BMJ Quality & Safety最新文献

{"title":"Improving weaning and liberation from mechanical ventilation for tracheostomy patients: a quality improvement initiative.","authors":"Michael Mikhaeil, Michelle Bernard, Jenna Currie, Caroline Bolduc, Jordana Radke, Savannah Kranjc, Joanne Meyer","doi":"10.1136/bmjqs-2024-018324","DOIUrl":"10.1136/bmjqs-2024-018324","url":null,"abstract":"<p><p>For patients in the intensive care unit (ICU), prolonged mechanical ventilation is associated with poor outcomes. A quality improvement (QI) initiative with the aim of reducing median time on the ventilator for tracheostomy patients was undertaken at a tertiary care ICU in Toronto, Canada. A QI team was formed, and using QI methodology, a deep understanding of our local process was achieved. Based on this information and on the latest evidence on weaning, a standard tracheostomy weaning protocol was designed. The protocol was refined through three developmental and two testing plan-do-study-act cycles. This study was a prospective time series showing the effect of the implementation of our intervention on tracheotomy patients' time on the ventilator. The baseline median number of days on the ventilator after tracheostomy insertion was 17. Within 12 months of the introduction of the intervention, a shift in the data showing a reduction in the median time on the ventilator to 10.6 days had developed. Length of stay in the ICU was reduced by 4.3 days. Adherence and compliance to the protocol also improved over time. A standard tracheostomy weaning protocol was successfully developed, tested and implemented in a tertiary care ICU. Using strategies such as frequent communication with key stakeholders and incorporating a tracheostomy weaning progress sheet to document and track tracheostomy patients and their outcomes, this QI intervention has become engrained in the local culture at our centre. This weaning protocol has successfully reduced the median time on the ventilator for tracheostomy patients by over 6 days.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"480-488"},"PeriodicalIF":5.6,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143976977","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":"We will take some team resilience, please: Evidence-based recommendations for supporting diagnostic teamwork.","authors":"Gabriela Fernández Castillo, Eduardo Salas, Eric J Thomas","doi":"10.1136/bmjqs-2025-018685","DOIUrl":"10.1136/bmjqs-2025-018685","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"429-432"},"PeriodicalIF":5.6,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143779025","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":"Workforce well-being is workforce readiness: it is time to advance from describing the problem to solving it.","authors":"Bryan Sexton, Jochen Profit","doi":"10.1136/bmjqs-2024-018198","DOIUrl":"10.1136/bmjqs-2024-018198","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"425-428"},"PeriodicalIF":5.6,"publicationDate":"2025-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144109627","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":"Checklist conundrum: are we checking the right boxes?","authors":"Gabriel Torrealba-Acosta, César E Escamilla-Ocañas","doi":"10.1136/bmjqs-2025-018798","DOIUrl":"https://doi.org/10.1136/bmjqs-2025-018798","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144324462","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":"Eliminating hospital nurse understaffing is a cost-effective patient safety intervention.","authors":"Karen B Lasater","doi":"10.1136/bmjqs-2025-018677","DOIUrl":"https://doi.org/10.1136/bmjqs-2025-018677","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144246362","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 and clinician perspectives on misgendering in healthcare.","authors":"Kyle Okamuro, Alan Card, Hanna J Barton, Falisha Kanji, Victor Trasvina, Jill Blumenthal, Tara Cohen, Jennifer T Anger","doi":"10.1136/bmjqs-2024-018364","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018364","url":null,"abstract":"<p><strong>Purpose: </strong>Misgendering of transgender and non-binary (TGNB) individuals in healthcare settings can lead to worsened mental and physical health outcomes and decreased utilisation of care. Few studies have investigated the factors that contribute to this phenomenon. The purpose of this study was to apply qualitative methods to explore sources of misgendering, its perceived impact, prevention strategies and clinician responses to accidentally misgendering a patient, as identified by TGNB patients and gender-affirming care clinicians.</p><p><strong>Methods: </strong>Between April and June 2022, 20 semi-structured interviews were performed at an academic medical centre in Southern California. Participants were recruited via purposive sampling and included: (1) TGNB patients (n=8) recruited from an interdisciplinary gender-affirming urological practice and (2) gender-affirming care clinicians (n=12) recruited from a regional interdisciplinary Gender Health conference, three of whom identified as TGNB. Interviews were conducted in person or virtually using an open-ended topic guide, audio recorded and transcribed verbatim. Inductive thematic analysis was performed by two independent study personnel who hand-coded the transcripts.</p><p><strong>Results: </strong>Four overarching themes were identified: (1) misgendering originates from multiple sources, (2) misgendering discourages individual access to healthcare, creates community hesitation and its perceived impact is modified by setting and intentionality, (3) building a gender-affirming healthcare system requires integration of behaviour, policy and technology and (4) clinicians respond to accidental misgendering by acknowledging, apologising, advancing and acting.</p><p><strong>Conclusion: </strong>Our data suggest that misgendering arises from both interpersonal communication and structural factors within healthcare systems, leading to perceived harm and diminished TGNB access to health services. Any potential solution to reduce this phenomenon will require a multifaceted approach integrating behavioural, technological and institutional policy strategies with system-level implementation efforts.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144246364","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 a patient-centred complex intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): a mixed-methods process evaluation.","authors":"Carmen Corral-Partearroyo, Alba Sánchez-Viñas, María Teresa Peñarrubia-María, Montserrat Gil-Girbau, Ignacio Aznar-Lou, Claudia Palma-Vasquez, Carmen Gallardo-González, María Del Carmen Olmos-Palenzuela, Maria Rubio-Valera","doi":"10.1136/bmjqs-2024-018403","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018403","url":null,"abstract":"<p><strong>Introduction: </strong>The initial medication adherence (IMA) intervention aims to improve adherence to cardiovascular disease (CVD) and diabetes treatments in primary care (PC) through standardised shared decision-making (SDM) and healthcare professional (HCP) collaboration (general practitioners (GPs), nurses and pharmacists). This study assessed the intervention's implementation (strategies, fidelity and integration into routine practice-based on the Normalisation Process Theory), mechanisms of action and the role of context.</p><p><strong>Methods: </strong>The IMA-cRCT was an effectiveness-implementation cluster-Randomised Controlled Trial involving 24 Spanish PC centres (>300 HCP; >3000 patients) based on real-world evidence. This nested process evaluation used quantitative (monitoring data; HCP questionnaires) and qualitative methods (field diaries; 36 semistructured individual interviews and two focus groups (19 patients, 28 HCPs)). Quantitative data explored implementation and context and were analysed descriptively, while qualitative data examined implementation, mechanisms of action and context and were analysed using framework analysis. Both analyses were integrated for interpretation.</p><p><strong>Results: </strong>Intervention implementation fidelity (6.5/10) and normalisation into clinical practice (7.6/10) were adequate, particularly regarding SDM and use of decision aids. HCPs recognised the importance of SDM, although some assumed it was already part of routine practice. The anticipated mechanisms of action were moderately supported. HCPs' knowledge and attitudes towards SDM improved as they acknowledged its relevance to practice. Some patients reported participation in decision-making, while others preferred the GP to decide on their behalf. Patients found leaflets helpful for understanding information. Contextual factors influencing the intervention were mainly organisational, such as lack of time and familiarity with SDM.</p><p><strong>Conclusions: </strong>The interprofessional SDM-based IMA intervention was considered beneficial for patients and HCPs, with adequate implementation fidelity and normalisation into practice. The intervention was important for HCPs, and patients accepted it. However, greater effort is needed to extend SDM throughout healthcare, moving towards patient-centred care. These results have enhanced understanding of SDM interventions and support their refinement for future implementation.</p><p><strong>Trial registration number: </strong>ClinicalTrials.gov, NCT05026775.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144246363","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":"Regulating voluntary assisted dying at the clinical coalface: a qualitative interview study in Victoria, Australia.","authors":"Casey M Haining, Lindy Willmott, Ben P White","doi":"10.1136/bmjqs-2024-018314","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018314","url":null,"abstract":"<p><strong>Background: </strong>Voluntary assisted dying (VAD) in Victoria, Australia, is governed by a stringent legislative framework, designed and enforced by the state, as well as other forms of regulation. However, there remains limited understanding about how these various forms of regulation operate at the frontline or how clinicians themselves can influence regulation.</p><p><strong>Objectives: </strong>This article explores how clinicians working at the frontline (clinical coalface) may influence the regulation of VAD in Victoria, and how this contributes to the safe and effective delivery of VAD.</p><p><strong>Methods: </strong>Reflexive thematic analysis of 30 semistructured interviews with 37 'regulators' (defined as those capable of steering and guiding behaviour with respect to VAD).</p><p><strong>Results: </strong>Data analysis resulted in the generation of three main themes: (1) coalface regulation extends regulations at the clinical level, ensuring adherence to laws while developing new standards and systems for safe and effective practice; (2) coalface regulation guides day-to-day VAD practice; and (3) coalface regulation plays a critical role in quality monitoring and improvement.</p><p><strong>Conclusions: </strong>Clinicians play a significant role in VAD regulation in Victoria and fulfil what we define as a 'coalface regulator' role. These coalface regulators are influential in ensuring the safe and effective delivery of VAD. Understanding how coalface regulation intersects with other forms of VAD regulation and how this regulatory influence can be harnessed is critical for optimising VAD regulation, safety and improving service delivery at a local and system level.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144233160","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":"Association between Child Opportunity Index and paediatric sepsis recognition and treatment in a large quality improvement collaborative: a retrospective cohort study.","authors":"Lori Rutman, Troy Richardson, Jeffery Auletta, Fran Balamuth, Amber Chambers, Julie Fitzgerald, Javier Gelvez, Karen A Genzel, Amy Grant, Vishal Gunnala, Hana Hakim, Leslie Hueschen, Sarah Kandil, Gitte Larsen, Justin Lockwood, Kate Lucey, Elizabeth Mack, Kate Madden, Matthew Niedner, Raina Paul, Anireddy Reddy, Ruth Riggs, Johanna Rosen, Melissa Schafer, Halden Scott, Jennifer Wilkes, Matthew A Eisenberg","doi":"10.1136/bmjqs-2024-017844","DOIUrl":"10.1136/bmjqs-2024-017844","url":null,"abstract":"<p><strong>Background: </strong>The Child Opportunity Index (COI) is a multidimensional measure of US neighbourhood-level conditions needed for healthy development. COI is associated with healthcare delivery and outcomes. Formal quality improvement (QI) may influence the relationship between COI, quality of care and outcomes in children.</p><p><strong>Objective: </strong>To assess the association between COI and paediatric sepsis care delivery and outcomes and determine if baseline disparities in care change over time among hospitals in the Improving Pediatric Sepsis Outcomes (IPSO) collaborative.</p><p><strong>Methods: </strong>Retrospective cohort study of IPSO patients probabilistically linked to the Pediatric Health Information System database from 2017 to 2021. Primary exposure was COI. We estimated differences in the proportions of patients in each COI quintile identified via standardised sepsis recognition protocols (screening tool, huddle documentation and/or order set use) and who received a bundle of recommended care (standardised sepsis recognition, plus bolus <1 hour and antibiotic <3 hours). We further assessed the timeliness of each bundle component and mortality. We evaluated changes in standardised sepsis recognition over time using generalised linear models.</p><p><strong>Results: </strong>31 260 sepsis cases from 24 hospitals were included. Cross-sectional analysis over the entire study period found patients in the Very High COI quintile were most likely to be identified via standardised recognition protocols and receive IPSO's recommended care bundle (67.7% and 46%, respectively). Over time, standardised sepsis recognition improved for all; the greatest improvements were among inpatients in the Very Low COI quintile.</p><p><strong>Conclusion: </strong>Disparities exist in paediatric sepsis care delivery by COI. Over the course of the IPSO collaborative, care improved most for children in the lowest COI quintile. QI collaboratives focused on standardisation and shared learning may reduce disparities.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143953794","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":"Effectiveness of computerised alerts to reduce drug-drug interactions (DDIs) and DDI-related harm in hospitalised patients: a quasi-experimental controlled pre-post study.","authors":"Melissa Therese Baysari, Sarah Nicole Hilmer, Richard O Day, Bethany Annemarie Van Dort, Wu Yi Zheng, Renee Quirk, Danielle Deidun, Maria Moran, Kristian Stanceski, Nanda Aryal, Ahmed Abo Salem, Lauren Farrow, Jannah Baker, Andrew Hargreaves, James Grant, Paula Doherty, Karma Zarif Sourial Mekhail, Johanna I Westbrook, Ling Li","doi":"10.1136/bmjqs-2024-018243","DOIUrl":"10.1136/bmjqs-2024-018243","url":null,"abstract":"<p><strong>Background: </strong>Drug-drug interaction (DDI) alerts target the co-prescription of two potentially interacting medications and are a frequent feature of electronic medical records (EMRs). There have been few controlled studies evaluating the effectiveness of DDI alerts. This study aimed to determine the impact of DDI alerts on rates of DDIs and on associated patient harms.</p><p><strong>Methods: </strong>Quasi-experimental controlled pre-post study in five Australian hospitals. Three hospitals acted as control hospitals (EMR with no DDI alerts) and two as intervention (EMR with DDI alerts). Only DDI alerts at the highest severity level (defined as 'major contraindicated') were switched on at intervention hospitals. These alerts were not tailored to clinical context (ie, patient, drug). A total of 2078 patients were randomly selected from all patients (adult and paediatric) admitted to hospitals 6 months before and 6 months after EMR implementation. A retrospective chart review was performed by study pharmacists. The primary outcome was the proportion of admissions with a clinically relevant DDI. Secondary outcomes included the proportions of admissions with a potential DDI and with DDI-related harm.</p><p><strong>Results: </strong>Potential DDIs were identified in the majority of admissions (n=1574, 74.7%) and clinically relevant DDIs identified in half (n=1026, 48.7%). DDI alerts were associated with a reduction in the proportion of admissions with potential DDIs (adjusted OR (AOR)=0.38 (0.19, 0.78)) but no change in clinically relevant DDIs (AOR=1.12 (0.68, 1.84)) or in DDI-related harm (AOR=2.42 (0.47,12.31)). 199 DDIs (76 at control and 123 at intervention hospitals) for 35 patient admissions were associated with patient harm, and 2 patients experienced severe DDI-related harm pre-EMR implementation.</p><p><strong>Discussion: </strong>Implementation of DDI alerts, without tailoring alerts to clinical context, is unlikely to reduce patient harms from DDIs. Organisations should reconsider implementation of DDI alerts in EMRs where significant tailoring of alerts is not possible. Future research should focus on identifying safe, efficient and cost-effective ways of refining DDI alerts, so expected clinical benefits are achieved, and negative consequences of excessive alerting are minimised.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-06-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143977307","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}