The Editor would like to publicly acknowledge the people listed below who served as reviewers on the journal during 2016. Without their efforts, the quality of the journal could not be sustained.
In this issue, Redley and Raggatt1 report on the use of risk assessment tools in the care of older people in Victoria, Australia. Concern with healthcare quality and safety has precipitated widespread use of a range of such seemingly simple interventions. Checklists, pathways, algorithms are a tempting way for organisations and healthcare professionals to signal to the outside world that they are making a good faith effort to ensure service quality. Yet the popularity of these everyday tools has not been matched by their systematic and critical analysis, leading to concern about the potential impact of a growing epidemic of ‘polyformacy’ on healthcare systems. Redley and Raggatt draw into view specific insights about risk management in older people, but their research highlights issues of wider relevance about the use of everyday technologies for healthcare quality and safety that merit further reflection.
A key finding from the study...
Healthcare leaders and scholars have articulated gaps in handoff quality across nearly all healthcare settings. A variety of drivers, including hospital accreditation, internal and external safety event analyses and medical education objectives, have given rise to a proliferation of imperatives to improve this situation. Healthcare leaders have developed a greater appreciation that handoff is a key component of a larger set of culture and teamwork strategies that are necessary to reduce harm. Researchers and medical educators have created handoff programmes, provided empirical evidence for their positive impact on safety and worked tirelessly to disseminate them.1 2 Quality improvers from a variety of disciplines have begun to adapt and apply standardised handoff in an increasingly diverse array of settings.
In light of this, one might think it less than noteworthy to discover a report of a single institution's hospital-wide handoff standardisation programme.3 To the...
The nature of today’s healthcare practice makes interruptions, distractions and multitasking commonplace, even during complex and high-risk tasks.1–3 Interruptions are often cited as a problem in medication safety, particularly in relation to nurses administering medication.1 4 Previous studies5 6 suggest an association between interruptions and medication administration errors. While a direct causal relationship remains to be proven, reducing interruptions during medication administration to decrease multitasking and cognitive load represents a generally accepted goal.1 4
In this issue of BMJ Quality and Safety, Westbrook7 and colleagues report a cluster randomised controlled trial of a bundled intervention to reduce interruptions during medication administration in a hospital using paper-based prescribing. This well-designed feasibility study tested a bundled intervention based on ‘Do Not Disturb’ vests and the education of healthcare professionals, patients and...
Standard risk screening and assessment forms are frequently used in strategies to prevent harm to older people in hospitals. Little is known about good practices for their use.Objective
Scope the preventable harms addressed by standard forms used to screen and assess older people and how standard forms are operationalised in hospitals across Victoria, Australia.Methods
Mixed methods study: (1) cross-sectional audit of the standard risk screening and assessment forms used to assess older people at 11 health services in 2015; (2) nine focus groups with a purposive sample of 69 participants at 9 health services. Descriptive analysis examined the number of items on forms, preventable harms assessed and sources of duplication. Qualitative thematic analysis of focus group data identified themes explaining issues commonly affecting how health services used the forms.Results
152 standard assessment forms from 11 Victorian health services included over 3700 items with 17% duplicated across multiple forms. Assessments of skin integrity and mobility loss (including falls) were consistently included in forms; however, nutrition, cognitive state, pain and medication risks were inconsistent; and continence, venous thromboembolism risk and hospital acquired infection from invasive devices were infrequent. Qualitative analyses revealed five themes explaining issues associated with current use of assessment forms: (1) comprehensive assessment of preventable harms; (2) burden on staff and the older person, (3) interprofessional collaboration, (4) flexibility to individualise care and (5) information management. Examples of good practice were identified.Conclusions
Current use of standard risk screening and assessment forms is associated with a high burden and gaps in assessment of several common preventable harms that can increase risk to older people in hospital. Improvement should focus on streamlining forms, increased guidance on interventions to prevent harm and facilitating front-line staff to manage complex decisions.
There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. To date, this has been challenging in the emergency department (ED) setting. To better understand the root of this challenge, we looked to ED physicians' perspectives on their role, relationships and responsibilities to inform future development and implementation of patient-reported outcome measures (PROMs).Methods
ED physicians from hospitals across Canada were invited to participate in interviews using a snowballing sampling technique. Semistructured interviews were conducted by phone with questions focused on the role and practice of ED physicians, their relationship with their patients and their thoughts on patient-reported feedback as a mechanism for quality improvement. Transcripts were analysed using a modified constant comparative method and interpretive descriptive framework.Results
Interviews were completed with 30 individual physicians. Respondents were diverse in location, training and years in practice. Physicians reported being interested in ‘objective’ postdischarge information including adverse events, readmissions, other physicians’ notes, etc in a select group of complex patients, but saw ‘patient-reported’ feedback as less valuable due to perceived biases. They were unsure about the impact of such feedback mainly because of the episodic nature of their work. Concerns about timing, as well as about their legal and ethical responsibilities to follow-up if poor patient outcomes are reported, were raised.Conclusions
Data collection and feedback are key elements of a learning health system. While patient-reported outcomes may have a role in feedback, ED physicians are conflicted about the actionability of such data and ethical implications, given the inherently episodic nature of their work. These findings have important implications for PROM design and implementation in this unique clinical setting.
Hospital electronic prescribing (ePrescribing) systems offer a wide range of patient safety benefits. Like other hospital health information technology interventions, however, they may also introduce new areas of risk. Despite recent advances in identifying these risks, the development and use of ePrescribing systems is still leading to numerous unintended consequences, which may undermine improvement and threaten patient safety. These negative consequences need to be analysed in the design, implementation and use of these systems. We therefore aimed to understand the roots of these reported threats and identify candidate avoidance/mitigation strategies.Methods
We analysed a longitudinal, qualitative study of the implementation and adoption of ePrescribing systems in six English hospitals, each being conceptualised as a case study. Data included semistructured interviews, observations of implementation meetings and system use, and a collection of relevant documents. We analysed data first within and then across the case studies.Results
Our dataset included 214 interviews, 24 observations and 18 documents. We developed a taxonomy of factors underlying unintended safety threats in: (1) suboptimal system design, including lack of support for complex medication administration regimens, lack of effective integration between different systems, and lack of effective automated decision support tools; (2) inappropriate use of systems—in particular, too much reliance on the system and introduction of workarounds; and (3) suboptimal implementation strategies resulting from partial roll-outs/dual systems and lack of appropriate training. We have identified a number of system and organisational strategies that could potentially avoid or reduce these risks.Conclusions
Imperfections in the design, implementation and use of ePrescribing systems can give rise to unintended consequences, including safety threats. Hospitals and suppliers need to implement short- and long-term strategies in terms of the technology and organisation to minimise the unintended safety risks.
To evaluate the effectiveness of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration.Methods
A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were randomised to the intervention which comprised wearing a vest when administering medications; strategies for diverting interruptions; clinician and patient education; and reminders. Control wards were blinded to the intervention. Structured direct observations of medication administration processes were conducted. The primary outcome was non-medication-related interruptions during individual medication dose administrations. The secondary outcomes were total interruption and multitasking rates. A survey of nurses' experiences was administered.Results
Over 8 weeks and 364.7 hours, 227 nurses were observed administering 4781 medications. At baseline, nurses experienced 57 interruptions/100 administrations, 87.9% were unrelated to the medication task being observed. Intervention wards experienced a significant reduction in non-medication-related interruptions from 50/100 administrations (95% CI 45 to 55) to 34/100 (95% CI 30 to 38). Controlling for clustering, ward type and medication route showed a significant reduction of 15 non-medication-related interruptions/100 administrations compared with control wards. A total of 88 nurses (38.8%) completed the poststudy survey. Intervention ward nurses reported that vests were time consuming, cumbersome and hot. Only 48% indicated that they would support the intervention becoming hospital policy.Discussion
Nurses experienced a high rate of interruptions. Few were related to the medication task, demonstrating considerable scope to reduce unnecessary interruptions. While the intervention was associated with a statistically significant decline in non-medication-related interruptions, the magnitude of this reduction and its likely impact on error rates should be considered, relative to the effectiveness of alternate interventions, associated costs, likely acceptability and long-term sustainability of such interventions.
Understanding a patient's hospital experience is fundamental to improving health services and policy, yet, little is known about their experiences of adverse events (AEs). This study redresses this deficit by investigating the experiences of patients in New South Wales hospitals who suffered an AE.Methods
Data linkage was used to identify a random sample of 20 000 participants in the 45 and Up Cohort Study, out of 267 153 adults aged 45 years and over, who had been hospitalised in the prior 6 months. A cross-sectional survey was administered to these patients to capture their experiences, including whether they had an AE and received honest communication about it.Results
Of the 18 993 eligible participants, 7661 completed surveys were received (40% response rate) and 474 (7%) reported having an AE. Most AEs related to clinical processes and procedures (33%), or medications and intravenous fluids (21%). Country of birth and admission through emergency were significant predictors of the occurrence of an event. An earlier admission in the prior 6 months or a transfer to another healthcare facility was also associated with more AEs. Of those who suffered an AE, 58% reported serious or moderate effects.Conclusions
Given the exclusions in our sample population (under 45 years), the AE rate reported by patients of 7% is similar to the approximately 10% rate reported in the general population by retrospective medical record reviews. AE data that include patient experience may provide contextual information currently missing. Capturing and using patient experience data more effectively is critical; there may be opportunities for applying co-design methodology to improve the management of AEs and be more responsive to patients' concerns.
Understanding the cultural characteristics of healthcare organisations is widely recognised to be an important component of patient safety. A growing number of vulnerable older people are living in care homes but little attention has been paid to safety culture in this sector. In this study, we aimed to adapt the Manchester Patient Safety Framework (MaPSaF), a commonly used tool in the health sector, for use in care homes and then to test its face validity and preliminary feasibility as a tool for developing a better understanding of safety culture in the sector.Methods
As part of a wider improvement programme to reduce the prevalence of common safety incidents among residents in 90 care homes in England, we adapted MaPSaF and carried out a multimethod participatory evaluation of its face validity and feasibility for care home staff. Data were collected using participant observation, interviews, documentary analysis and a survey, and were analysed thematically.Results
MaPSaF required considerable adaptation in terms of its length, language and content in order for it to be perceived to be acceptable and useful to care home staff. The changes made reflected differences between the health and care home sectors in terms of the local context and wider policy environment, and the expectations, capacity and capabilities of the staff. Based on this preliminary study, the adapted tool, renamed ‘Culture is Key’, appears to have reasonable face validity and, with adequate facilitation, it is usable by front-line staff and useful in raising their awareness about safety issues.Conclusions
‘Culture is Key’ is a new tool which appears to have acceptable face validity and feasibility to be used by care home staff to deepen their understanding of the safety culture of their organisations and therefore has potential to contribute to improving care for vulnerable older people.
Healthcare has become increasingly complex and care delivery models have changed dramatically (eg, team-based care, duty-hour restrictions). However, approaches to critical communications among providers have not evolved to meet these new challenges. Evidence from safety culture surveys, academic studies and malpractice claims suggests that healthcare handover quality is problematic, leading to preventable errors and adverse outcomes. To address this concern, from 2013 to 2016 Massachusetts General Hospital completed phase I of a multifaceted programme to implement standardised, structured handovers across all departments, units and direct care providers.Methods
A multidisciplinary Handovers Committee selected the I-PASS handover system. Phase I implementation focused on large-scale training and shift-to-shift handovers. Important features included administrative and clinical leadership support; EHR templates for I-PASS; hospital handover policy revision; varied educational modalities, venues and durations; concomitant TeamSTEPPS training; unit-level I-PASS champions; handover observations; and solicitation of caregiver feedback and suggestions.Results
More than 6000 doctors, nurses and therapists have been trained. Trended observation scores demonstrate progressive but non-uniform adoption of I-PASS, with significant improvements in the correct sequencing and percentage of I-PASS elements included in handovers. Adoption of Synthesis (readback) has been challenging, with lower scores.Conclusions
Comprehensive I-PASS implementation in a large academic medical centre necessitated major cultural change. I-PASS education is straightforward, whereas assuring consistent and sustained adoption across all services is more challenging, requiring adaptation of the basic I-PASS structure to local needs and workflows. EHR I-PASS templates facilitated caregiver acceptance. Initial phase I results are encouraging and the lessons learned should be helpful to other programmes planning handover initiatives. Phase II is ongoing, focusing on more uniform and consistent adoption, spread and sustainability.
As medical students transition to become trainee doctors, they must confront the potential for making medical errors. In the high stakes environment of medicine, errors can be catastrophic for the patients and for doctors themselves. Doctors have been found to experience guilt, shame, fear, humiliation, loss of confidence, deep concerns about their professional skills and social isolation, effectively becoming the second victim of an error.1 2
A number of programmes and practices have been suggested to provide psychological first aid to second victims after an error has occurred.3 Little attention, however, has focused on how medical training can prepare doctors for the inevitability of error, and thus help protect them from potentially severe emotional consequences in the future. The WHO has developed the Patient Safety Curriculum Guide for Medical Schools, which includes training on understanding and learning from mistakes.4...
Choosing Wisely (CW) identifies low-value, wasteful medical interventions whose elimination increases the quality of care and likely reduces its costs.1 Since its launch in 2012, this grassroot campaign has galvanised many in the medical world. Physicians acknowledge their collective responsibility in reducing overuse, and patient engagement in the campaign suggests times are changing in the medical office.
CW was set up in response to the publication of a charter coauthored by the American Board of Internal Medicine, ‘Medical Professionalism in the New Millennium’ (2002).2 This physician charter mentioned the principle of ‘primacy of patient welfare’ along with the commitment to ‘a just distribution of finite resources’. Thus, CW would kill two birds with one stone: reduce waste and receive quality and financial sustainability in exchange. However, the CW campaign quickly reached consensus on dropping the cost objective and focusing instead on ‘quality and no-harm’. CW...