulated by Arrington and colleagues,1 adopting a racial equity lens to the interpretation of stratified QIPS data is an essential skill that …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":"47 1","pages":""},"PeriodicalIF":5.4,"publicationDate":"2024-04-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140840503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}