BMJ Quality & Safety最新文献

{"title":"Large-scale observational study of AI-based patient and surgical material verification system in ophthalmology: real-world evaluation in 37 529 cases.","authors":"Hitoshi Tabuchi, Naofumi Ishitobi, Hodaka Deguchi, Yuta Nakaniida, Hayato Tanaka, Masahiro Akada, Mao Tanabe","doi":"10.1136/bmjqs-2024-018018","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018018","url":null,"abstract":"<p><strong>Background: </strong>Surgical errors in ophthalmology can have devastating consequences. We developed an artificial intelligence (AI)-based surgical safety system to prevent errors in patient identification, surgical laterality and intraocular lens (IOL) selection. This study aimed to evaluate its effectiveness in real-world ophthalmic surgical settings.</p><p><strong>Methods: </strong>In this retrospective observational before-and-after implementation study, we analysed 37 529 ophthalmic surgeries (18 767 pre-implementation, 18 762 post implementation) performed at Tsukazaki Hospital, Japan, between 1 March 2019 and 31 March 2024. The AI system, integrated with the WHO surgical safety checklist, was implemented for patient identification, surgical laterality verification and IOL authentication.</p><p><strong>Results: </strong>Post implementation, five medical errors (0.027%) occurred, with four in non-authenticated cases (where the AI system was not fully implemented or properly used), compared with one (0.0053%) pre-implementation (p=0.125). Of the four non-authenticated errors, two were laterality errors during the initial implementation period and two were IOL implantation errors involving unlearned IOLs (7.3% of cases) due to delayed AI updates. The AI system identified 30 near misses (0.16%) post implementation, vs 9 (0.048%) pre-implementation (p=0.00067), surgical laterality errors/near misses occurred at 0.039% (7/18 762) and IOL recognition at 0.29% (28/9713). The system achieved>99% implementation after 3 months. Authentication performance metrics showed high efficiency: facial recognition (1.13 attempts, 11.8 s), surgical laterality (1.05 attempts, 3.10 s) and IOL recognition (1.15 attempts, 8.57 s). Cost-benefit analysis revealed potential benefits ranging from US$181 946.94 to US$2 769 129.12 in conservative and intermediate scenarios, respectively.</p><p><strong>Conclusions: </strong>The AI-based surgical safety system significantly increased near miss detection and showed potential economic benefits. However, errors in non-authenticated cases underscore the importance of consistent system use and integration with existing safety protocols. These findings emphasise that while AI can enhance surgical safety, its effectiveness depends on proper implementation and continuous refinement.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142754517","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":"Comparing safety, performance and user perceptions of a patient-specific indication-based prescribing tool with current practice: a mixed methods randomised user testing study.","authors":"Calandra Feather, Jonathan Clarke, Nicholas Appelbaum, Ara Darzi, Bryony Dean Franklin","doi":"10.1136/bmjqs-2024-017733","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017733","url":null,"abstract":"<p><strong>Background: </strong>Medication errors are the leading cause of preventable harm in healthcare. Despite proliferation of medication-related clinical decision support systems (CDSS), current systems have limitations. We therefore developed an indication-based prescribing tool. This performs dose calculations using an underlying formulary and provides patient-specific dosing recommendations. Objectives were to compare the incidence and types of erroneous medication orders, time to prescribe (TTP) and perceived workload using the NASA Task Load Index (TLX), in simulated prescribing tasks with and without this intervention. We also sought to identify the workflow steps most vulnerable to error and to gain participant feedback.</p><p><strong>Methods: </strong>A simulated, randomised, cross-over exploratory study was conducted at a London NHS Trust. Participants completed five simulated prescribing tasks with, and five without, the intervention. Data collection methods comprised direct observation of prescribing tasks, self-reported task load and semistructured interviews. A concurrent triangulation design combined quantitative and qualitative data.</p><p><strong>Results: </strong>24 participants completed a total of 240 medication orders. The intervention was associated with fewer prescribing errors (6.6% of 120 orders) compared with standard practice (28.3% of 120 orders; odds ratio 0.18, p<0.01), a shorter TTP and lower overall NASA-TLX scores (p<0.01). Control arm workflow vulnerabilities included failures in identifying correct doses, applying maximum dose limits and calculating patient-specific dosages. Intervention arm errors primarily stemmed from misidentifying patient-specific information from the medication scenario. Thematic analysis of participant interviews identified six themes: navigating trust and familiarity, addressing challenges and suggestions for improvement, integration of local guidelines and existing CDSS, intervention endorsement, 'search by indication' and targeting specific patient and staff groups.</p><p><strong>Conclusion: </strong>The intervention represents a promising advancement in medication safety, with implications for enhancing patient safety and efficiency. Further real-world evaluation and development of the system to meet the needs of more diverse patient groups, users and healthcare settings is now required.</p><p><strong>Trial registration number: </strong>NCT05493072.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142692320","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":"Results of a healthcare transition learning collaborative for emerging adults with sickle cell disease: the ST3P-UP study transition quality improvement collaborative.","authors":"Ifeyinwa Osunkwo, Jennifer S Cornette, Laura Noonan, Cheryl Courtlandt, Sarah Mabus, Patience H White, Margaret McManus, Myra M Robinson, Michelle L Wallander, James R Eckman, Elna Saah, Ofelia A Alvarez, Mark Goodwin, Leila Jerome Clay, Payal Desai, Raymona H Lawrence","doi":"10.1136/bmjqs-2024-017725","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017725","url":null,"abstract":"<p><strong>Background: </strong>Individuals with sickle cell disease (SCD) experience poor clinical outcomes while transitioning from paediatric to adult care. Standards for SCD transition are needed. We established a Quality Improvement (QI) Collaborative that aimed to improve the quality of care for all young adults with SCD by establishing a standardised SCD transition process. This study evaluates the implementation of the Six Core Elements (6CE) of Health Care Transition, which was a fundamental component of the cluster-randomised Sickle Cell Trevor Thompson Transition Project (ST3P-UP) study.</p><p><strong>Methods: </strong>A central QI team trained 14 ST3P-UP study sites on QI methodologies, 6CE and Got Transition's process measurement tool (PMT). Site-level QI teams included a transition coordinator, clinic physicians/staff, patients/parents with SCD and community representatives. Sites completed the PMT every 6 months for 54 months and monthly audits of 10 randomly-selected charts to verify readiness/self-care assessments and emergency care plans.</p><p><strong>Results: </strong>Of a possible 100, the aggregate mean (±SD) PMT score for paediatric clinics was 23.9 (±13.8) at baseline, 95.9 (±6.0) at 24 months and 98.9 (±2.1) at 54 months. The aggregate mean PMT score for adult clinics was 15.0 (±13.5) at baseline, 88.4 (±11.8) at 24 months and 95.8 (±6.8) at 54 months. The overall QI Collaborative PMT score improved by 402%. At baseline, readiness/self-care assessments were current for 38% of paediatric and 20% of adult patients; emergency care plans were current for 20% of paediatric and 3% of adult patients. Paediatric clinics had one median readiness assessment shift (76%) and four median emergency care plan shifts (65%, 77%, 79%, 84%). Adult clinics experienced three median self-care assessment shifts (58%, 63%, 70%) and two median emergency care plan shifts (57%, 70%).</p><p><strong>Conclusions: </strong>The ST3P-UP QI Collaborative successfully embedded the 6CE of Health Care Transition into routine care and increased administration of assessments and emergency care plans for transition-aged patients with SCD.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2024-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142692327","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":"Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis.","authors":"Miriam E Craske, Wendy Hardeman, Nicholas Steel, Michael J Twigg","doi":"10.1136/bmjqs-2024-017283","DOIUrl":"10.1136/bmjqs-2024-017283","url":null,"abstract":"<p><strong>Introduction: </strong>Pharmacist-led medication reviews are an established intervention to support patients prescribed multiple medicines or with complex medication regimes. For this systematic review, a medication review was defined as 'a consultation between a pharmacist and a patient to review the patient's total medicines use with a view to improve patient health outcomes and minimise medicines-related problems'. It is not known how varying approaches to medication reviews lead to different outcomes.</p><p><strong>Aim: </strong>To explore the common themes associated with positive outcomes from pharmacist-led medication reviews.</p><p><strong>Method: </strong>Randomised controlled trials of pharmacist-led medication reviews in adults aged 18 years and over were included. The search terms used in MEDLINE, EMBASE and Web of Science databases were \"medication review\", \"pharmacist\", \"randomised controlled trial\" and their synonyms, time filter 2015 to September 2023. Studies published before 2015 were identified from a previous systematic review. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Descriptions of medication reviews' components, implementation and outcomes were narratively synthesised to draw out common themes. Results are presented in tables.</p><p><strong>Results: </strong>Sixty-eight papers describing 50 studies met the inclusion criteria. Common themes that emerged from synthesis include collaborative working which may help reduce medicines-related problems and the number of medicines prescribed; patient involvement in goal setting and action planning which may improve patients' ability to take medicines as prescribed and help them achieve their treatment goals; additional support and follow-up, which may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems.</p><p><strong>Conclusion: </strong>This systematic review identified common themes and components, for example, goal setting, action planning, additional support and follow-up, that may influence outcomes of pharmacist-led medication reviews. Researchers, health professionals and commissioners could use these for a comprehensive evaluation of medication review implementation.</p><p><strong>Prospero registration number: </strong>CRD42020173907.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"808-822"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141625934","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":"Longitudinal cohort study of discrepancies between prescribed and administered polypharmacy rates: implications for National Aged Care Quality Indicator Programs.","authors":"Nasir Wabe, Rachel Urwin, Karla Seaman, Johanna I Westbrook","doi":"10.1136/bmjqs-2023-017042","DOIUrl":"10.1136/bmjqs-2023-017042","url":null,"abstract":"<p><strong>Background: </strong>Polypharmacy is frequently used as a quality indicator for older adults in Residential Aged Care Facilities (RACFs) and is measured using a range of definitions. The impact of data source choice on polypharmacy rates and the implications for monitoring and benchmarking remain unclear. We aimed to determine polypharmacy rates (≥9 concurrent medicines) by using prescribed and administered data under various scenarios, leveraging electronic data from 30 RACFs.</p><p><strong>Method: </strong>A longitudinal cohort study of 5662 residents in New South Wales, Australia. Both prescribed and administered polypharmacy rates were calculated biweekly from January 2019 to September 2022, providing 156 assessment times. 12 different polypharmacy rates were computed separately using prescribing and administration data and incorporating different combinations of items: <i>medicines and non-medicinal products</i>, <i>any medicines</i> and <i>regular medicines</i> across four scenarios: no, 1-week, 2-week and 4-week look-back periods. Generalised estimating equation models were employed to identify predictors of discrepancies between prescribed and administered polypharmacy.</p><p><strong>Results: </strong>Polypharmacy rates among residents ranged from 33.9% using data on administered <i>regular medicines</i> with no look-back period to 63.5% using prescribed <i>medicines and non-medicinal products</i> with a 4-week look-back period. At each assessment time, the differences between prescribed and administered polypharmacy rates were consistently more than 10.0%, 4.5%, 3.5% and 3.0%, respectively, with no, 1-week, 2-week and 4-week look-back periods. Diabetic residents faced over two times the likelihood of polypharmacy discrepancies compared with counterparts, while dementia residents consistently showed reduced likelihood across all analyses.</p><p><strong>Conclusion: </strong>We found notable discrepancies between polypharmacy rates for prescribed and administered medicines. We recommend a review of the guidance for calculating and interpreting polypharmacy for national quality indicator programmes to ensure consistent measurement and meaningful reporting.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"780-789"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11671870/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141625935","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":"Integration and connection: the key to effectiveness of large-scale pharmacist-led medication reviews?","authors":"Andrew Husband, Anna Robinson-Barella","doi":"10.1136/bmjqs-2024-017740","DOIUrl":"10.1136/bmjqs-2024-017740","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"765-768"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142104180","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 sociotechnical framework is necessary to address diagnostic error.","authors":"Meagan M Ladell, Sarah Yale, Brett J Bordini, Matthew C Scanlon, Nancy Jacobson, Elizabeth Lerner Papautsky","doi":"10.1136/bmjqs-2024-017231","DOIUrl":"10.1136/bmjqs-2024-017231","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"823-828"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11671979/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141888426","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":"Role of communicating diagnostic uncertainty in the safety-netting process: insights from a vignette study.","authors":"Caitríona Cox, Thea Hatfield, Zoë Fritz","doi":"10.1136/bmjqs-2023-017037","DOIUrl":"10.1136/bmjqs-2023-017037","url":null,"abstract":"<p><strong>Background: </strong>Safety-netting is intended to protect against harm from uncertainty in diagnosis/disease trajectory. Despite recommendations to communicate diagnostic uncertainty when safety-netting, this is not always done.</p><p><strong>Aims: </strong>To explore how and why doctors safety-netted in response to several clinical scenarios, within the broader context of exploring how doctors communicate diagnostic uncertainty.</p><p><strong>Methods: </strong>Doctors working in internal medical specialties (n=36) from five hospitals were given vignettes in a randomised order (all depicting different clinical scenarios involving diagnostic uncertainty). After reading each, they told an interviewer what they would tell a 'typical patient' in this situation. A follow-up semistructured interview explored reasons for their communication. Interviews were recorded, transcribed and coded. We examined <i>how</i> participants safety-netted using a content analysis approach, and <i>why</i> they safety-netting with thematic analysis of the semistructured follow-up interviews using thematic analysis.</p><p><strong>Results: </strong>We observed n=78 instances of safety-netting (across 108 vignette encounters). We found significant variation in how participants safety-netted. Safety-netting was common (although not universal), but clinicians differed in the detail provided about symptoms to be alert for, and the action advised. Although many viewed safety-netting as an important tool for managing diagnostic uncertainty, diagnostic uncertainty was infrequently explicitly discussed; most advised patients to return if symptoms worsened or new 'red flag' symptoms developed, but they rarely linked this directly to the possibility of diagnostic error. Some participants expressed concerns that communicating diagnostic uncertainty when safety-netting may cause anxiety for patients or could drive inappropriate reattendance/over-investigation.</p><p><strong>Conclusions: </strong>Participants safety-netted variously, even when presented with identical clinical information. Although safety-netting was seen as important in avoiding diagnostic error, concerns about worrying patients may have limited discussion about diagnostic uncertainty. Research is needed to determine whether communicating diagnostic uncertainty makes safety-netting more effective at preventing harm associated with diagnostic error, and whether it causes significant patient anxiety.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"769-779"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11671892/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142139172","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":"Safety netting: time to stop relying on verbal interventions to manage diagnostic uncertainty?","authors":"Georgia B Black","doi":"10.1136/bmjqs-2024-017344","DOIUrl":"10.1136/bmjqs-2024-017344","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"759-761"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494912","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":"Beyond polypharmacy to the brave new world of minimum datasets and artificial intelligence: thumbing a nose to Henry.","authors":"Adam Todd, Barbara Hanratty","doi":"10.1136/bmjqs-2024-017577","DOIUrl":"10.1136/bmjqs-2024-017577","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"762-764"},"PeriodicalIF":5.6,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142494910","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}