BMJ Quality & Safety最新文献

{"title":"Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study.","authors":"Elizabeth Sutton, Mudathir Ibrahim, William Plath, Lesley Booth, Mark Sujan, Peter McCulloch, Nicola Mackintosh","doi":"10.1136/bmjqs-2024-017132","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017132","url":null,"abstract":"<p><strong>Background: </strong>The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).</p><p><strong>Methods: </strong>The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.</p><p><strong>Results: </strong>We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.</p><p><strong>Conclusions: </strong>This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141431280","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":"Factors associated with proximal femoral fractures in older adults during hospital stay: a cross-sectional study.","authors":"Mutsuko Moriwaki, Asuka Takae, Mikayo Toba, Miki Sasaki, Yasuko Ogata, Satoshi Obayashi, Masayuki Kakehashi, Kiyohide Fushimi","doi":"10.1136/bmjqs-2023-016865","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-016865","url":null,"abstract":"<p><strong>Background: </strong>Proximal femoral fractures in older adults affect prognosis, quality of life and medical expenses. Therefore, identifying patients with an elevated risk for proximal femoral fractures and implementing preventive measures to mitigate their occurrence are crucial.</p><p><strong>Objective: </strong>This study aimed to develop an accurate in-hospital fracture prediction model that considers patients' daily conditions and medical procedure status. Additionally, it investigated the changes in their conditions associated with fractures during hospital stays.</p><p><strong>Design: </strong>A retrospective observational study.</p><p><strong>Settings: </strong>Acute care hospitals in Japan.</p><p><strong>Participants: </strong>Participants were 8 514 551 patients from 1321 medical facilities who had been discharged between April 2018 and March 2021 with hip and proximal femoral fractures.</p><p><strong>Methods: </strong>Logistic regression analysis determined the association between patients' changes in their ability to transfer at admission and the day before fracture, and proximal femoral fracture during hospital stays.</p><p><strong>Results: </strong>Patients were classified into fracture and non-fracture groups. The mean ages were 77.4 (SD: 7.7) and 82.6 (SD: 7.8), and the percentages of women were 42.7% and 65.3% in the non-fracture and fracture groups (p<0.01), respectively. Model 4 showed that even if a patient required partial assistance with transfer on the day before the fracture, the fracture risk increased in each category of change in ability to transfer in the following order: 'declined', 'improved' and 'no change'.</p><p><strong>Conclusions: </strong>Patients showing improved ability to transfer during their hospitalisation are at a higher risk for fractures. Monitoring patients' daily conditions and tracking changes can help prevent fractures during their hospital stays.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141431369","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":"Connecting pathogen transmission and healthcare worker cognition: a cognitive task analysis of infection prevention and control practices during simulated patient care.","authors":"Joel M Mumma, Bradley W Weaver, Jill S Morgan, Golpar Ghassemian, Paige R Gannon, Kylie B Burke, Brandon A Berryhill, Rebecca E MacKay, Lindsay Lee, Colleen S Kraft","doi":"10.1136/bmjqs-2023-016230","DOIUrl":"10.1136/bmjqs-2023-016230","url":null,"abstract":"<p><strong>Background: </strong>Relatively little is known about the cognitive processes of healthcare workers that mediate between performance-shaping factors (eg, workload, time pressure) and adherence to infection prevention and control (IPC) practices. We taxonomised the cognitive work involved in IPC practices and assessed its role in how pathogens spread.</p><p><strong>Methods: </strong>Forty-two registered nurses performed patient care tasks in a standardised high-fidelity simulation. Afterwards, participants watched a video of their simulation and described what they were thinking, which we analysed to obtain frequencies of macrocognitive functions (MCFs) in the context of different IPC practices. Performance in the simulation was the frequency at which participants spread harmless surrogates for pathogens (bacteriophages). Using a tertiary split, participants were categorised into a performance group: high, medium or low. To identify associations between the three variables-performance groups, MCFs and IPC practices-we used multiblock discriminant correspondence analysis (MUDICA).</p><p><strong>Results: </strong>MUDICA extracted two factors discriminating between performance groups. Factor 1 captured differences between high and medium performers. High performers monitored the situation for contamination events and mitigated risks by applying formal and informal rules or managing their uncertainty, particularly for sterile technique and cleaning. Medium performers engaged more in future-oriented cognition, anticipating contamination events and planning their workflow, across many IPC practices. Factor 2 distinguished the low performers from the medium and high performers who mitigated risks with informal rules and sacrificed IPC practices when managing tradeoffs, all in the context of minimising cross-contamination from physical touch.</p><p><strong>Conclusions: </strong>To reduce pathogen transmission, new approaches to training IPC (eg, cognitive skills training) and system design are needed. Interventions should help nurses apply their knowledge of IPC fluidly during patient care, prioritising and monitoring situations for risks and deciding how to mitigate risks. Planning IPC into one's workflow is beneficial but may not account for the unpredictability of patient care.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11228200/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138481957","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":"Variation in quality of care between hospitals: how to identify learning opportunities.","authors":"Alex Bottle, Pia Kjær Kristensen","doi":"10.1136/bmjqs-2024-017071","DOIUrl":"10.1136/bmjqs-2024-017071","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140064787","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":"Between-hospital variation in indicators of quality of care: a systematic review.","authors":"Margrietha van der Linde, Nèwel Salet, Nikki van Leeuwen, Hester F Lingsma, Frank Eijkenaar","doi":"10.1136/bmjqs-2023-016726","DOIUrl":"10.1136/bmjqs-2023-016726","url":null,"abstract":"<p><strong>Background: </strong>Efforts to mitigate unwarranted variation in the quality of care require insight into the 'level' (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores.</p><p><strong>Methods: </strong>Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type.</p><p><strong>Results: </strong>In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%-9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%-33.5%) and lowest for final clinical outcomes (1.4%, 0.6%-4.2%) and patient-reported outcomes (1.0%, 0.9%-1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores.</p><p><strong>Conclusion: </strong>Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered.</p><p><strong>Prospero registration number: </strong>CRD42022315850.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139939573","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":"\"It's probably an STI because you're gay\": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.","authors":"Aaron A Wiegand, Taharat Sheikh, Fateha Zannath, Noah M Trudeau, Vadim Dukhanin, Kathryn M McDonald","doi":"10.1136/bmjqs-2022-015629","DOIUrl":"10.1136/bmjqs-2022-015629","url":null,"abstract":"<p><strong>Background: </strong>There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.</p><p><strong>Purpose: </strong>To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients' lives and elicit solutions.</p><p><strong>Methods: </strong>Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.</p><p><strong>Results: </strong>Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.</p><p><strong>Conclusions: </strong>Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients' gender identity, sexual orientation, race, age, economic status and system-level changes.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9448843","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":"Can virtual reality simulations improve macrocognition?","authors":"Michelle Aebersold, Laura Gonzalez","doi":"10.1136/bmjqs-2023-016858","DOIUrl":"10.1136/bmjqs-2023-016858","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.6,"publicationDate":"2024-06-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140012103","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Quality and safety in the literature: August 2024","authors":"Abiola Alaka, Ashwin Gupta, Nathan Houchens","doi":"10.1136/bmjqs-2024-017595","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017595","url":null,"abstract":"Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals. ### Key points JAMA Intern Med , 11 Mar 2024 Chronic kidney disease (CKD) is a global health challenge, affecting approximately 8–16% of the world’s population,1 and is associated with comorbidities such as hypertension.2 Hypertension is independently associated with significant morbidity and cost.2 3 In the USA alone, healthcare costs of hypertension were estimated to be greater than $130 billion between 2003 and 2014.3 …","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141515436","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":"Closing the gap on healthcare quality for equity-deserving groups: a scoping review of equity-focused quality improvement interventions in medicine.","authors":"Jane Jomy, Ke Xin Lin, Ryan S Huang, Alisia Chen, Aleena Malik, Michelle Hwang, Tahara D Bhate, Nazia Sharfuddin","doi":"10.1136/bmjqs-2023-017022","DOIUrl":"https://doi.org/10.1136/bmjqs-2023-017022","url":null,"abstract":"<p><strong>Introduction: </strong>Quality improvement (QI) efforts are critical to promoting health equity and mitigating disparities in healthcare outcomes. Equity-focused QI (EF-QI) interventions address the unique needs of equity-deserving groups and the root causes of disparities. This scoping review aims to identify themes from EF-QI interventions that improve the health of equity-deserving groups, to serve as a resource for researchers embarking on QI.</p><p><strong>Methods: </strong>In adherence with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines, several healthcare and medical databases were systematically searched from inception to December 2022. Primary studies that report results from EF-QI interventions in healthcare were included. Reviewers conducted screening and data extraction using Covidence. Inductive thematic analysis using NVivo identified key barriers to inform future EF-QI interventions.</p><p><strong>Results: </strong>Of 5,330 titles and abstracts screened, 36 articles were eligible for inclusion. They reported on EF-QI interventions across eight medical disciplines: primary care, obstetrics, psychiatry, paediatrics, oncology, cardiology, neurology and respirology. The most common focus was racialised communities (15/36; 42%). Barriers to EF-QI interventions included those at the provider level (training and supervision, time constraints) and institution level (funding and partnerships, infrastructure). The last theme critical to EF-QI interventions is sustainability. Only six (17%) interventions actively involved patient partners.</p><p><strong>Discussion: </strong>EF-QI interventions can be an effective tool for promoting health equity, but face numerous barriers to success. It is unclear whether the demonstrated barriers are intrinsic to the equity focus of the projects or can be generalised to all QI work. Researchers embarking on EF-QI work should engage patients, in addition to hospital and clinic leadership in the design process to secure funding and institutional support, improving sustainability. To the best of our knowledge, no review has synthesised the results of EF-QI interventions in healthcare. Further studies of EF-QI champions are required to better understand the barriers and how to overcome them.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":null,"pages":null},"PeriodicalIF":5.4,"publicationDate":"2024-06-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141310027","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

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