BMJ Quality & Safety最新文献

{"title":"Risk-adjusted observed minus expected cumulative sum (RA O-E CUSUM) chart for visualisation and monitoring of surgical outcomes.","authors":"Quentin Cordier, Hugo Prieur, Antoine Duclos","doi":"10.1136/bmjqs-2024-017935","DOIUrl":"10.1136/bmjqs-2024-017935","url":null,"abstract":"<p><p>To improve patient safety, surgeons can continually monitor the surgical outcomes of their patients. To this end, they can use statistical process control tools, which primarily originated in the manufacturing industry and are now widely used in healthcare. These tools belong to a broad family, making it challenging to identify the most suitable methodology to monitor surgical outcomes. The selected tools must balance statistical rigour with surgeon usability, enabling both statistical interpretation of trends over time and comprehensibility for the surgeons, their primary users. On one hand, the observed minus expected (O-E) chart is a simple and intuitive tool that allows surgeons without statistical expertise to view and interpret their activity; however, it may not possess the sophisticated algorithms required to accurately identify important changes in surgical performance. On the other hand, a statistically robust tool like the cumulative sum (CUSUM) method can be helpful but may be too complex for surgeons to interpret and apply in practice without proper statistical training. To address this issue, we developed a new risk-adjusted (RA) O-E CUSUM chart that aims to provide a balanced solution, integrating the visualisation strengths of a user-friendly O-E chart with the statistical interpretation capabilities of a CUSUM chart. With the RA O-E CUSUM chart, surgeons can effectively monitor patients' outcomes and identify sequences of statistically abnormal changes, indicating either deterioration or improvement in surgical outcomes. They can also quantify potentially preventable or avoidable adverse events during these sequences. Subsequently, surgical teams can try implementing changes to potentially improve their performance and enhance patient safety over time. This paper outlines the methodology for building the tool and provides a concrete example using real surgical data to demonstrate its application.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"330-338"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12013565/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142715258","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":"Diagnostic delay: lessons learnt from marginalised voices.","authors":"Farah Acher Kaiksow","doi":"10.1136/bmjqs-2024-018192","DOIUrl":"10.1136/bmjqs-2024-018192","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"279-281"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142791133","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 randomised trial assessing the impact of peer comparison and therapeutic recommendations, including repetition, on antibiotic prescribing patterns of family physicians across British Columbia for uncomplicated lower urinary tract infections.","authors":"Greg Carney, Malcolm Maclure, David M Patrick, Jessica Otte, Anshula Ambasta, Wade Thompson, Colin Dormuth","doi":"10.1136/bmjqs-2024-017296","DOIUrl":"10.1136/bmjqs-2024-017296","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate the impact of a personalised audit and feedback prescribing report (AF) and brief educational summary (ES) on empiric treatment of uncomplicated lower urinary tract infections (UTIs) by family physicians (FPs).</p><p><strong>Design: </strong>Cluster randomised control trial.</p><p><strong>Setting: </strong>The intervention was conducted in British Columbia, Canada between 23 September 2021 and 28 March 2022.</p><p><strong>Participants: </strong>We randomised 5073 FPs into a standard AF and ES intervention arm (n=1691), an ES-only arm (n=1691) and a control arm (n=1691).</p><p><strong>Interventions: </strong>The AF contained personalised and peer-comparison data on first-line antibiotic prescriptions for women with uncomplicated lower UTI and key therapeutic recommendations. The ES contained detailed, evidence-based UTI management recommendations, incorporated regional antibiotic resistance data and recommended nitrofurantoin as a first-line treatment.</p><p><strong>Main outcome measures: </strong>Nitrofurantoin as first-line pharmacological treatment for uncomplicated lower UTI, analysed using an intention-to-treat approach.</p><p><strong>Results: </strong>We identified 21 307 cases of uncomplicated lower UTI among the three trial arms during the study period. The impact of receiving both the AF and ES increased the relative probability of prescribing nitrofurantoin as first-line treatment for uncomplicated lower UTI by 28% (OR 1.28; 95% CI 1.07 to 1.52), relative to the delay arm. This translates to additional prescribing of nitrofurantoin as first-line treatment, instead of alternates, in an additional 8.7 cases of uncomplicated UTI per 100 FPs during the 6-month study period.</p><p><strong>Conclusion: </strong>AF prescribing data with educational materials can improve primary care prescribing of antibiotics for uncomplicated lower UTI.</p><p><strong>Trial registration number: </strong>NCT05817253.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"295-304"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12013583/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142457766","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":"Audit and feedback to improve antibiotic prescribing in primary care-the time is now.","authors":"Bradley J Langford, Kevin L Schwartz","doi":"10.1136/bmjqs-2024-018081","DOIUrl":"10.1136/bmjqs-2024-018081","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"282-284"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142969581","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":"Co-production in maternal health services: creating culturally safe spaces, respecting difference and supporting collaborative solutions.","authors":"Jennifer MacLellan, Carmen Byrne, Catherine Pope","doi":"10.1136/bmjqs-2024-018157","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018157","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":"34 5","pages":"285-287"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143973803","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":"Do healthcare professionals work around safety standards, and should we be worried? A scoping review.","authors":"Debbie Clark, Rebecca Lawton, Ruth Baxter, Laura Sheard, Jane K O'Hara","doi":"10.1136/bmjqs-2024-017546","DOIUrl":"10.1136/bmjqs-2024-017546","url":null,"abstract":"<p><strong>Background: </strong>Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.</p><p><strong>Objectives: </strong>In this scoping review, we explore the circumstances and perceived implications of safety standard workarounds (SSWAs) conducted in the delivery of frontline care.</p><p><strong>Method: </strong>We searched MEDLINE, CINAHL, PsycINFO and Web of Science for articles reporting on the circumstances and perceived implications of SSWAs in healthcare. Data charting was undertaken by two researchers. A narrative synthesis was developed to produce a summary of findings.</p><p><strong>Results: </strong>We included 27 papers in the review, which reported on workarounds of 21 safety standards. Over half of the papers (59%) described working around standards related to medicine safety. As medication standards featured frequently in papers, SSWAs were reported to be performed by registered nurses in 67% of papers, doctors in 41% of papers and pharmacists in 19% of papers. Organisational causes were the most prominent reason for workarounds.Papers reported on the perceived impact of SSWAs for care quality. At times SSWAs were being used to support the delivery of person-centred, timely, efficient and effective care. Implications of SSWAs for safety were diverse. Some papers reported SSWAs had both positive and negative implications for safety simultaneously. SSWAs were reported to be beneficial for patients more often than they were detrimental.</p><p><strong>Conclusion: </strong>SSWAs are used frequently during the delivery of everyday care, particularly during medication-related processes. These workarounds are often used to balance different risks and, in some circumstances, to achieve safe care.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"317-329"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12013549/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142341462","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":"Randomised controlled trial of audit-and-feedback strategies to reduce imaging overutilisation in the emergency department.","authors":"Karl T Chamberlin, Christopher DiTullio, Jennifer Rossman, Bruce A Barton, Martin Reznek, Kevin Kotkowski","doi":"10.1136/bmjqs-2024-018374","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018374","url":null,"abstract":"<p><strong>Background: </strong>Evaluation of neck trauma is a common reason for emergency department (ED) visits. There are several validated clinical decision rules, such as the National Emergency X-Radiography Utilization Study (NEXUS) Cervical Spine (C-spine) Rule, that can be used to risk stratify these patients and identify low-risk patients who do not require CT imaging. Overutilisation of CT imaging exposes patients to unnecessary radiation, impairs hospital throughput and increases healthcare costs. Various audit-and-feedback strategies have been described in other settings, but it is not known whether these strategies are effective for reducing imaging overutilisation in the ED. Additionally, the effectiveness of face-to-face feedback strategies as compared with digital feedback strategies for addressing this problem has not been previously evaluated. The aim of this study was to compare audit-and-feedback strategies to reduce CT overutilisation in the ED.</p><p><strong>Methods: </strong>This was a prospective randomised controlled trial, in which emergency medicine clinicians were randomised into three arms to receive digital feedback, hybrid face-to-face/digital feedback or no feedback. Each clinician received three rounds of feedback on patient encounters in which they ordered a CT of the C-spine. Patient encounters were retrospectively reviewed to determine each clinician's overutilisation rate, defined as the percentage of patients who underwent CT of the C-spine despite being classified as low risk by NEXUS criteria.</p><p><strong>Results: </strong>A total of 78 emergency medicine clinicians were randomised into three arms. Baseline overutilisation rates for each group were 46%-47% of CT of the C-spine studies. After three rounds of audit-and-feedback strategy, the clinicians in the digital feedback group had an overutilisation rate of 33%, compared with 44% in the control group (p=0.020). The hybrid feedback group had an overutilisation rate of 36% (p=0.055 vs control; p=0.577 vs digital feedback). Over the study period, the digital group saw a reduction of 1.26 CT of the C-spine studies per provider per month (p=0.049), and the hybrid feedback group saw a reduction of 1.43 CTs per provider per month (p=0.044).</p><p><strong>Conclusion: </strong>A digital audit-and-feedback strategy is effective for reducing overutilisation of CT imaging of the C-spine in the ED, while the effectiveness of a hybrid strategy requires further investigation.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-04-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143779021","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":"Patient-reported harm from NHS treatment or care, or the lack of access to care: a cross-sectional survey of general population prevalence, impact and responses.","authors":"Helen Crocker, David A Cromwell, Shivali Modha, Alastair McIntosh Gray, Chris Graham, Lavanya Thana, Raymond Fitzpatrick, Charles Vincent, Helen Hogan, Michele Peters","doi":"10.1136/bmjqs-2024-017213","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017213","url":null,"abstract":"<p><strong>Objectives: </strong>The aim of this article is to provide an estimate of the proportion of the general public reporting healthcare-related harm in Great Britain, its location, impact, responses post-harm and desired reactions from healthcare providers.</p><p><strong>Design: </strong>We used a cross-sectional survey, using quota sampling.</p><p><strong>Setting: </strong>This research was conducted in Great Britain.</p><p><strong>Participants: </strong>The survey had 10 064 participants (weighted analysis).</p><p><strong>Results: </strong>In our survey 9.7% participants reported harm caused by the National Health Service (NHS) in the last 3 years through treatment or care (6.2%) or the lack of access to care (3.5%). The main location where the harm first occurred was hospitals. A total of 37.6% of participants reported a moderate impact and 44.8% a severe impact of harm. The most common response to harm was to share their experience with others (67.1%). Almost 60% sought professional advice and support, with 11.6% contacting the Patient Advice and Liaison Service (PALS). Only 17% submitted a formal complaint, and 2.1% made a claim for financial compensation. People wanted treatment or care to redress the harm (44.4%) and an explanation (34.8%). Two-thirds of those making a complaint felt it was not handled well and approximately half were satisfied with PALS. Experiences and responses differed according to sex and age (eg, women reported more harm). People with long-term illness or disability, those in lower social grades, and people in other disadvantaged groups reported higher rates and more severe impact of harm.</p><p><strong>Conclusions: </strong>We found that 9.7% of the British general population reported harm by the NHS, a higher rate than reported in two previous surveys. Our study used a broader and more inclusive definition of harm and was conducted during the COVID-19 pandemic, making comparison to previous surveys challenging. People responded to harm in different ways, such as sharing experiences with others and seeking professional advice and support. Mostly, people who were harmed wanted help to redress the harm or to gain access to the care needed. Low satisfaction with PALS and complaints services may reflect that these services do not always deliver the required support. There is a need to better understand the patient perspective following harm and for further consideration of what a person-centred approach to resolution and recovery might look like.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143771163","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":"False hope of a single generalisable AI sepsis prediction model: bias and proposed mitigation strategies for improving performance based on a retrospective multisite cohort study.","authors":"Rudolf Schnetler, Anton van der Vegt, Vikrant R Kalke, Paul Lane, Ian Scott","doi":"10.1136/bmjqs-2024-018328","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018328","url":null,"abstract":"<p><strong>Objective: </strong>To identify bias in using a single machine learning (ML) sepsis prediction model across multiple hospitals and care locations; evaluate the impact of six different bias mitigation strategies and propose a generic modelling approach for developing best-performing models.</p><p><strong>Methods: </strong>We developed a baseline ML model to predict sepsis using retrospective data on patients in emergency departments (EDs) and wards across nine hospitals. We set model sensitivity at 70% and determined the number of alerts required to be evaluated (number needed to evaluate (NNE), 95% CI) for each case of true sepsis and the number of hours between the first alert and timestamped outcomes meeting sepsis-3 reference criteria (HTS3). Six bias mitigation models were compared with the baseline model for impact on NNE and HTS3.</p><p><strong>Results: </strong>Across 969 292 admissions, mean NNE for the baseline model was significantly lower for EDs (6.1 patients, 95% CI 6 to 6.2) than for wards (7.5 patients, 95% CI 7.4 to 7.5). Across all sites, median HTS3 was 20 hours (20-21) for wards vs 5 (5-5) for EDs. Bias mitigation models significantly impacted NNE but not HTS3. Compared with the baseline model, the best-performing models for NNE with reduced interhospital variance were those trained separately on data from ED patients or from ward patients across all sites. These models generated the lowest NNE results for all care locations in seven of nine hospitals.</p><p><strong>Conclusions: </strong>Implementing a single sepsis prediction model across all sites and care locations within multihospital systems may be unacceptable given large variances in NNE across multiple sites. Bias mitigation methods can identify models demonstrating improved performance across most sites in reducing alert burden but with no impact on the length of the prediction window.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143728434","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":"Selecting and tailoring implementation strategies for deimplementing fall prevention alarms in US hospitals: a group concept mapping study.","authors":"Kea Turner, Mona Al Taweel, Carrie Petrucci, Scott Rosas, Catima Potter, Emily Cramer, Ronald I Shorr, Lorraine C Mion, Molly McNett","doi":"10.1136/bmjqs-2024-018391","DOIUrl":"10.1136/bmjqs-2024-018391","url":null,"abstract":"<p><strong>Objectives: </strong>Many hospitals use fall prevention alarms, despite the limited evidence of effectiveness. The objectives of this study were (1) to identify, conceptualise and select strategies to deimplement fall prevention alarms and (2) to obtain feedback from key stakeholders on tailoring selected deimplementation strategies for the local hospital context.</p><p><strong>Methods: </strong>Hospital staff working on fall prevention participated in group concept mapping (GCM) to brainstorm strategies that could be used for fall prevention alarm deimplementation, sort statements into conceptually similar categories and rate statements based on importance and current use. Hospital staff also participated in site-specific focus groups to discuss current fall prevention practices, strategies prioritised through GCM and theory-informed strategies recommended by the study team, and potential barriers/facilitators to deimplementing fall prevention alarms.</p><p><strong>Results: </strong>90 hospital staff across 13 hospitals brainstormed, rated and sorted strategies for alarm deimplementation. Strategies that were rated as highly important but underutilised included creating/revising staff roles to support fall prevention (eg, hiring or designating mobility technicians) and revising policies and procedures to encourage tailored rather than universal fall precautions. 192 hospital staff across 22 hospitals participated in site-specific focus groups. Participants provided feedback on each strategy's relevance for their site (eg, if site currently has a mobility technician) and local barriers or facilitators (eg, importance of having separate champions for day and night shift). Findings were used to develop a tailored implementation package for each site that included a core set of strategies (eg, external facilitation, education, audit-and-feedback, champions), a select set of site-specific strategies (eg, designating a mobility technician to support fall prevention) and guidance for how to operationalise and implement each strategy given local barriers and facilitators.</p><p><strong>Conclusion: </strong>Findings from this study can be used to inform future programmes and policies aimed at deimplementing fall prevention alarms in hospitals.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143728438","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}