BMJ quality improvement reports最新文献

{"title":"Hypokalaemia: Addressing human factors and improving education around prescription and administration of Intravenous(IV) Potassium infusion in Trauma and Orthopaedics.","authors":"Vanushia Thirumal,&nbsp;Gavin Love","doi":"10.1136/bmjquality.u213676.w7336","DOIUrl":"https://doi.org/10.1136/bmjquality.u213676.w7336","url":null,"abstract":"<p><p>A high incidence of hypokalaemia was noted in Trauma and Orthopaedics of Ninewells Hospital. We sought to establish the reason behind this and implemented three PDSA cycles via questionnaires to 30 ward staff, both doctors and nurses over a 1 week period in December, February and July 2016. Key baseline measures include availability of IV fluids with 40mmol potassium on the wards, confidence prescribing or administering IV fluids with 40mmol potassium, necessity for cardiac monitoring during slow IV potassium replacement and recognition of confusion and learning need in this area. Interventions made include awareness and education session, departmental guideline, improving stock of IV fluids and hypokalaemia management pathway for mild, moderate and severe hypokalaemia. Post-intervention results showed 70% from 33% who said 40mmol IV potassium was available, 87% from 67% were confident prescribing or administering IV potassium and 70% from 27% were aware that cardiac monitoring was not necessary.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u213676.w7336","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Bisphosphonate Infusion Monitoring at Haematology Medical Day Unit.","authors":"Michal Wen Sheue Ong, Lydia Jones","doi":"10.1136/bmjquality.u206586.w4692","DOIUrl":"10.1136/bmjquality.u206586.w4692","url":null,"abstract":"<p><p>This project was started after an incident of bisphosphonate-induced hypocalcaemia in September 2015. As part of management of lytic bone lesions in patients with multiple myeloma were given either Zoledronic Acid or Pamidronate Disodium at our Haematology Day Unit. According to the British National Formulary (BNF), it is necessary to correct disturbances of calcium metabolism (e.g. vitamin D deficiency, hypocalcaemia) and consider dental check-ups before starting bisphosphonate infusion due to the risk of osteonecrosis of the jaw. There was no formal checklist in place for all patients prior to starting bisphosphonate infusion. The aim of this quality improvement project was (1) to avoid preventable bisphosphonate induced adverse effects, (2) to improve safety of bisphosphonate prescribing and administration and (3) to increase patient's awareness of needing regular dental checks. Interventions were modified over multiple Plan-Do-Study-Act (PDSA) improvement cycles to improve bisphosphonate infusion monitoring and patient safety.There was an overall improvement in ensuring safety checks were done prior to administration of bisphosphonate infusion compared to baseline measurements. At baseline, 36% (n=9) of patients had a dental check within the last 6 months; after PDSA cycle 3, there was an improvement of up to 69% (n=11). All patients had renal function and bone profile checked prior to infusion from throughout the study. It was all recorded in the blood results section of the checklist with no missing data. We found that 32% (n=8) of patients had never had 25-OHD at baseline. After PDSA cycle 3, all patients had 25-OHD checked at some point.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/ec/c6/bmjqir.u206586.w4692.PMC5388016.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34966405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Elimination of Emergency Department Medication Errors Due To Estimated Weights.","authors":"Mary Greenwalt,&nbsp;David Griffen,&nbsp;Jim Wilkerson","doi":"10.1136/bmjquality.u214416.w5476","DOIUrl":"https://doi.org/10.1136/bmjquality.u214416.w5476","url":null,"abstract":"<p><p>From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u214416.w5476","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34966404","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving Outpatient Clinic Experience for Core Medical Trainees.","authors":"Natalie King,&nbsp;Catherine Zhu","doi":"10.1136/bmjquality.u221836.w8226","DOIUrl":"https://doi.org/10.1136/bmjquality.u221836.w8226","url":null,"abstract":"<p><p>Outpatient clinic experience is an important component of core medical training. Trainees are expected to attend up to 40 clinics, with a minimum requirement of 24, over the two-year programme. 1 Yet on a local and national level they have reported difficulties with attending even the minimum number of clinics, largely due to ward commitments and service demands. 5 A survey of local core medical trainees revealed a baseline mean clinic attendance of 0.5 clinics per month, with only 13% of trainees having attended the minimum number of clinics. The project aimed to increase the mean clinic attendance to one clinic per month, which would enable trainees to meet their curriculum requirements. Clinic attendance data was collected from core medical trainees at two-monthly intervals, to coincide with rotation changeover. The problem was initially discussed at our local medical faculty meeting and interventions were proposed. Firstly, an up to date clinic timetable was distributed and consultants encouraged to invite their trainees to clinic. Subsequently a clinic booking system was implemented, to enable trainees to arrange protected time in which to attend outpatient clinics. This intervention was unsuccessful in improving clinic attendance. A revised system of pre-allocating protected clinic time was therefore devised and implemented, which resulted in an increase in clinic attendance figures to above the target. Trainees have been allocated clinic days for the rest of the year, which should enable them to meet their curriculum requirements. Through the use of PDSA cycles, we were able to rapidly determine the effect of our interventions and make improvements that have led to an increase in trainee clinic attendance. This is a sustainable model that could be easily implemented by other hospital trusts for core medical trainees.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u221836.w8226","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34965540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A multifaceted approach to improving the quality of ENT Emergency Clinic referrals.","authors":"Chloe Swords,&nbsp;Laura Leach,&nbsp;Anand Kasbekar,&nbsp;Piyush Jani","doi":"10.1136/bmjquality.u206639.w6166","DOIUrl":"https://doi.org/10.1136/bmjquality.u206639.w6166","url":null,"abstract":"<p><p>It is imperative that primary care referrals are directed to the appropriate secondary care service. Patients presenting to a primary care physician with ENT conditions may require review in an Emergency Clinic. The latter clinics provide patients with rapid access to secondary care, for urgent, yet non-life-threatening conditions. In our department, we noticed that patients with conditions inappropriate to the capabilities of the Clinic were being booked in or reviewed too late; thus causing wasted journeys for the patient. We conducted a Quality Improvement Project to improve the efficiency of the referral process. A prospective evaluation of referrals was collected continuously over a two-month period. Overall, 5 domains were deemed crucial to enable timely and accurate booking of patients to clinic: booking date, urgency, legibility, patient identification and appropriateness. Our proposed standard set for this project was 100% compliance over the 5 domains. Three separate interventions were instigated following the first cycle. The main components of the intervention were the phased development of an electronic referral system and an educational initiative for junior doctors. 20 referral forms were analysed during the initial 3-week period. No referrals met the recommended overall compliance standard of 100% (mean number of domains achieved: 3.38; standard deviation (SD): 0.637). Legibility and patient information were included in 21% and 30% of referrals, respectively. There was a trend of improvement following initiation of interventions. The mean number of domains achieved was 4.27 (SD 0.647; n=13) in the second data collection period, 4.53 (SD 0.514; n=16) in the third, and 4.75 (SD 0.452; n=24) in the fourth. Using linear regression, this change demonstrates a statistically significant improvement (p<0.001). An e-Proforma referral system represents a safe and efficient communication technology. When implementing policy change, it is crucial to acquire managerial and consultant support.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u206639.w6166","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34863583","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Systems for physical health care for mental health patients in the community: different approaches to improve patient care and safety in an Early Intervention in Psychosis Service.","authors":"Josie Mouko,&nbsp;Rebecca Sullivan","doi":"10.1136/bmjquality.u209141.w3798","DOIUrl":"https://doi.org/10.1136/bmjquality.u209141.w3798","url":null,"abstract":"<p><p>Patients with mental illnesses have a high rate of physical comorbidity, and specifically, those with psychosis are at an increased risk of cardiometabolic disease and shortened lifespans, due to medication, lifestyle and illness factors. There are recognised challenges with physical health care in this group. At baseline, no patients on the Bath and North East Somerset Early Intervention in Psychosis caseload had a fully completed physical health assessment. Our aim was to offer a physical health check, blood tests, and ECG for all patients, trialling four phases of interventions. The four phases were (1) increased awareness, education and data collection tools; (2) mobile physical health clinics; (3) letters sent to patients and GPs to request health checks be conducted, (4) a combination of the above approaches, as well as regular caseload reviews and prompts to professionals. At the time of our study (2015-16), many of the above parameters were also incentivised nationally by Commissioning for Quality and Innovation (CQUIN) payments. The mobile physical health clinic offered patient choice of home visits or clinic checks, to increase engagement and provide flexible care. The most successful approach overall was the combination approach, resulting in 48% of all patients having fully completed physical health checks, bloods and ECGs. The mobile clinic resulted in physical health checks completion rates of 60%, and blood tests in 65-70%. 92% of patients undertook ECG's, following letter requests to GPs and patients. Combining mobile physical health clinics, GP letters, financial incentives and managerial engagement produced much improved results, but was very time consuming, and in our case was inefficient due to using multiple professionals. We recommend embedding such approaches within the team, using sustainable systems, and would encourage teams to trial dedicated trained clinicians to establish sustainable systems to improve the physical health care of this vulnerable group.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u209141.w3798","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34863584","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Electronic Printed Ward Round Proformas: Freeing Up Doctors' Time.","authors":"Darren Fernandes,&nbsp;Philip Eneje","doi":"10.1136/bmjquality.u212969.w5171","DOIUrl":"https://doi.org/10.1136/bmjquality.u212969.w5171","url":null,"abstract":"<p><p>The role of a junior doctor involves preparing for the morning ward round. At a time when there are gaps on rotas and doctors' time is more stretched, this can be a source of significant delay and thus a loss of working time. We therefore looked at ways in which we could make the ward round a more efficient place by introducing specific electronic, printed ward round proformas. We used the average time taken to write proformas per patient and the average time taken per patient on the ward round. This would then enable us to make fair comparisons with future changes that were made using the plan, do, study, and act principles of quality improvement. Our baseline measurement found that the average time taken to write up the proforma for each patient was 1 minute 9 seconds and that the average time taken per patient on the ward round was 8 minutes 30 seconds. With the changes we made during our 3 PDSA cycles and the implementation of an electronic, printed ward round proforma, we found that we were able to reduce the average time spent per patient on the ward round to 6 minutes 32 seconds, an improvement of 1 min 58 seconds per patient. The project has thus enabled us to reduce the time taken per patient during the ward round. This improved efficiency will enable patients to be identified earlier for discharge. It will also aid in freeing up the time of junior doctors, allowing them to complete discharge letters sooner, order investigations earlier and enable them to complete their allocated tasks within contracted hours.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u212969.w5171","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34863585","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Introduction of a Microsoft Excel-based unified electronic weekend handover document in Acute and General Medicine in a DGH: aims, outcomes and challenges.","authors":"Pablo Kostelec, Pietro Emanuele Garbelli, Pietro Emanuele Garbelli","doi":"10.1136/bmjquality.u212152.w5721","DOIUrl":"10.1136/bmjquality.u212152.w5721","url":null,"abstract":"<p><p>On-call weekends in medicine can be a busy and stressful time for junior doctors, as they are responsible for a larger pool of patients, most of whom they would have never met. Clinical handover to the weekend team is extremely important and any communication errors may have a profound impact on patient care, potentially even resulting in avoidable harm or death. Several senior clinical bodies have issued guidelines on best practice in written and verbal handover. These include: standardisation, use of pro forma documents prompting doctors to document vital information (such as ceiling of care/resuscitation status) and prioritisation according to clinical urgency. These guidelines were not consistently followed in our hospital site at the onset of 2014 and junior doctors were becoming increasingly dissatisfied with the handover processes. An initial audit of handover documents used across the medical division on two separate weekends in January 2014, revealed high variability in compliance with documentation of key information. For example, ceiling of care was documented for only 14-42% of patients and resuscitation status in 26-72% of patients respectively. Additionally, each ward used their own self-designed pro forma and patients were not prioritised by clinical urgency. Within six months from the introduction of a standardised, hospital-wide weekend handover pro forma across the medical division and following initial improvements to its layout, ceiling of therapy and resuscitation status were documented in approximately 80% of patients (with some minor variability). Moreover, 100% of patients in acute medicine and 75% of those in general medicine were prioritised by clinical urgency and all wards used the same handover pro forma.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/93/f8/bmjqir.u212152.w5721.PMC5361068.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34863586","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early Aspirin administration post Coronary Artery Bypass Graft Surgery - Changing hospital culture through a two-cycled audit.","authors":"Shefali Parikh,&nbsp;Justin Ratnasingham","doi":"10.1136/bmjquality.u211402.w6306","DOIUrl":"https://doi.org/10.1136/bmjquality.u211402.w6306","url":null,"abstract":"<p><p>\"Early Aspirin\" or a medium dose of aspirin 6 hours after Coronary Artery Bypass Graft (CABG) Surgery is strongly recommend by international guidelines (EACTS 2007/AHA 2011 guidelines, Level1a evidence) to protect venous graft patency. However, compliance with Early Aspirin prescription at our centre is poor due to long standing hospital cultural practices and lack of awareness. We completed a two-cycled retrospective audit of 53 (September 2015 Baseline), 65 (January 2016 First Cycle) and 58 (June 2016 Second Cycle) consecutive CABG patients. Interval interventions included educational presentations, educational leaflets/posters, pharmacy liaison and modifications to e-prescription order-sets. Medical, nursing and pharmacy staff were involved in the audit strategies. Early aspirin prescription improved from 23% to 48% to 55% while administration of Early Aspirin improved from 17% to 38% and finally to 48% by second improvement cycle. Significantly, the proportion of patients with omission of early aspirin despite a clear clinical indication, decreased by 50% over the audit period. Important practical considerations were the last dose of anti-platelets preoperatively and amount of of bleeding from mediastinal drains post operatively. A multidisciplinary team based approach led to a 139% improvement in prescription and 182% improvement in administration of \"Early Aspirin\" after CABG surgery.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u211402.w6306","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34836648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identifying, highlighting and reducing polypharmacy in a UK hospice inpatient unit using improvement Science methods.","authors":"Alison Phippen,&nbsp;Jennie Pickard,&nbsp;Douglas Steinke,&nbsp;Matt Cope,&nbsp;Dai Roberts","doi":"10.1136/bmjquality.u211783.w5035","DOIUrl":"https://doi.org/10.1136/bmjquality.u211783.w5035","url":null,"abstract":"<p><p>Polypharmacy, the concurrent use of multiple medications by one individual is a growing global issue driven by an ageing population and increasing prevalence of multi-morbidity[1]. Polypharmacy can be problematic: interactions between medications, reduced adherence to medication, burden of medication to patients, administration time, increased risk of errors and increased cost. Quality improvement methods were applied to identify and highlight polypharmacy patients with the aim of reducing their average number of regular tablets/capsules per day by 25%. The project was delivered within a UK based 27 bedded hospice inpatient unit. A series of PDSA cycles studied interventions focusing on the identification of patients with polypharmacy, the highlighting of these patients to prescribers for review and the views of patients about their medication. For the purposes of the study, polypharmacy was defined as greater than ten regular medicines and/or greater than twenty regular tablets/capsules each day. The interventions tested included patients on regular paracetamol and strong opioids being offered a trial without regular paracetamol, a constipation guide promoting the use of combination laxatives, education of prescribers around dose strengths, checklist of recommendations was placed in case notes and a sticker was used on the medicine chart to highlight patients in need of polypharmacy review. The introduction of a trial without paracetamol and a laxative guide led to reductions in polypharmacy. The sticker and checklist were successful interventions for highlighting patients with polypharmacy. Quality improvement methods were used to plan, try, test and implement simple interventions for patients on the hospice inpatient unit. This has led to a 25% reduction in the average regular tablet/capsules burden , a 16% reduction in the average number of regular medications and a 30% reduction in the average volume of liquid medication per patient without an increase in the use of 'as required' medication or length of stay.</p>","PeriodicalId":91218,"journal":{"name":"BMJ quality improvement reports","volume":"6 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2017-03-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1136/bmjquality.u211783.w5035","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"34836647","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}