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Rigorous evaluations of evolving interventions: can we have our cake and eat it too?

Quality and Safety in Health Care Journal -

The years immediately following the widespread interest in patient safety1 and then healthcare quality2 saw considerable debate between pragmatically oriented improvers and research-oriented evaluators3–6 —or between ‘evangelists’ and ‘snails’ as one longtime observer characterised the two groups.7 Too often, enthusiastic improvers (‘evangelists’) relied on simple pre-post designs within a single context leading to erroneous claims of efficacy.8 In contrast, research-oriented investigators (‘snails’) and journals pushed for ever more rigorous designs including randomised trials, potentially at the cost of discouraging many improvers without this training and leading to slower development and deployment of effective interventions.9 10 Many clinicians, quality improvement (QI) experts and researchers are thus caught in a quandary: how best to evaluate a candidate QI intervention? How can we best balance the pragmatic needs of improvement—including the frequent need...

Using ethnography to study improving healthcare: reflections on the 'ethnographic label

Quality and Safety in Health Care Journal -

While methods broadly described as ‘ethnographic’ have been increasingly employed to research the organisation and delivery of healthcare,1–4 a single or widely accepted definition of ethnography has proved elusive and perhaps unnecessary.1 5 Nonetheless, even as authors publishing in this journal have adapted ethnographic approaches for the purpose of studying improving quality and safety in healthcare, they have often attempted to retain some of its anthropological ‘essence’.6 For instance, Dixon-Woods7 characterises ethnography in terms of its focus on observational methods, questioning of the taken for granted, description and analysis of routine behaviours in their natural settings, and use of the researcher’s own skill and judgement to both gather data and to interpret them drawing on social theory.

In a recent debate over use of the ethnographic label in this journal, Jowsey8 argued...

Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout

Quality and Safety in Health Care Journal -

Background

There is a poorly understood relationship between Leadership WalkRounds (WR) and domains such as safety culture, employee engagement, burnout and work-life balance.

Methods

This cross-sectional survey study evaluated associations between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture, employee engagement, burnout and work-life balance, across 829 work settings.

Results

16 797 of 23 853 administered surveys were returned (70.4%). 5497 (32.7% of total) reported that they had participated in WR, and 4074 (24.3%) reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores (first vs fourth quartile Cohen’s d range: 0.34–0.84; % increase range: 15–27) and significantly higher engagement scores for four of its six domains (first vs fourth quartile Cohen’s d range: 0.02–0.76; % increase range: 0.48–0.70).

Conclusion

This WR study of patient safety and organisational outcomes tested relationships with a comprehensive set of safety culture and engagement metrics in the largest sample of hospitals and respondents to date. Beyond measuring simply whether WRs occur, we examine WR with feedback, as WR being done well. We suggest that when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout. Whether WR with feedback is a manifestation of better norms, or a cause of these norms, is unknown, but the link is demonstrably potent.

Improving PICC use and outcomes in hospitalised patients: an interrupted time series study using MAGIC criteria

Quality and Safety in Health Care Journal -

Background

Although important in clinical care, reports of inappropriate peripherally inserted central catheter (PICC) use are growing.

Objective

To test whether implementation of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) can improve PICC use and patient outcomes.

Design

Quasi-experimental, interrupted time series design at one study site with nine contemporaneous external controls.

Setting

Ten hospitals participating in a state-wide quality collaborative from 1 August 2014 to 31 July 2016.

Patients

963 hospitalised patients who received a PICC at the study site vs 6613 patients at nine control sites.

Intervention

A multimodal intervention (tool, training, electronic changes, education) derived from MAGIC.

Measurements

Appropriateness of PICC use and rates of PICC-associated complications. Segmented Poisson regression was used for analyses.

Results

Absolute rates of inappropriate PICC use decreased substantially at the study site versus controls (91.3% to 65.3% (–26.0%) vs 72.2% to 69.6% (–2.6%); P<0.001). After adjusting for underlying trends and patient characteristics, however, a marginally significant 13.8% decrease in inappropriate PICC use occurred at the study site (incidence rate ratio 0.86 (95% CI 0.74 to 0.99; P=0.048)); no change was observed at control sites. While the incidence of all PICC complications decreased to a greater extent at the study site, the absolute difference between controls and intervention was small (33.9% to 26.7% (–7.2%) vs 22.4% to 20.8% (–1.6%); P=0.036).

Limitations

Non-randomised design limits inference; the most effective component of the multimodal intervention is unknown; effects following implementation were modest.

Conclusions

In a multihospital quality improvement project, implementation of MAGIC improved PICC appropriateness and reduced complications to a modest extent. Given the size and resources required for this study, future work should consider cost-to-benefit ratio of similar approaches.

Interprofessional collaboration among care professionals in obstetrical care: are perceptions aligned?

Quality and Safety in Health Care Journal -

Background

In an obstetrical team, obstetricians, midwives and nurses work together in a dynamic and complex care setting. Different professional cultures can be a barrier for effective interprofessional collaboration. Although the different professional cultures in obstetrical care are well known, little is understood about discrepancies in mutual perceptions of collaboration. Similar perceptions of collaboration are important to ensure patient safety. We aimed to understand how different care professionals in an obstetrical team assess interprofessional collaboration in order to gain insight into the extent to which their perceptions are aligned.

Methods

This cross-sectional study was performed in the north-western region of the Netherlands. Care professionals from five hospitals and surrounding primary-care midwifery practices were surveyed. The respondents consisted of four groups of care professionals: obstetricians (n=74), hospital-based midwives known as clinical midwives (n=42), nurses (n=154) and primary-care midwives (n=109). The overall response rate was 80.8%. We used the Interprofessional Collaboration Measurement Scale (IPCMS) to assess perceived interprofessional collaboration. The IPCMS distinguishes three subscales: communication, accommodation and isolation. Data were analysed using non-parametrical tests.

Results

Overall, ratings of interprofessional collaboration were good. Obstetricians rated their collaboration with clinical midwives, nurses and primary-care midwives more positively than these three groups rated the collaboration with obstetricians. Discrepancies in mutual perceptions were most apparent in the isolation subscale, which is about sharing opinions, discussing new practices and respecting each other.

Conclusion

We found relevant discrepancies in mutual perceptions of collaboration in obstetrical care in the Netherlands. Obstetrical care is currently being reorganised to enable more integrated care, which will have consequences for interprofessional collaboration. The findings of this study indicate opportunities for improvement especially in terms of perceived isolation.

Do the stars align? Distribution of high-quality ratings of healthcare sectors across US markets

Quality and Safety in Health Care Journal -

Background

The US government created five-star rating systems to evaluate hospital, nursing homes, home health agency and dialysis centre quality. The degree to which quality is a property of organisations versus geographical markets is unclear.

Objectives

To determine whether high-quality healthcare service sectors are clustered within US healthcare markets.

Design

Using data from the Centers for Medicare and Medicaid Services’ Hospital, Dialysis, Nursing Home and Home Health Compare databases, we calculated the mean star ratings of four healthcare sectors in 304 US hospital referral regions (HRRs). For each sector, we ranked HRRs into terciles by mean star rating. Within each HRR, we assessed concordance of tercile rank across sectors using a multirater kappa. Using t-tests, we compared characteristics of HRRs with three to four top-ranked sectors, one to two top-ranked sectors and zero top-ranked sectors.

Results

Six HRRs (2.0% of HRRs) had four top-ranked healthcare sectors, 38 (12.5%) had three top-ranked health sectors, 71 (23.4%) had two top-ranked sectors, 111 (36.5%) had one top-ranked sector and 78 (25.7%) HRRs had no top-ranked sectors. A multirater kappa across all sectors showed poor to slight agreement (K=0.055). Compared with HRRs with zero top-ranked sectors, those with three to four top-ranked sectors had higher median incomes, fewer black residents, lower mortality rates and were less impoverished. Results were similar for HRRs with one to two top-ranked sectors.

Conclusions

Few US healthcare markets exhibit high-quality performance across four distinct healthcare service sectors, suggesting that high-quality care in one sector may not be dependent on or improve care quality in other sectors. Policies that promote accountability for quality across sectors (eg, bundled payments and shared quality metrics) may be needed to systematically improve quality across sectors.

Outpatient CPOE orders discontinued due to 'erroneous entry: prospective survey of prescribers explanations for errors

Quality and Safety in Health Care Journal -

Background

Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous.

Objective

To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous.

Methods

During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason ‘Error (erroneous entry)." Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders.

Results

From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error.

Conclusion

Drugs are not infrequently discontinued ‘in error.’ Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future.

Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders

Quality and Safety in Health Care Journal -

Objective

Medication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.

Method

Using voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.

Results

We conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based reasons as the gold standard, we found that clinician-CPOE-selected reasons were less reflective (PPV=70.2%, 95% CI 61.0% to 79.4%) than clinician-reported (interview) (PPV=86.1%, 95%CI 78.2% to 94.1%) reasons for medication ordering errors. Duplicate (n=44) and improperly composed (n=41) ordering errors were common, often caused by predefined order sets and data entry issues. A striking finding was the use of intentional violations as a mechanism to notify and seek ordering assistance from pharmacy service. Nearly half of the medication ordering errors were voided by pharmacists.

Discussion

We demonstrated that voided orders effectively captured medication ordering errors. The mismatch between clinician-CPOE-selected and the chart review-based reasons for error emphasises the need for developing standardised operational descriptions for medication ordering errors. Such standardisation can help in accurately identifying, tracking, managing and sharing erroneous orders and their root contributors between healthcare institutions, and with patient safety organisations.

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge

Quality and Safety in Health Care Journal -

Background

Pharmacists’ completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.

Methods

This is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively.

Results

Fourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre–post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload.

Conclusions

Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.

Quick and dirty? A systematic review of the use of rapid ethnographies in healthcare organisation and delivery

Quality and Safety in Health Care Journal -

Background

The ability to capture the complexities of healthcare practices and the quick turnaround of findings make rapid ethnographies appealing to the healthcare sector, where changing organisational climates and priorities require actionable findings at strategic time points. Despite methodological advancement, there continue to be challenges in the implementation of rapid ethnographies concerning sampling, the interpretation of findings and management of field research. The purpose of this review was to explore the benefits and challenges of using rapid ethnographies to inform healthcare organisation and delivery and identify areas that require improvement.

Methods

This was a systematic review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We used the Mixed Methods Appraisal Tool to assess the quality of the articles. We developed the search strategy using the Population, Intervention, Comparison, Outcomes, Settingframework and searched for peer-reviewed articles in MEDLINE, CINAHL PLUS, Web of Science and ProQuest Central. We included articles that reported findings from rapid ethnographies in healthcare contexts or addressing issues related to health service use.

Results

26 articles were included in the review. We found an increase in the use of rapid ethnographies in the last 2years. We found variability in terminology and developed a typology to clarify conceptual differences. The studies generated findings that could be used to inform policy and practice. The main limitations of the studies were: the poor quality of reporting of study designs, mainly data analysis methods, and lack of reflexivity.

Conclusions

Rapid ethnographies have the potential to generate findings that can inform changes in healthcare practices in a timely manner, but greater attention needs to be paid to the reflexive interpretation of findings and the description of research methods.

Trial registration number

CRD42017065874.

Implementation science at the crossroads

Quality and Safety in Health Care Journal -

Martin Marshall and colleagues1 take themselves to task for the suboptimal design of a complex (multicomponent) intervention to improve safety of services for people in care homes. The authors make much of the complexity of the intervention—service interventions are ‘not like a pill’. Interventions must be adapted—when first promulgated the intervention in question had nine components, and this inflated to 15 over the course of the project. Contrast all of these with a financial incentive promulgated by the Specialist Services Commissioning authority for the West Midlands, England. Hospitals were simply given a financial incentive to promote a switch from facility to home haemodialysis.2

So here we have accounts of what appear to be two very different types of interventions; Marshall’s intervention encapsulates 15 components, while the commissioning agent’s intervention was of one component only. One might think that Marshall’s intervention was complex and the commissioning agent’s...

WIHI: Mindfulness and Patient Safety

Institute for Healthcare Improvement -

March 8, 2018 | As stress-reduction and other health benefits of mindfulness become better known, clinicians are discovering that they, too, need new ways to deal with stress. Can practicing mindfulness be restorative in the middle of a hectic day, create mental space to be more tuned into patients, and reduce the likelihood of medical errors?

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