WHO regards access to primary care as a priority for all health systems, because of the benefits for population health and because of the changing nature of populations (more older people with chronic conditions) and the growing expectations of the public.1 In most developed countries, progress has been made in enabling people to use primary care services during routine office hours, and policymakers have begun to ask "how much access is enough"?
The two main drivers for extending access to general practices beyond traditional office hours are the possibility that longer opening hours would lead to reduced pressure on hospital services and the need for policy to respond to the pressure from patients for appointments with their primary care providers.
Difficulty in getting appointments in general practice is associated with higher use of hospital emergency departments,2 and evidence from a US study of extended hours...
Many healthcare systems recommend root-cause analysis (RCA) as a key method for investigating critical incidents and developing recommendations for preventing future events. In practice, however, RCAs vary widely in terms of their conduct and the utility of the recommendations they produce.1 2 RCAs often fail to explore deep system problems that contributed to safety events3 due to the limited methods used, constrained time and meagre financial/human resources to conduct RCAs.4 Furthermore, healthcare organisations often lack the mandate and authority required to develop and implement sophisticated and effective corrective actions.4 Consequently, corrective actions primarily aim at changing human behaviour rather than system-based changes.5 6
In this issue of BMJ Quality and Safety, Kellogg et al7 confirm these concerns about RCAs. Reviewing 302 RCAs conducted over an 8-year period at a US academic medical centre,...
The average person remembers less than half of the information provided by healthcare professionals during a medical visit.1 The situation is arguably most challenging for patients leaving the hospital, where acute illness, sleep deprivation and delirium add to the challenge of learning and memory.2 3 Indeed, research has shown that after hospital discharge, only 59.6% of patients are able to accurately describe their discharge diagnoses, and 43.9% can accurately recall follow-up appointments.4 Approximately one-third of patients have difficulty understanding their discharge medication regimen.5
It is not the patients' fault. Hospital resources and processes of care are oriented toward acute treatment. They are not as well designed to provide high-quality patient education in the hospital and across the transition home. Few hospitals have fully developed their capacity as ‘health-literate healthcare organisations’, which involves providing patients with information that is easy...
Despite significant advances in medication safety, errors related to confusion between drug names are a cause of preventable adverse events and serious harm,1 and remain a patient safety priority.2 3 Although drug name confusion is recognised as a factor contributing to error, its minimisation or elimination is a prevailing challenge.4 5 In this issue, Schroeder et al6 postulate that despite industry's efforts to follow regulators' guidance7 on how to review drug names, more objective evidence, in a standardised format, is needed to improve decision-making about the acceptability of a name. To address this concern, the authors assessed the association between error rates in laboratory-based tests of drug name memory and perception and rates of real-world errors related to drug name confusion.
We commend the authors for their contribution to this important area of study. Results...
The UK government plans to extend the opening hours of general practices in England. The ‘extended hours access scheme’ pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week.Objective
To determine the association between extended hours access scheme participation and patient experience.Methods
Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013–2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis.Results
Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63).Conclusions
Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.
Clinical summaries are electronic health record (EHR)-generated documents given to hospitalised patients during the discharge process to review their hospital stays and inform postdischarge care. Presently, it is unclear whether clinical summaries include relevant content or whether healthcare organisations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge. We assessed clinical summaries in three relevant domains: (1) content; (2) organisation; and (3) readability, understandability and actionability.Methods
Two authors performed independent retrospective chart reviews of 100 clinical summaries generated at two Michigan hospitals using different EHR vendors for patients discharged 1 April –30 June 2014. We developed an audit tool based on the Meaningful Use view-download-transmit objective and the Society of Hospital Medicine Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organisation); and five readability formulas and the Patient Education Materials Assessment Tool (readability, understandability and actionability).Results
Clinical summaries averaged six pages (range 3–12). Several content elements were universally auto-populated into clinical summaries (eg, medication lists); others were not (eg, care team). Eighty-five per cent of clinical summaries contained discharge instructions, more often generated from third-party sources than manually entered by clinicians. Clinical summaries contained an average of 14 unique messages, including non-clinical elements irrelevant to postdischarge care. Medication list organisation reflected reconciliation mandates, and dosing charts, when present, did not carry column headings over to subsequent pages. Summaries were written at the 8th–12th grade reading level and scored poorly on assessments of understandability and actionability. Inter-rater reliability was strong for most elements in our audit tool.Conclusions
Our study highlights opportunities to improve clinical summaries for guiding patients' postdischarge care.
Despite over a decade of efforts to reduce the adverse event rate in healthcare, the rate has remained relatively unchanged. Root cause analysis (RCA) is a process used by hospitals in an attempt to reduce adverse event rates; however, the outputs of this process have not been well studied in healthcare. This study aimed to examine the types of solutions proposed in RCAs over an 8-year period at a major academic medical institution.Methods
All state-reportable adverse events were gathered, and those for which an RCA was performed were analysed. A consensus rating process was used to determine a severity rating for each case. A qualitative approach was used to categorise the types of solutions proposed by the RCA team in each case and descriptive statistics were calculated.Results
302 RCAs were reviewed. The most common event types involved a procedure complication, followed by cardiopulmonary arrest, neurological deficit and retained foreign body. In 106 RCAs, solutions were proposed. A large proportion (38.7%) of RCAs with solutions proposed involved a patient death. Of the 731 proposed solutions, the most common solution types were training (20%), process change (19.6%) and policy reinforcement (15.2%). We found that multiple event types were repeated in the study period, despite repeated RCAs.Conclusions
This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams.