I thank Dr O’Donnell for his letter asking if we did not name the vendors in a study of the electronic health record (EHR)-generated discharge summaries1 as a matter of policy or simply due to an oversight. The vulnerabilities and unintended consequences of health information technologies have appeared as recurring themes in both research papers2–7 and editorials8–10 at BMJ Quality & Safety. We agree that such studies should generally mention the vendors involved, just as one would expect to occur in studies of medical devices, such as infusion pumps or surgical implants.
In this case, the omission of the vendors did indeed result from an oversight. We had asked the authors to identify the vendors in our comments as part of the editorial comments added to those from external...
The study by Sarzynski and colleagues1 uses rigorous analysis to obtain important insights about the real-time information that patients receive at discharge. It is puzzling that the electronic health records (EHRs) used were not named. One can infer from a look through the Michigan State University website that they have both Cerner and Epic, but why is such detective work necessary? The heart of quality/safety work is one of transparency balanced by humility. We should not expect health information technology systems to be any more perfect than we are. But, these systems would not improve if we do not have more openness about their shortcomings.
The lack of scientific foundations and published postmarketing surveillance for our EHRs, especially the ascendant ones, was initially surprising. However, as they achieve complete market dominance, with less overt scientific review and public guidance and commentary,2 the silence is deafening....
We were very interested to read the article by Meddings et al which evaluated the association between patient safety culture and catheter-associated infections among hospitals in two infection-reducing collaboratives.1 The authors found that while infection rates declined, there was no association between 13 dimensions of patient safety culture, as measured by the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS), and unadjusted infection rates (catheter-associated urinary tract infections (CAUTI) and central-line-associated bloodstream infection (CLABSI) rates per 1000 catheter days).
We comment on several of the article’s conclusions and pose some questions about the data collection and analysis methods used to examine the relationship between HSOPS and infection rates.
First, the study reported HSOPS response rates averaging 24% for the CLABSI collaborative and 43% for the CAUTI collaborative, which were described as ’a low response rate' and ’important finding' which they attribute to...
The importance of the respiratory rate (RR) as a vital sign is hardly new, but the recent article by Badawy et al1 uses an elegant and scientific approach to shine new light on an old issue, that of the reliability of recorded vital signs. The article relates to an important function of healthcare: early detection and prevention of patient deterioration. From where I write, in Australia, recognising and responding to deterioration is one of ten National Health Standards.2 I believe RR is a microcosm of the challenges we face in healthcare and Badawy’s article has implications for patient safety and quality as a whole.
RR is an extremely valuable indicator; it is an integral part of early warning systems (EWS) and a diagnostic criterion for systemic inflammatory response syndrome.3 Its prognostic value can even rival complex prognostic tools such as the Pneumonia Severity...
We thank Dr Wong for his detailed description of the importance of respiratory rate (RR) and his astute reflections on the interactions between predictable human errors and the systems in which humans work. We agree that RR is prone to error because of the human element. However, what is unique to healthcare compared with aviation is not that human error exists, but that tolerance for these errors has become an accepted part of everyday practice.1 We hypothesise that RRs can be measured both accurately and efficiently, but this requires institutional culture change starting with improvements in staff education, expectations and accountability, which can be accomplished through a quality improvement (QI) initiative. We have initiated this process at our own institution.
To guide our local ongoing QI initiative, we mapped the workflows for routine RR measurements by patient care assistants (PCA) through direct observation in a single inpatient...
Shaw J, McKillop A, Sheridan N, et al. BMJ Qual Saf 2017; doi:10.1136/bmjqs-2017-006696.2.
The corrected affiliations for this paper should read as follows:
James Shaw,1, 4 Ann McKillop,2 Nicolette Sheridan,2 Carolyn Steele Gray,3, 4 Peter Carswell,2 Walter P Wodchis,4, 7, 8 Mylaine Breton,5 Jean-Louis Denis,6 G. Ross Baker,4 Timothy Kenealy2
Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
Département des sciences de la santé communautaire, Universite de Sherborooke, Longueuil, Quebec, Canada
Département d’administration de la santé, Universite de Montreal, Montreal, Quebec, Canada
Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
In his book on the psychology of persuasion, Robert Cialdini noted: "as the stimuli saturating our lives continue to grow more intricate and variable, we will have to depend increasingly on our shortcuts to handle them all".1 Such cognitive shortcuts, or heuristics, are responsible for much of human success in complex environments. Heuristics allow us to skip steps and save mental energy. Similarly, emotions provide a shorthand for remembering and reacting to complex situations and sociability allows us to function well in groups.
Medicine is the art of managing complexity. Physicians’ success similarly depends on effective use of these heuristics, emotion and sociability. When admitting a patient to the hospital, a physician must diagnose the presenting symptoms, reconcile and start medications, order diagnostic testing, communicate with consultants and participate in shared-decision making. In ambulatory visits, the time pressure and tasks are slightly different, but comparably complex. In both...
Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.Methods
We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.Results
During the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (–46.6%, 95% CI –66.2% to –15.6%), but urinalysis (0.4%, 95% CI –30.1 to 44.4%), microscopy (–6.5%, 95% CI –36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI –16.9 to 67.4) were unchanged.Conclusions
A simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.
Universal protocol implementation can be challenging in low-income or middle-income countries, particularly when providers work together across language barriers. The aim of this quality improvement initiative was to test the implementation of a colour-coded universal protocol in a Guatemalan hospital staffed by US and Guatemalan providers.Methods
From 2013 to 2016, a US and Guatemalan team implemented a universal protocol at a Guatemalan surgical centre for children undergoing general surgical or urologic procedures. The protocol was a two-step patient identification and documentation checklist, with the first step of all chart element verification in the preoperative area, after which a blue hat was placed on the patient as a visual cue that this was completed. The second step included checklist confirmation in the operating room prior to the procedure. We tested protocol implementation over three phases, identifying implementation barriers and modifying clinical workflow after each phase. We measured the error rate in documentation or other universal protocol steps at each phase and made modifications based on iterative analysis.Results
Over the course of programme implementation, we substantially decreased the rate of errors in documentation or other universal protocol elements. After the first phase, 30/51 patients (58.8%) had at least one error. By the third phase, only 2/43 patients (4.6%) had any errors. All errors were corrected prior to surgery with no adverse outcomes.Conclusions
Care teams of providers from different countries pose potential challenges with patient safety. Implementation of a colour-coded universal protocol in this setting can prevent and reduce errors that could potentially lead to patient harm.
Traditional strategies for surveillance of surgical site infections (SSI) have multiple limitations, including delayed and incomplete outbreak detection. Statistical process control (SPC) methods address these deficiencies by combining longitudinal analysis with graphical presentation of data.Methods
We performed a pilot study within a large network of community hospitals to evaluate performance of SPC methods for detecting SSI outbreaks. We applied conventional Shewhart and exponentially weighted moving average (EWMA) SPC charts to 10 previously investigated SSI outbreaks that occurred from 2003 to 2013. We compared the results of SPC surveillance to the results of traditional SSI surveillance methods. Then, we analysed the performance of modified SPC charts constructed with different outbreak detection rules, EWMA smoothing factors and baseline SSI rate calculations.Results
Conventional Shewhart and EWMA SPC charts both detected 8 of the 10 SSI outbreaks analysed, in each case prior to the date of traditional detection. Among detected outbreaks, conventional Shewhart chart detection occurred a median of 12 months prior to outbreak onset and 22 months prior to traditional detection. Conventional EWMA chart detection occurred a median of 7months prior to outbreak onset and 14 months prior to traditional detection. Modified Shewhart and EWMA charts additionally detected several outbreaks earlier than conventional SPC charts. Shewhart and SPC charts had low false-positive rates when used to analyse separate control hospital SSI data.Conclusions
Our findings illustrate the potential usefulness and feasibility of real-time SPC surveillance of SSI to rapidly identify outbreaks and improve patient safety. Further study is needed to optimise SPC chart selection and calculation, statistical outbreak detection rules and the process for reacting to signals of potential outbreaks.
To evaluate mortality differences between weekend and weekday emergency stroke admissions in England over time, and in particular, whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.Design, setting and participants
Risk-adjusted difference-in-difference time trend analysis using hospital administrative data. All emergency patients with stroke admitted to English hospitals from 1 January 2008 to 31 December 2014 were included.Main outcomes
Mortality difference between weekend and weekday emergency stroke admissions.Results
We identified 507 169 emergency stroke admissions: 26% of these occurred during the weekend. The 7-day in-hospital mortality difference between weekend and weekday admissions declined across England throughout the study period. In Greater London, where the reorganisation of stroke services took place, an adjusted 28% (relative risk (RR)=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant. In the rest of England, an 11% (RR=1.11, 95% CI 1.07 to 1.15) higher weekend/weekday 30-day mortality ratio declined to a non-significant 4% higher risk (RR=1.04, 95% CI 0.99 to 1.09) in 2014. We found no statistically significant association between decreases in the weekend/weekday admissions difference in mortality and the centralisation of stroke services in Greater London.Conclusions
There was a steady reduction in weekend/weekday differences in mortality in stroke admissions across England. It appears statistically unrelated to the centralisation of stroke services in Greater London, and is consistent with an overall national focus on improving stroke services.
Two strategies for rating the quality of nursing homes (NHs) in the USA are exemplified by the Nursing Home Compare (NHC) website, launched by the federal Centers for Medicare and Medicaid Services in 1998, and Yelp.com, an online consumer review site that has grown in popularity since its founding in 2004. Both sites feature a 5-star rating system. While much is known about NHC ratings, little is known about NH Yelp ratings. This study examines Yelp ratings for NHs in California and compares these ratings with NHC ratings. Understanding how these ratings relate can inform efforts to empower consumers and enhance NH decision-making.Methods
We collected NHC and Yelp ratings for all California NHs between September and November 2016. For each NH with a Yelp review, we recorded the star rating and the total number of reviews. We also recorded the NHC 5-star rating and NHC ratings for inspections, staffing and quality measures (QMs). We conducted descriptive statistics and frequencies for these variables. We conducted correlations and tested means to compare the ratings.Results
A total of 675 NHs (68.1% of the total sample of 991 NHs) had both Yelp ratings and NHC ratings. Correlations between the Yelp and NHC ratings were relatively weak. The Yelp rating was significantly lower than the 5-star NHC rating and the NHC ratings for staffing and QMs. It was significantly higher than the NHC inspection rating.Conclusions
This study found that when consumers rate NHs on Yelp, their ratings differ considerably from NHC ratings, a finding in keeping with similar studies of NH quality measurement. Further research is needed to analyse the content of Yelp reviews and compare the themes and topics consumers identify with those reported on NHC.
Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.Methods
This is a qualitative study of 19 National Health Service (NHS) organisations, 7 of which had community service provision. We conducted ethnographic observations of practice and interviews with front-line nursing and senior staff. Analysis was based on the constant comparison method.Results
Measurement in community settings presents distinct challenges, calling into question the extent to which measures can be easily transferred. The NHS-ST was seen as more appropriate for acute care, not least because community nurses did not have the same access to information. Data collection requirements were in tension with maintaining a relationship of trust with patients. The aim to collect data across care settings acted to undermine perceptions of the representativeness of community data. Although the tool was designed to measure preventable harms, care providers questioned their preventability within a community setting. Different harms were seen as priorities for measurement and improvement within community settings.Conclusions
Measurement tools are experienced by healthcare staff as socially situated. In the community setting, there are distinct challenges to improving care quality not experienced in the acute sector. Strategies to measure harms, and use of any resulting data for improvement work, need to be cognisant of the complexity of an environment where healthcare staff often have little opportunity to monitor and influence patients.
A safe delivery is part of a good start in life, and a continuous focus on preventing harm during delivery is crucial, even in settings with a good safety record. In January 2013, the labour unit at Copenhagen University Hospital, Hvidovre, undertook a quality improvement (QI) project to prevent asphyxia and reduced the percentage of newborns with asphyxia by 48%.Methods
The change theory consisted of two primary elements: (1) the clinical content, including three clinical bundles of evidence-based care, a ‘delivery bundle’, an ‘oxytocin bundle’ and a ‘vacuum extraction bundle’; (2) an implementation theory, including improving skills in interpretation of cardiotocography, use of QI methods and participation in a national learning network. The Model for Improvement and Deming’s system of profound knowledge were used as a methodological framework. Data on compliance with the care bundles and the number of deliveries between newborns with asphyxia (Apgar <7 after 5 min or pH <7) were analysed using statistical process control.Results
Compliance with all three clinical care bundles improved to 95% or more, and the percentages of newborns with pH <7 and Apgar <7 after 5 min were reduced by 48% and 31%, respectively. In general, the QI approach strengthened multidisciplinary teamwork, systematised workflow and structured communication around the deliveries. Changes included making a standard memo in the medical record, the use of a bedside whiteboard, bedside handovers, shared decisions with a peer when using an oxytocin infusion and the use of a checklist before vacuum extractions.Conclusion
This QI project illustrates how aspects of patient safety, such as the prevention of asphyxia, can be improved using QI methods to more reliably implement best practice, even in high-performing systems.
The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England.Methods
The study included 8124 general practices between 2011–2012 and 2013–2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0–100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification.Results
Mean practice-level rates of A&E visits and emergency admissions increased from 2011–2012 to 2013–2014 (310.3–324.4 and 98.8–102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011–2012 and 76.6 in 2013–2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI –2.4% to –1.2%) in A&E visit rates and 1.4% (95% CI –1.9% to –0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses.Conclusions
Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions.
Interruptions and multitasking have been demonstrated in experimental studies to reduce individuals’ task performance. These behaviours are frequently used by clinicians in high-workload, dynamic clinical environments, yet their effects have rarely been studied.Objective
To assess the relative contributions of interruptions and multitasking by emergency physicians to prescribing errors.Methods
36 emergency physicians were shadowed over 120 hours. All tasks, interruptions and instances of multitasking were recorded. Physicians’ working memory capacity (WMC) and preference for multitasking were assessed using the Operation Span Task (OSPAN) and Inventory of Polychronic Values. Following observation, physicians were asked about their sleep in the previous 24 hours. Prescribing errors were used as a measure of task performance. We performed multivariate analysis of prescribing error rates to determine associations with interruptions and multitasking, also considering physician seniority, age, psychometric measures, workload and sleep.Results
Physicians experienced 7.9 interruptions/hour. 28 clinicians were observed prescribing 239 medication orders which contained 208 prescribing errors. While prescribing, clinicians were interrupted 9.4 times/hour. Error rates increased significantly if physicians were interrupted (rate ratio (RR) 2.82; 95% CI 1.23 to 6.49) or multitasked (RR 1.86; 95% CI 1.35 to 2.56) while prescribing. Having below-average sleep showed a >15-fold increase in clinical error rate (RR 16.44; 95% CI 4.84 to 55.81). WMC was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.Conclusion
Interruptions, multitasking and poor sleep were associated with significantly increased rates of prescribing errors among emergency physicians. WMC mitigated the negative influence of these factors to an extent. These results confirm experimental findings in other fields and raise questions about the acceptability of the high rates of multitasking and interruption in clinical environments.
The cluster randomised trial (CRT) is commonly used in healthcare research. It is the gold-standard study design for evaluating healthcare policy interventions. A key characteristic of this design is that as more participants are included, in a fixed number of clusters, the increase in achievable power will level off. CRTs with cluster sizes that exceed the point of levelling-off will have excessive numbers of participants, even if they do not achieve nominal levels of power. Excessively large cluster sizes may have ethical implications due to exposing trial participants unnecessarily to the burdens of both participating in the trial and the potential risks of harm associated with the intervention. We explore these issues through the use of two case studies. Where data are routinely collected, available at minimum cost and the intervention poses low risk, the ethical implications of excessively large cluster sizes are likely to be low (case study 1). However, to maximise the social benefit of the study, identification of excessive cluster sizes can allow for prespecified and fully powered secondary analyses. In the second case study, while there is no burden through trial participation (because the outcome data are routinely collected and non-identifiable), the intervention might be considered to pose some indirect risk to patients and risks to the healthcare workers. In this case study it is therefore important that the inclusion of excessively large cluster sizes is justifiable on other grounds (perhaps to show sustainability). In any randomised controlled trial, including evaluations of health policy interventions, it is important to minimise the burdens and risks to participants. Funders, researchers and research ethics committees should be aware of the ethical issues of excessively large cluster sizes in cluster trials.