BMJ Quality & Safety最新文献

{"title":"Please document the nature of the medical emergency.","authors":"Jeffrey A Gold","doi":"10.1136/bmjqs-2026-020219","DOIUrl":"10.1136/bmjqs-2026-020219","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"587-590"},"PeriodicalIF":6.8,"publicationDate":"2026-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13419664/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148263226","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":"Effectiveness of clinician-directed default nudges on reducing overuse of tests and treatments in healthcare: a systematic review of randomised controlled trials.","authors":"Gemma Altinger, Caitlin M P Jones, Giovanni E Ferreira, Jason Soon, Tammy C Hoffmann, Christopher Maher, Rui Chang, Jeffrey A Linder, Adrian Traeger","doi":"10.1136/bmjqs-2025-018793","DOIUrl":"10.1136/bmjqs-2025-018793","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the effectiveness of clinician-directed default nudges for reducing overuse of tests and treatments.</p><p><strong>Design: </strong>A systematic review was conducted to synthesise evidence from randomised controlled trials examining the effect of clinician-directed default nudges on overuse of tests or treatments, measured as a proportion of encounters or patients. Four databases and three clinical trial registries were searched up to 13 January 2025. Two reviewers screened, extracted data, assessed risk of bias and certainty of evidence using Cochrane guidance. Because there was high clinical heterogeneity, we used the Synthesis Without Meta-analysis guidelines for our overall analysis. A secondary exploratory meta-analysis was performed on a subgroup of default nudge interventions targeting opioid prescriptions.</p><p><strong>Results: </strong>We included six trials (five cluster randomised trials and one patient randomised trial, n=767 to 21 331). Trials targeted overuse of opioids, antibiotics, high-risk medicines for older patients and imaging during palliative radiotherapy. Lowering default quantities of opioids may cause reductions in opioid overuse, but on one occasion increased overuse. It is unclear if opt-out defaults reduce antibiotic overuse in patients with sepsis eligible for de-escalation or if lowering default doses reduce overuse of high-risk medications in older patients. Reducing the default frequency of imaging probably causes large reductions in unnecessary imaging in people receiving palliative radiotherapy. A subgroup meta-analysis was only possible on one type of default for opioids. A 10-tablet default may reduce overuse of large packs of opioids (risk difference=-14.3%, 95% CI -51.4% to +22.9%, 3 trials, 18 186 encounters, very low certainty evidence).</p><p><strong>Conclusions: </strong>Clinician-directed default nudges had inconsistent effects on overuse of healthcare, with limited and mostly low certainty evidence. High-quality trials are essential to determine whether default nudges reduce overuse or improve patient outcomes.</p><p><strong>Prospero registration number: </strong>42024516423.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"632-645"},"PeriodicalIF":6.8,"publicationDate":"2026-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144667026","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":"Healthcare provision in prisons: an ongoing challenge.","authors":"Emma Plugge, Caroline Watson","doi":"10.1136/bmjqs-2026-020252","DOIUrl":"10.1136/bmjqs-2026-020252","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"583-586"},"PeriodicalIF":6.8,"publicationDate":"2026-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148155032","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":"Operationalising 'what matters'-will we ever find a way to patient-centred care?","authors":"Margaret Schwarze, Kate Telma, Lauren J Taylor","doi":"10.1136/bmjqs-2026-020447","DOIUrl":"10.1136/bmjqs-2026-020447","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"579-582"},"PeriodicalIF":6.8,"publicationDate":"2026-08-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13274961/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147986575","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":"Beyond 'diagnostic error': an ethnography of resilient behaviours and system adaptations in paediatric outpatient diagnosis.","authors":"Christina L Cifra, Katherine Melton, Kathleen E Walsh, Ellen A Lipstein, Alisa Khan, Alyna T Chien, Irit R Rasooly, Trisha L Marshall, Patrick W Brady, Samira Ahmed, Kimberly Asitimbay, Alexander Fidel, Tamaki Hashiramoto, Ruby Hyland-Brown, Nolan Joyce, Brynn Telenko, Sara L Toomey, Christopher P Landrigan, Ken Catchpole","doi":"10.1136/bmjqs-2026-020175","DOIUrl":"10.1136/bmjqs-2026-020175","url":null,"abstract":"<p><strong>Background: </strong>Improving paediatric diagnosis by addressing errors (Safety-I) is insufficient for diagnostic excellence. Resilience engineering's approach to understanding adaptations to achieve success in everyday work may elucidate how individuals and systems manage diagnostic complexity to achieve diagnostic success (Safety-II). Our objective was to characterise resilience-promoting behaviours of patients/families and clinicians and resilient organisational properties in outpatient diagnosis of children with medical complexity.</p><p><strong>Methods: </strong>This ethnographic study included observations of outpatient visits and semistructured interviews of parents/guardians and providers. Resilience engineering frameworks informed data collection and analysis. We prospectively sampled patients <18 years old with medical complexity presenting with acute problems in clinics at three academic health systems from 25 January 2024 to 26 February 2025. We qualitatively coded field notes and interview transcripts, focusing on individual resilient behaviours and instances of organisational resilience. We identified resilience themes using directed content analysis and described the frequency and types of resilience concepts.</p><p><strong>Results: </strong>We observed 258 unique resilience-promoting behaviours and organisational properties in 31 of 33 (94%) patient visits, with an average of 7.8 resilient behaviours/properties per visit. Of these, 178 (69%) reflected patient/family and clinician activities to promote diagnostic resilience and 80 (31%) reflected organisational resilience relevant to diagnosis. The most frequently identified resilience behaviours/properties were anticipation (prediction of future events and contingency planning), monitoring (vigilant observation for clinical evolution), robustness (comprehensiveness and redundancy in the diagnostic process) and graceful extensibility (stretching resources to meet diagnostic needs).</p><p><strong>Conclusions: </strong>Resilient behaviours by patients/families and clinicians and resilient organisational properties supporting diagnostic excellence can be prevalent in outpatient paediatrics for children with medical complexity. Future research should characterise diagnostic resilience's impact on diagnostic safety and patient/family outcomes.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-08-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148711182","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":"Economic evaluation of deimplementation interventions: a systematic review.","authors":"Comlan Lucien Hountongbé, Jason Robert Guertin, Soualio Gnanou, Blanchard Conombo, Pier-Alexandre Tardif, Noah Michael Ivers, Rohit Gandhi, Lynne Moore","doi":"10.1136/bmjqs-2025-019895","DOIUrl":"10.1136/bmjqs-2025-019895","url":null,"abstract":"<p><strong>Background: </strong>Low-value practices, defined as tests or treatments that are used in practice despite not being supported by evidence, account for 20%-30% of healthcare expenditure; moreover, some identified low-value practices represent 16%-26% of primary care clinical services. Given the growing financial constraints healthcare systems face, evaluating the cost-effectiveness of interventions designed to reduce these practices is becoming urgent.</p><p><strong>Objective: </strong>We aimed to synthesise data on the economic value of deimplementation interventions.</p><p><strong>Methods: </strong>We evaluated the cost-effectiveness of interventions targeting the deimplementation of low-value practices among healthcare professionals and organisations (clinicians, hospitals and medical centres). Our comparator was either no intervention or a deimplementation intervention limited to a subset of the intervention components. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios and benefit-to-cost ratios. Studies where the intervention was dominant or dominated by the comparator were also considered. We developed search strategies for Cochrane, EMBASE, MEDLINE, CINAHL and Web of Science to February 2025. Pairs of independent reviewers sequentially screened titles, abstracts and full texts for eligibility and extracted data using a prepiloted extraction sheet. Methodological quality was assessed by two reviewers using the 19-item Consensus on Health Economic Criteria (CHEC), and results were synthesised visually using permutation matrices globally and for predefined subgroups.</p><p><strong>Results: </strong>Of the 35 575 unique records identified, 19 met our eligibility criteria. Deimplementation interventions were found to be dominant (ie, effective with lower cost) in 10 evaluations (53%), potentially favourable (more effective with higher cost) in 8 (42%) and unfavourable in 1 (5%). Deimplementation interventions were more likely to be economically favourable in studies accounting for both medical and intervention costs, those targeting healthcare professionals and those with high methodological quality.</p><p><strong>Conclusion: </strong>Our findings suggest that deimplementation interventions targeting low-value practices are highly likely to be cost-effective. However, the results should be interpreted with caution due to the low methodological quality of the studies and the lack of consideration of the societal perspective.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148263161","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":"Implementing evidence in residential aged care facilities: a longitudinal multi-method evaluation of knowledge broker evolution.","authors":"Madeleine Tan, J Simon Bell, Shakti Shrestha, Adam La Caze, Terry P Haines, Annie Ml Ea, Sarah Nicole Hilmer, Jacqueline Wesson, Michael Lawless, Brooke Blakeley, Sara Whittaker, Constance Dimity Pond, Angelita Martini, Nancy Ochieng, Francesca Glamorgan, Julie Normoyle, Dayna Cenin, Rebecca Walton, Alison Kitson, Alexandra Bennett, Amelia Stapley, Michelle Steeper, Monica Jung, Amanda J Cross","doi":"10.1136/bmjqs-2026-020577","DOIUrl":"https://doi.org/10.1136/bmjqs-2026-020577","url":null,"abstract":"<p><strong>Background: </strong>Knowledge brokers act as intermediaries to bridge evidence-to-practice gaps. Limited evidence describes how the knowledge broker role in health settings evolves over time. This study aimed to (a) examine the evolution of knowledge broker activities over a 12-month implementation trial and (b) identify enablers necessary to strengthen and support the role.</p><p><strong>Methods: </strong>This longitudinal multi-method study is nested within the 12-month Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial. The EMBRACE intervention involved knowledge brokers working in 19 residential aged care facilities (RACFs) to support implementation of Australia's Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia in Residential Aged Care. Seventy-six knowledge broker local action plans, representing 19 RACFs at four time points, were analysed to characterise core knowledge broker functions and the frequency of planned quality improvement activities targeting seven pre-defined sub-indicators of psychotropic appropriateness. The Consolidated Framework for Implementation Research informed thematic analysis of 76 separate quarterly written reflections and 28 semistructured interviews with knowledge brokers.</p><p><strong>Results: </strong>The number and breadth of knowledge broker activities increased over time. At baseline, six RACF local action plans included activities targeted towards at least one sub-indicator, increasing to all 19 local action plans from the 3-month timepoint onwards. Knowledge brokers enacted overlapping functions as knowledge managers, linkage agents and capacity builders, although the timing and extent of role progression varied across RACFs and individuals. Evolution of activities was shaped by individual (clinical leaders, implementation facilitators, peer support) organisational (culture, governance pathways, digital integration) and outer setting factors (COVID-19 disruptions, national policy directives).</p><p><strong>Conclusion: </strong>The knowledge broker role fundamentally evolved from assessing local context and establishing foundational rapport to driving systemic change. Effective translation of guidelines into practice requires future implementation programmes to support this role with a strong organisational culture, robust infrastructure and strategic alignment with RACFs and national priorities.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148677206","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":"Real-time clinical decision support system for early identification of infection and sepsis in the intensive care unit: a retrospective development and prospective deployment study.","authors":"Fang-Ju Sun, Yen-Yu Liu, Li-Kuo Kuo, Ting-Yu Hu, Kuang-Hua Cheng, Hung-Ting Chen, Po-Jen Chang, Min-Ching Wu, Hung-I Yeh, Kun-Pin Wu","doi":"10.1136/bmjqs-2026-020104","DOIUrl":"https://doi.org/10.1136/bmjqs-2026-020104","url":null,"abstract":"<p><strong>Background: </strong>Sepsis and infection are distinct yet overlapping conditions in the intensive care unit (ICU), posing diagnostic and management challenges due to non-specific clinical features and delayed microbiological confirmation. This study aimed to develop and evaluate a real-time dual-model clinical decision support system for early identification of infection and sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) framework.</p><p><strong>Methods: </strong>We conducted a retrospective model development and prospective non-interventional deployment study of adult ICU admissions between 2018 and 2020 at a tertiary-care medical centre. Infection was defined by positive microbiological culture results while sepsis was defined according to Sepsis-3 criteria. Two machine learning models were developed using structured clinical features from an 8-hour feature window to predict infection and sepsis. The framework included an 8-hour lead time and a 1-hour prediction window. Class imbalance was addressed using propensity score matching and Borderline Synthetic Minority Oversampling Technique. External validation was performed using the Medical Information Mart for Intensive Care IV database. Real-time deployment analyses evaluated ICU risk surveillance and cluster-based stratification using combined sepsis and infection probabilities.</p><p><strong>Results: </strong>The dual-model system demonstrated consistent discrimination across internal, reduced-feature and external validation cohorts, with area under the receiver operating characteristic curves ranging from 0.75 to 0.85. Both models prioritised high sensitivity and negative predictive value to minimise missed cases. During real-time ICU implementation, the decision support dashboard provided interpretable risk estimates at the bedside. Exploratory pre-post comparisons showed numerically lower point estimates across most clinical and resource-utilisation outcomes, without adjustment for confounding factors. Cluster-based analysis further identified a high-risk subgroup with greater healthcare resource utilisation.</p><p><strong>Conclusion: </strong>This real-time clinical decision support system enables early identification of infection and sepsis, supports timely clinical decision-making and may inform antibiotic and resource use in the ICU.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148668249","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":"Why a 'human-in-the-loop' is not an adequate safety strategy: the case for vendor accountability in clinical AI safety.","authors":"Cassiopeia Frank","doi":"10.1136/bmjqs-2026-020713","DOIUrl":"https://doi.org/10.1136/bmjqs-2026-020713","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148648200","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":"Identifying latent safety threats through varied modalities: a comparative analysis.","authors":"Mireille T Gharib, Patricia Trbovich, Walter Tavares, Andrew Petrosoniak, Seona Dunbar, Alison Dodds, Jabeen Fayyaz, Jonathan Pirie, Trevor Dell, Catharine M Walsh","doi":"10.1136/bmjqs-2026-020128","DOIUrl":"10.1136/bmjqs-2026-020128","url":null,"abstract":"<p><strong>Importance: </strong>Patient safety and systems integration (PSSI) simulations help uncover hazards that jeopardise patient safety. Using direct observation, video analysis and systems-focused debriefing, they identify and categorise latent safety threats (LSTs). We aimed to compare the number, nature and potential risk of LSTs across the three modalities.</p><p><strong>Methods: </strong>In a prospective observational cohort, six unannounced simulations were conducted in a paediatric emergency department during active shifts. Two raters independently identified LSTs, which were coded deductively using the adapted Systems Engineering Initiative for Patient Safety (SEIPS) framework and inductively for emergent themes. Harm potential was graded using Healthcare Failure Mode and Effect Analysis (HFMEA). LSTs were mapped onto a framework matrix for comparison within and across detection modalities. The primary outcome was differences in LSTs detected by each modality; number, nature (SEIPS) and proportion of critical threats (HFMEA score ≥8).</p><p><strong>Results: </strong>Seventy-two providers participated (mean 12.0±2.3/simulation). 2576 unique LSTs were identified. Video detected the most LSTs (n=1908), compared with observation (n=426) or debriefing (n=242, p<0.01). Although fewer overall, debriefing yielded the highest proportion of critical threats (54.9% (124/226), p<0.01) compared with observation (26.3% (109/414)) or video (23.6% (442/1875)). Debriefing often revealed task-specific and communication-related threats, whereas video excelled at physical workspace and infection control deficits. Inter-rater reliability for SEIPS coding was acceptable (κ≥0.7).</p><p><strong>Conclusion: </strong>Although debriefing yielded fewer LSTs, it is valuable for surfacing critical LSTs (54.9% vs 23.6% video). We highlight the strengths of LST detection modalities and provide insights for institutions selecting strategies to mitigate harm and enhance system resilience.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":6.8,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148577094","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}