BMJ Quality & Safety最新文献

{"title":"Increasing surgical volumes in resource limited-healthcare systems: team-based quality improvement as a novel approach to quantity improvement.","authors":"Nobhojit Roy, Asad Latif","doi":"10.1136/bmjqs-2024-018296","DOIUrl":"10.1136/bmjqs-2024-018296","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"364-366"},"PeriodicalIF":5.6,"publicationDate":"2025-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143728436","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":"Systems analysis of clinical incidents: development of a new edition of the London Protocol.","authors":"Charles Vincent, Dulcie Irving, Tommaso Bellandi, Helen Higham, Philippe Michel, Anthony Staines, Sally Adams, Jeff Brown, Peter Damian Hibbert, Carole Hemmelgarn, Lallu Joseph, Karina Pires, Susan Sheridan, Rosa Sunol, Shin Ushiro, Albert W Wu, Lucas Zambon","doi":"10.1136/bmjqs-2024-017987","DOIUrl":"10.1136/bmjqs-2024-017987","url":null,"abstract":"<p><p>The investigation of incidents and accidents, together with subsequent reflection and action, is an essential component of safety management in every safety-critical industry, including healthcare. A number of formal methods of incident analysis were developed in the early days of risk management and patient safety, including the London Protocol which was published in 2004. In this paper, we describe the development of a new edition of the London Protocol. We explain the need for a revised and expanded version of the London Protocol, addressing both the changes in healthcare in the last two decades and what has been learnt from the experience of incident analysis across the world. We describe a systematic process of development of the new edition drawing on the findings of a narrative review of incident analysis methods. The principal changes in the new edition are as follows: increased emphasis and guidance on the engagement of patients and families as partners in the investigation; giving more attention to the support of patients, families and staff in the aftermath of an incident; emphasising the value of a small number of in-depth analyses combined with thematic reviews of wider problems; including proposals and guidance for the examination of much longer time periods; emphasising the need to highlight good care as well as problems; adding guidance on direct observation of the work environment; providing a more structured and wide-ranging approach to recommendations and including more guidance on how to write safety incident reports. Finally, we offer some proposals to place research on incident analysis on a firmer foundation and make suggestions for the practice and implementation of incident investigation within safety management systems.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"413-420"},"PeriodicalIF":5.6,"publicationDate":"2025-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12171414/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143475957","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":"Patient portal messaging to address delayed follow-up for uncontrolled diabetes: a pragmatic, randomised clinical trial.","authors":"Arielle R Nagler, Leora Idit Horwitz, Aamina Ahmed, Amrita Mukhopadhyay, Isaac Dapkins, William King, Simon A Jones, Adam Szerencsy, Claudia Pulgarin, Jennifer Gray, Tony Mei, Saul Blecker","doi":"10.1136/bmjqs-2024-018249","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018249","url":null,"abstract":"<p><strong>Importance: </strong>Patients with poor glycaemic control have a high risk for major cardiovascular events. Improving glycaemic monitoring in patients with diabetes can improve morbidity and mortality.</p><p><strong>Objective: </strong>To assess the effectiveness of a patient portal message in prompting patients with poorly controlled diabetes without a recent glycated haemoglobin (HbA1c) result to have their HbA1c repeated.</p><p><strong>Design: </strong>A pragmatic, randomised clinical trial.</p><p><strong>Setting: </strong>A large academic health system consisting of over 350 ambulatory practices.</p><p><strong>Participants: </strong>Patients who had an HbA1c greater than 10% who had not had a repeat HbA1c in the prior 6 months.</p><p><strong>Exposures: </strong>A single electronic health record (EHR)-based patient portal message to prompt patients to have a repeat HbA1c test versus usual care.</p><p><strong>Main outcomes: </strong>The primary outcome was a follow-up HbA1c test result within 90 days of randomisation.</p><p><strong>Results: </strong>The study included 2573 patients with a mean (SD) HbA1c of 11.2%. Among 1317 patients in the intervention group, 24.2% had follow-up HbA1c tests completed within 90 days, versus 21.1% of 1256 patients in the control group (p=0.07). Patients in the intervention group were more likely to log into the patient portal within 60 days as compared with the control group (61.2% vs 52.3%, p<0.001).</p><p><strong>Conclusions: </strong>Among patients with poorly controlled diabetes and no recent HbA1c result, a brief patient portal message did not significantly increase follow-up testing but did increase patient engagement with the patient portal. Automated patient messages could be considered as a part of multipronged efforts to involve patients in their diabetes care.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143979063","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":"Using implementation science to define the model and outcomes for improving quality in NEST360, a multicountry alliance for reducing newborn mortality in sub-Saharan Africa.","authors":"Kylie Dougherty, Nebiyou Hailemariam, Georgia Jenkins, Junwei Chen, Jackson Ilangali, John Mwangi, Julius Thomas, Hannah Mwaniki Mwaniki, Olabisi Dosunmu, Robert Tillya, Samuel Ngwala, Joy E Lawn, Rebecca Richards-Kortum, Z Maria Oden, Christine Bohne, Lisa R Hirschhorn","doi":"10.1136/bmjqs-2024-018471","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018471","url":null,"abstract":"<p><strong>Background: </strong>Improving small and sick newborn care (SSNC) is crucial in resource-limited settings. Newborn Essential Solutions and Technologies (NEST360), a multicountry alliance, aims to reduce newborn mortality through evidence-based interventions. NEST360 developed a multipronged approach to improving quality. We use implementation research (IR) to describe this approach and report emerging implementation outcomes.</p><p><strong>Methods: </strong>The implementation research logic model (IRLM) was applied to link contextual factors, implementation strategies, mechanisms and implementation outcomes, capturing successes and challenges of the improving quality approach. Data sources included programme data, peer-reviewed publications and team input. Contextual factors were organised by the NEST360-UNICEF SSNC implementation toolkit. Strategies were grouped by the Expert Recommendations for Implementation Change list, and implementation outcomes were measured using Proctor's implementation outcomes.</p><p><strong>Results: </strong>We developed an IRLM to describe the implementation of NEST360's improving quality model. This IRLM included 33 contextual factors; 42% were barriers, 42% were facilitators, and 15% were both a barrier and facilitator. Additionally, we identified 10 implementation strategies that NEST360 used. The logic model also describes the connections between the contextual factors, the strategies that address them, and the preliminary implementation outcomes. Examples of the outcomes measured include <i>Reach</i> with 100% of units logging into the NEST360-Implementation Tracker (NEST-IT) at least once (October 2023 to March 2024), <i>Adoption</i> with 100% of units conducting a quality improvement (QI) project (April 2024 to June 2024), and <i>Feasibility</i> with 93% of units reporting NEST-IT data in their QI project documentation (April 2024 to June 2024). Finally, this study identified sustainability strategies as a critical need.</p><p><strong>Conclusions: </strong>Integrating IR and QI enhances SSNC in resource-limited settings. Addressing barriers, leveraging facilitators and using structured IR frameworks advanced QI efforts, thereby improving intervention reach, adoption and feasibility while building scalable systems for high-quality healthcare.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143979155","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":"Addressing the risk of look-alike, sound-alike medication errors: bending metal or twisting arms?","authors":"Denham L Phipps","doi":"10.1136/bmjqs-2025-018648","DOIUrl":"https://doi.org/10.1136/bmjqs-2025-018648","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-05-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143973858","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":"Better bottom lines: patient satisfaction associated with addressing sexual and gender minority health.","authors":"Carl Streed, Jessica Halem, Amy LeClair","doi":"10.1136/bmjqs-2025-018587","DOIUrl":"https://doi.org/10.1136/bmjqs-2025-018587","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143963120","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":"Does the use of structured interventions to guide ward rounds affect patient outcomes? A systematic review.","authors":"Victoria Ando, Alexia Cavin-Trombert, David Gachoud, Matteo Monti","doi":"10.1136/bmjqs-2024-018039","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018039","url":null,"abstract":"<p><strong>Background: </strong>Ward rounds are an essential activity occurring in hospital settings. Despite their fundamental role in guiding patient care, they have no standardised approach. Implementation of structured interventions during ward rounds was shown to improve outcomes such as efficiency, documentation and communication. Whether these improvements have an impact on clinical outcomes is unclear. Our systematic review assessed whether structured interventions to guide ward rounds affect patient outcomes.</p><p><strong>Methods: </strong>A systematic search was carried out in May 2023 on Embase, Medline, CINAHL, ERIC, Web of Science Core Collection, the Cochrane Library (Wiley) and Google Scholar, and a backward and forward citation search in January 2024. We included peer-reviewed, original studies assessing the use of structured interventions during bedside ward rounds (BWRs) on clinical outcomes. All inpatient hospital settings where BWRs are performed were included. We excluded papers looking at board, teaching or medication rounds.</p><p><strong>Results: </strong>Our search strategy yielded 29 studies. Two were randomised controlled trials (RCTs) and 27 were quasi-experimental interventional studies. The majority (79%) were conducted in intensive care units. The main clinical outcomes reported were mortality, infectious complications, length of stay (LOS) and duration of mechanical ventilation (DoMV). Mortality, LOS and rates of urinary tract and central-line associated bloodstream infections did not seem to be affected, positively or negatively, by interventions structuring BWRs, while evidence was conflicting regarding their effects on rates of ventilator-associated pneumonia and DoMV, with a signal towards improved outcomes. Studies were generally of low-to-moderate quality.</p><p><strong>Conclusion: </strong>The impact of structured interventions during BWRs on clinical outcomes remains inconclusive. Higher quality research focusing on multicentric RCTs or on prospective pre-post trials with concurrent cohorts, matched for key characteristics, is needed.</p><p><strong>Prospero registration number: </strong>CRD42023412637.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-04-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144062014","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":"Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation.","authors":"Christina Saville, Jeremy Jones, Paul Meredith, Chiara Dall'Ora, Peter Griffiths","doi":"10.1136/bmjqs-2024-018138","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-018138","url":null,"abstract":"<p><strong>Background: </strong>Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective?</p><p><strong>Methods: </strong>This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. We modelled the association between a patient's exposure to ward nurse understaffing (days where staffing was below the ward mean) over the first 5 days of stay and risk of death, risk of readmission and length of stay, using survival analysis and linear mixed models. We estimated the incremental cost-effectiveness of eliminating understaffing by registered nurses (RN) and nursing support (NS) staff, estimating net costs per quality-adjusted life year (QALY). We took a hospital cost perspective.</p><p><strong>Findings: </strong>Exposure to RN understaffing is associated with increased hazard of death (adjusted HR (aHR) 1.079, 95% CI 1.070 to 1.089), increased chance of readmission (aHR 1.010, 95% CI 1.005 to 1.016) and increased length of stay (ratio 1.687, 95% CI 1.666 to 1.707), while exposure to NS understaffing is associated with smaller increases in hazard of death (aHR 1.072, 95% CI 1.062 to 1.081) and length of stay (ratio 1.608, 95% CI 1.589 to 1.627) but reduced readmissions (aHR 0.994, 95% CI 0.988 to 0.999). Eliminating both RN and NS understaffing is estimated to cost £2778 per QALY (staff costs only), £2685 (including benefits of reduced staff sickness and readmissions) or save £4728 (including benefits of reduced lengths of stay). Using agency staff to eliminate understaffing is less cost-effective and would save fewer lives than using permanent members of staff. Targeting specific patient groups with improved staffing would save fewer lives and, in the scenarios tested, cost more per QALY than eliminating all understaffing.</p><p><strong>Interpretation: </strong>Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in RNs over NS staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-04-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143963742","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 national guidelines on antenatal magnesium sulfate for neonatal neuroprotection: extended evaluation of the effectiveness and cost-effectiveness of the National PReCePT Programme in England.","authors":"Hannah B Edwards, Carlos Sillero-Rejon, Hugh McLeod, Elizabeth M Hill, Brent C Opmeer, Colin Peters, David Odd, Frank de Vocht, Karen Luyt","doi":"10.1136/bmjqs-2024-017763","DOIUrl":"https://doi.org/10.1136/bmjqs-2024-017763","url":null,"abstract":"<p><strong>Background: </strong>Since 2015, the National Institute for Health and Care Excellence (NICE) guidelines have recommended antenatal magnesium sulfate (MgSO₄) for mothers in preterm labour (<30 weeks' gestation) to reduce the risk of cerebral palsy (CP) in the preterm baby. However, the implementation of this guideline in clinical practice was slow, and MgSO₄ use varied between maternity units. In 2018, the PRrevention of Cerebral palsy in PreTerm labour (PReCePT) programme, an evidence-based quality improvement (QI) intervention to improve use of MgSO₄, was rolled out across England. Earlier evaluation found this programme to be effective and cost-effective over the first 12 months. We extended the original evaluation to determine the programme's longer-term impact over 4 years, its impact in later preterm births, the impact of the COVID-19 pandemic, and to compare MgSO₄ use in England (where PReCePT was implemented) to Scotland and Wales (where it was not).</p><p><strong>Methods: </strong>Quasi-experimental longitudinal study using data from the National Neonatal Research Database on babies born <30 weeks' gestation and admitted to a National Health Service neonatal unit. Primary outcome was the percentage of eligible mothers receiving MgSO₄, aggregated to the national level. Impact of PReCePT on MgSO₄ use was estimated using multivariable linear regression. The net monetary benefit (NMB) of the programme was estimated.</p><p><strong>Results: </strong>MgSO₄ administration rose from 65.8% in 2017 to 85.5% in 2022 in England. PReCePT was associated with a 5.8 percentage points improvement in uptake (95% CI 2.69 to 8.86, p<0.001). Improvement was greater when including older preterm births (<34 weeks' gestation, 8.67 percentage points, 95% CI 6.38 to 10.96, p<0.001). Most gains occurred in the first 2 years following implementation. PReCePT had a NMB of £597 000 with 89% probability of being cost-effective. Following implementation, English uptake appeared to accelerate compared with Scotland and Wales. There was some decline in use coinciding with the onset of the pandemic.</p><p><strong>Conclusions: </strong>The PReCePT QI programme cost-effectively improved use of antenatal MgSO₄, with anticipated benefits to the babies who have been protected from CP.</p>","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":""},"PeriodicalIF":5.6,"publicationDate":"2025-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143971903","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":"Using data science to improve patient care: rethinking clinician responsibility.","authors":"Irene Grossmann, Perla J Marang-van de Mheen","doi":"10.1136/bmjqs-2025-018514","DOIUrl":"10.1136/bmjqs-2025-018514","url":null,"abstract":"","PeriodicalId":9077,"journal":{"name":"BMJ Quality & Safety","volume":" ","pages":"288-290"},"PeriodicalIF":5.6,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143540082","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}