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Our mission and how we hope to move the field forward: statement from the BMJ Quality & Safety senior editorial team 2023

Quality and Safety in Health Care Journal -

The challenge

Despite progress in many areas, the world continues to face significant and growing challenges to the delivery of high-quality healthcare. Consistently high levels of avoidable harm are reported internationally.1 Inequities in quality persist and solutions are in short supply.2 Implementing initiatives to increase the uptake of effective care and de-implement ineffective technologies has also proven difficult.3 4 Patient-centred care is on the ‘to do’ list for healthcare systems but in too many instances it is deprioritised by decisions that seem arbitrary and not connected to any clear ethical framework.5 Delayed care is another widespread problem and we have long known that crude top-down solutions such as targets are unlikely to work.6

These challenges are formidable and exist against a backdrop of demographic pressures, staffing crises and financial constraints. In the context of these challenges,...

Changing the patient safety mindset: can safety cases help?

Quality and Safety in Health Care Journal -

Safety cases in industry

In the UK and several other countries, including Norway, Australia and New Zealand, operators of safety-critical systems, such as nuclear power plants, public transportation systems and defence equipment, must develop a safety case to demonstrate that their systems are acceptably safe to operate.1 In these countries, the development, review and maintenance of safety cases are regulatory requirements. In the UK, this regulatory practice extends as of October 2023 to high-rise residential buildings following the Grenfell Tower fire in 2017, during which 72 people died.

So, why are these countries promoting the safety case approach across their safety-critical industries? The most tangible reason is the shift from a prescriptive regulatory regime towards a goal-based approach.2 In this approach, regulators establish overall safety goals, offering developers and system operators flexibility to determine the most suitable methods for ensuring compliance. A safety argument...

Using patient and carer perspectives to improve medication safety at transitions of care

Quality and Safety in Health Care Journal -

It is widely known—among healthcare professionals as well as patient safety researchers—that transfers of care are a high-risk area in relation to patient safety.1 And even more importantly, the experience of patients and their families suggests likewise. For example, in a research priority setting exercise focusing on safe care for adults with complex health needs, 6 of the top 10 priorities related to transfers of care, either within or between organisations.2 While care transitions affect all elements of a person’s care, medication safety is a particular cause for concern, with a Cochrane review finding that 56% of patients are at risk of having at least one medication discrepancy as part of standard care.3 Accepted wisdom among many people working in the quality and safety field is that measurement is essential both to understand the risks and to target and evaluate interventions to address...

Identifying patients with additional needs isnt enough to improve care: harnessing the benefits and avoiding the pitfalls of classification

Quality and Safety in Health Care Journal -

Classification—the process of sorting people or things into groups according to shared qualities or characteristics—is increasingly used within healthcare as a means of identifying patients with particular needs and/or risks. This is important because receiving care in hospital can expose some particularly vulnerable groups of patients to increased risk of harm and poor outcomes, for example, the systemic safety inequities experienced by people with learning disabilities.1

Identifying and responding to patients with additional needs

In order to deliver care that meets individual patients’ needs, health services must, first, be able to identify those with additional needs and, second, be able to mobilise an appropriate response to these. Various ways of identifying patients with additional needs and/or risks have been developed. One obvious example is the use of wristbands for those with drug allergies, although the potential for confusion between different schemes at different hospitals has been...

What can Safety Cases offer for patient safety? A multisite case study

Quality and Safety in Health Care Journal -

Background

The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. We examined the first documented attempt to apply the Safety Case methodology to clinical pathways.

Methods

Data are drawn from a mixed-methods evaluation of the Safer Clinical Systems programme. The development of a Safety Case for a defined clinical pathway was a centrepiece of the programme. We base our analysis on 143 interviews covering all aspects of the programme and on analysis of 13 Safety Cases produced by clinical teams.

Results

The principles behind a proactive, systematic approach to identifying and controlling risk that could be curated in a single document were broadly welcomed by participants, but was not straightforward to deliver. Compiling Safety Cases helped teams to identify safety hazards in clinical pathways, some of which had been previously occluded. However, the work of compiling Safety Cases was demanding of scarce skill and resource. Not all problems identified through proactive methods were tractable to the efforts of front-line staff. Some persistent hazards, originating from institutional and organisational vulnerabilities, appeared also to be out of the scope of control of even the board level of organisations. A particular dilemma for organisational senior leadership was whether to prioritise fixing the risks proactively identified in Safety Cases over other pressing issues, including those that had already resulted in harm.

Conclusions

The Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.

Talking about falls: a qualitative exploration of spoken communication of patients fall risks in hospitals and implications for multifactorial approaches to fall prevention

Quality and Safety in Health Care Journal -

Background

Inpatient falls are the most common safety incident reported by hospitals worldwide. Traditionally, responses have been guided by categorising patients’ levels of fall risk, but multifactorial approaches are now recommended. These target individual, modifiable fall risk factors, requiring clear communication between multidisciplinary team members. Spoken communication is an important channel, but little is known about its form in this context. We aim to address this by exploring spoken communication between hospital staff about fall prevention and how this supports multifactorial fall prevention practice.

Methods

Data were collected through semistructured qualitative interviews with 50 staff and ethnographic observations of fall prevention practices (251.25 hours) on orthopaedic and older person wards in four English hospitals. Findings were analysed using a framework approach.

Findings

We observed staff engaging in ‘multifactorial talk’ to address patients’ modifiable risk factors, especially during multidisciplinary meetings which were patient focused rather than risk type focused. Such communication coexisted with ‘categorisation talk’, which focused on patients’ levels of fall risk and allocating nursing supervision to ‘high risk’ patients. Staff negotiated tensions between these different approaches through frequent ‘hybrid talk’, where, as well as categorising risks, they also discussed how to modify them.

Conclusion

To support hospitals in implementing multifactorial, multidisciplinary fall prevention, we recommend: (1) focusing on patients’ individual risk factors and actions to address them (a ‘why?’ rather than a ‘who’ approach); (2) where not possible to avoid ‘high risk’ categorisations, employing ‘hybrid’ communication which emphasises actions to modify individual risk factors, as well as risk level; (3) challenging assumptions about generic interventions to identify what individual patients need; and (4) timing meetings to enable staff from different disciplines to participate.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

Quality and Safety in Health Care Journal -

Background

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

Objectives

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

Methods

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) ‘Key Components of an Ideal Transfer of Care’, (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

Results

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

Conclusion

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

Systematic review of clinical debriefing tools: attributes and evidence for use

Quality and Safety in Health Care Journal -

Background and objectives

Clinical debriefing (CD) following a clinical event has been found to confer benefits for staff and has potential to improve patient outcomes. Use of a structured tool to facilitate CD may provide a more standardised approach and help overcome barriers to CD; however, we presently know little about the tools available. This systematic review aimed to identify tools for CD in order to explore their attributes and evidence for use.

Methods

A systematic review was conducted in line with PRISMA standards. Five databases were searched. Data were extracted using an electronic form and analysed using critical qualitative synthesis. This was guided by two frameworks: the ‘5 Es’ (defining attributes of CD: educated/experienced facilitator, environment, education, evaluation and emotions) and the modified Kirkpatrick’s levels. Tool utility was determined by a scoring system based on these frameworks.

Results

Twenty-one studies were included in the systematic review. All the tools were designed for use in an acute care setting. Criteria for debriefing were related to major or adverse clinical events or on staff request. Most tools contained guidance on facilitator role, physical environment and made suggestions relating to psychological safety. All tools addressed points for education and evaluation, although few described a process for implementing change. Staff emotions were variably addressed. Many tools reported evidence for use; however, this was generally low-level, with only one tool demonstrating improved patient outcomes.

Conclusion

Recommendations for practice based on the findings are made. Future research should aim to further examine outcomes evidence of these tools in order to optimise the potential of CD tools for individuals, teams, healthcare systems and patients.

Choosing Wisely and the climate crisis: a role for clinicians

Quality and Safety in Health Care Journal -

There are growing calls for healthcare to confront it’s role in the climate crisis. Estimates suggest that carbon emissions from healthcare constitute 5% of net global emissions. To put this into context, emissions from all air travel are estimated at 3.5% of net global emissions.1 Health systems, organisations and clinicians have been called on to lead efforts to reduce emissions given that the climate crisis presents a major threat to human health.

Ensuring appropriateness of care, and reducing overuse are central planks of strategies suggested in the literature and are increasingly being enacted by large healthcare systems and provider organisations to reduce healthcare’s climate impact.2 However, individual clinicians are often left with little guidance or support in terms of how to do this in practice. To illustrate, the Agency for Health Care Research and Quality (AHRQ) within the United States Department of Health and Human...

Is targeting healthcares carbon footprint really the best we can do to help address the climate crisis?

Quality and Safety in Health Care Journal -

I write this commentary as wildfires rage around the world, including in Greece, Italy, Siberia, Algeria and the USA. In my own country, Canada, fires have already consumed over 130 000 km21—the size of Greece—and the wildfire season has not yet ended. Recent months have also seen hundreds of millions of people suffering scorching heatwaves across Europe, China and North America. Residents of Phoenix, Arizona, endured temperatures over 43°C for 31 consecutive days this summer. In Italy, harsh heat in the south occurred at the same time as storms delivered hail the size of tennis balls in the country’s north. This almost ‘end of days’ juxtaposition of extreme weather events within a single country comes as new research indicates that the Gulf Stream may collapse as soon as 2025.1 Loss of these vital ocean currents would constitute a climate tipping point, making extreme storms more frequent...

Today The World Issues Voluntary Nationwide Recall of All Lots of Sustain and Schwinnng brand Dietary Supplement Capsules Due to the Presence of Undeclared Tadalafil and Nortadalafil

FDA MedWatch -

“Today The World” is voluntarily recalling two lots of Sustain herbal dietary supplement capsules and one lot of Schwinnng capsules to the consumer level. FDA analysis has found the products to contain undeclared Tadalafil and Nortadalafil (structurally similar to Tadalafil). Tadalafil and Nortadala

Today The World Issues Voluntary Nationwide Recall of All Lots of Arize Herbal Dietary Supplement Capsules Due to the Presence of Undeclared Nortadalafil

FDA MedWatch -

“Today The World” is voluntarily recalling one lot of Arize Herbal Dietary Supplement capsules to the consumer level.
FDA analysis has found the products to contain undeclared Nortadalafil (structurally similar to Tadalafil). Nortadalafil is an active drug ingredient known for treatment of male ere

Insight Pharmaceuticals Issues Voluntary Nationwide Recall of TING® 1% Tolnaftate Athlete’s Foot Spray Antifungal Spray Liquid Due to the Presence of Benzene

FDA MedWatch -

Insight Pharmaceuticals, a Prestige Consumer Healthcare Inc. company (“Insight”), is voluntarily recalling two lots of TING® 1% Tolnaftate Athlete’s Foot Spray Antifungal Spray Liquid to the consumer level. A recent review by our manufacturer and their third-party lab found that samples from two lot

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