Quality and Safety in Health Care Journal

What have we learnt after 15 years of research into the 'weekend effect?

It is now 15 years since Bell and Redelemeier published their landmark study demonstrating higher mortality for people admitted to hospital during weekdays compared with the weekend.1 Examining the records of 3.8 million patients admitted over a 10-year period to emergency departments in Ontario, Canada, this ‘weekend effect’ existed over a range of acute conditions, including 23 out of the 100 leading causes of death.

Since that paper in 2001, over 100 studies have explored the weekend effect, across a range of patient populations and health systems.2 Surprisingly, despite this large number of studies, there remains ongoing debate about whether the weekend effect exists, and if so, what causes it. For example, one recent and highly influential study found higher rates of in-hospital death following admission on Saturday or Sunday compared with Wednesday admissions (HR 1.10 for Saturday and 1.15 for Sunday).3

Policy makers...

Getting to grips with the beast: the potential of multi-method operational research approaches

Many of us will be familiar with the parable of the blind men and the elephant, beautifully retold by the 19th century American poet John Godfrey Saxe.1 In this tale, each man in turn describes the small part of the elephant they are touching (the flank, the tusk, the trunk, etc.), declaring with confidence that they know the true nature of the object (‘It's a wall!’, ‘A spear!’, ‘A snake!’). Saxe ends with the moral of the tale:

So, oft in theologic wars

The disputants, I ween,

Rail on in utter ignorance

Of what each other mean;

And prate about an Elephant

Not one of them has seen!1

This seems to be a fair summary of where we still too frequently find ourselves in health services research and delivery. Though the rise of extensive, multi-method programmes of work evaluating complex,...

Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England


Studies finding higher mortality rates for patients admitted to hospital at weekends rely on routine administrative data to adjust for risk of death, but these data may not adequately capture severity of illness. We examined how rates of patient arrival at accident and emergency (A&E) departments by ambulance—a marker of illness severity—were associated with in-hospital mortality by day and time of attendance.


Retrospective observational study of 3 027 946 admissions to 140 non-specialist hospital trusts in England between April 2013 and February 2014. Patient admissions were linked with A&E records containing mode of arrival and date and time of attendance. We classified arrival times by day of the week and daytime (07:00 to 18:59) versus night (19:00 to 06:59 the following day). We examined the association with in-hospital mortality within 30 days using multivariate logistic regression.


Over the week, 20.9% of daytime arrivals were in the highest risk quintile compared with 18.5% for night arrivals. Daytime arrivals on Sundays contained the highest proportion of patients in the highest risk quintile at 21.6%. Proportions of admitted patients brought in by ambulance were substantially higher at night and higher on Saturday (61.1%) and Sunday (60.1%) daytimes compared with other daytimes in the week (57.0%). Without adjusting for arrival by ambulance, risk-adjusted mortality for patients arriving at night was higher than for daytime attendances on Wednesday (0.16 percentage points). Compared with Wednesday daytime, risk-adjusted mortality was also higher on Thursday night (0.15 percentage points) and increased throughout the weekend from Saturday daytime (0.16 percentage points) to Sunday night (0.26 percentage points). After adjusting for arrival by ambulance, the raised mortality only reached statistical significance for patients arriving at A&E on Sunday daytime (0.17 percentage points).


Using conventional risk-adjustment methods, there appears to be a higher risk of mortality following emergency admission to hospital at nights and at weekends. After accounting for mode of arrival at hospital, this pattern changes substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime. This suggests that risk-adjustment based on inpatient administrative data does not adequately account for illness severity and that elevated mortality at weekends and at night reflects a higher proportion of more severely ill patients arriving by ambulance at these times.

Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention


To evaluate the efficacy of the Patient Reporting and Action for a Safe Environment intervention.


A multicentre cluster randomised controlled trial.


Clusters were 33 hospital wards within five hospitals in the UK.


All patients able to give informed consent were eligible to take part. Wards were allocated to the intervention or control condition.


The ward-level intervention comprised two tools: (1) a questionnaire that asked patients about factors contributing to safety (patient measure of safety (PMOS)) and (2) a proforma for patients to report both safety concerns and positive experiences (patient incident reporting tool). Feedback was considered in multidisciplinary action planning meetings.


Primary outcomes were routinely collected ward-level harm-free care (HFC) scores and patient-level feedback on safety (PMOS).


Intervention uptake and retention of wards was 100% and patient participation was high (86%). We found no significant effect of the intervention on any outcomes at 6 or 12 months. However, for new harms (ie, those for which the wards were directly accountable) intervention wards did show greater, though non-significant, improvement compared with control wards. Analyses also indicated that improvements were largest for wards that showed the greatest compliance with the intervention.


Adherence to the intervention, particularly the implementation of action plans, was poor. Patient safety outcomes may represent too blunt a measure.


Patients are willing to provide feedback about the safety of their care. However, we were unable to demonstrate any overall effect of this intervention on either measure of patient safety and therefore cannot recommend this intervention for wider uptake. Findings indicate promise for increasing HFC where wards implement ≥75% of the intervention components.

Trial registration number

ISRCTN07689702; pre-results.

The associations between work-life balance behaviours, teamwork climate and safety climate: cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions


Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work–life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work–life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement.


1. To describe a novel survey scale for evaluating work–life climate based on specific behavioural frequencies in healthcare workers.

2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system.

3. To investigate associations between work–life climate, teamwork climate and safety climate.


Cross-sectional survey study of US healthcare workers within a large healthcare system.


7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work–life climate scale internal consistency was Cronbach α=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work–life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting.


The work–life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes.

Combining qualitative and quantitative operational research methods to inform quality improvement in pathways that span multiple settings


Improving integration and continuity of care across sectors within resource constraints is a priority in many health systems. Qualitative operational research methods of problem structuring have been used to address quality improvement in services involving multiple sectors but not in combination with quantitative operational research methods that enable targeting of interventions according to patient risk. We aimed to combine these methods to augment and inform an improvement initiative concerning infants with congenital heart disease (CHD) whose complex care pathway spans multiple sectors.


Soft systems methodology was used to consider systematically changes to services from the perspectives of community, primary, secondary and tertiary care professionals and a patient group, incorporating relevant evidence. Classification and regression tree (CART) analysis of national audit datasets was conducted along with data visualisation designed to inform service improvement within the context of limited resources.


A ‘Rich Picture’ was developed capturing the main features of services for infants with CHD pertinent to service improvement. This was used, along with a graphical summary of the CART analysis, to guide discussions about targeting interventions at specific patient risk groups. Agreement was reached across representatives of relevant health professions and patients on a coherent set of targeted recommendations for quality improvement. These fed into national decisions about service provision and commissioning.


When tackling complex problems in service provision across multiple settings, it is important to acknowledge and work with multiple perspectives systematically and to consider targeting service improvements in response to confined resources. Our research demonstrates that applying a combination of qualitative and quantitative operational research methods is one approach to doing so that warrants further consideration.

Modifying head nurse messages during daily conversations as leverage for safety climate improvement: a randomised field experiment


Recent literature reviews lament the paucity of high-quality intervention studies designed to test safety culture improvement in hospitals. The current study adapts an empirically supported strategy developed for manufacturing companies by focusing on patient care and safety messages head nurses communicate during daily conversations with nurses.


The study was designed as randomised control trial coupled with before-after measurement of outcome variables. We randomly assigned 445 nurses working in 27 inpatient departments in a midsize hospital in Israel to experimental and control groups. Ten randomly chosen nurses in both groups filled a brief questionnaire referring to last conversation with head nurse. One month later, head nurses in the experimental group received individual feedback, comparing individual with mean hospital scores, coupled with self-set goals for the following feedback session. Head nurses in the control group received no feedback, except for a summary report by the end of intervention.


Patient care messages increased by 16% and professional development messages by 12%, accompanied by 17% decline in nurse-blaming messages in the experimental group, remaining unchanged in the control group. Such changes led to statistically significant increase in patient care behaviours (17%), safety climate (13%), teamwork (9%) and supervisory leadership quality (18%). Rule-compliance messages and workaround behaviours remained unchanged in experimental and control departments.


These data support the utility of our intervention strategy for improving patient safety climate and resultant caring behaviours in healthcare organisations. The fact that our intervention used easy-to-deliver feedback requiring only two sessions minimised its organisational costs.

Towards high-reliability organising in healthcare: a strategy for building organisational capacity

In a high-reliability organisation (HRO), safety and quality (SQ) is an organisational priority, and all workforce members are engaged, continuously learning and improving their work. To build organisational capacity for SQ work, we have developed a role-tailored capacity-building framework that we are currently employing at the Johns Hopkins Armstrong Institute for Patient Safety and Quality as part of an organisational strategy towards HRO. This framework considers organisation-wide competencies for SQ that includes all staff and faculty and is integrated into a broader organisation-wide operating management system for improving quality. In this framework, achieving safe, high-quality care is connected to healthcare workforce preparedness. Capacity-building efforts are tailored to the needs of distinct groups within the workforce that fall within three categories: (1) front-line providers and staff, (2) managers and local improvement personnel and (3) SQ leaders and experts. In this paper we describe this framework, our implementation efforts to date, challenges met and lessons learnt.

The problem with '5 whys

‘The Problem with...’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.


The ‘5 whys’ technique is one of the most widely taught approaches to root-cause analysis (RCA) in healthcare. Its use is promoted by the WHO,1 the English National Health Service,2 the Institute for Healthcare Improvement,3 the Joint Commission4 and many other organisations in the field of healthcare quality and safety. Like most such tools, though, its popularity is not the result of any evidence that it is effective.5–8 Instead, it probably owes its place in the curriculum and practice of RCA to a combination of pedigree, simplicity and pedagogy.

In terms of pedigree, ‘5 whys’ traces its roots...

Remembering to learn: the overlooked role of remembrance in safety improvement

Memory, and remembering the past, are fundamental to patient safety. One of the core objectives of safety improvement is to learn from the past in order to improve the future. This commitment to remember and to learn is central to the strategies that have shaped the evolution of patient safety such as ‘An organisation with a memory’,1 and underpins definitive academic research such as Bosk's ‘Forgive and Remember’.2 Remembering the past to improve the future is institutionalised across healthcare in a variety of activities such as safety incident reporting, morbidity and mortality meetings, coroner investigations and public inquiries. Despite this, healthcare systems still suffer striking and acute episodes of forgetfulness3 that are deeply consequential: when harmful events are forgotten, they are likely to be repeated.

Given the central importance of memory in patient safety, it is surprising that one of the most long-standing...

Recognising the value of infection prevention and its role in addressing the antimicrobial resistance crisis

Healthcare-associated infections, particularly ones caused by antibiotic-resistant bacteria, are associated with high morbidity, mortality and economic costs. In the USA, on average, 2 out of 10 patients admitted to a hospital contract a healthcare-associated infection and their mortality is estimated to exceed breast and prostate cancers, combined.1 Antibiotic-resistant pathogens are responsible for more than two million infections and 23 000 deaths each year in the USA, at a direct cost of $20 billion and additional productivity losses of $35 billion.2 In the European Union, an estimated 37 000 deaths are attributable to antibiotic-resistant infections, costing 1.5 billion annually in direct and indirect costs.3 Although these numbers are well known to hospital epidemiologists and infection preventionists, the magnitude of these numbers is often not appreciated by other clinicians and healthcare executives. Importantly, a large proportion of these infections are preventable. For example, a recent systematic review...

Engaging patients and the public in Choosing Wisely

Why patient and public engagement is important for tackling overuse

Choosing Wisely campaigns aim to engage physicians and the public in tackling the problem of overuse in medicine.1 Choosing Wisely has been adopted by medical and other clinician societies worldwide, having now spread to approximately 20 countries. While physicians have demonstrated a high degree of interest, engaging patients and building wider public awareness is far more challenging. The belief that more testing and more treatment lead to better outcomes is widespread, and physicians rarely discuss the risks and harms of overuse with patients.2–4 Indeed, there is a marked tendency among both patients and physicians to overestimate the benefits of medical interventions and underestimate harms.5 Further, physicians’ perceptions of the unacceptability to patients of applying Choosing Wisely recommendations appear to be a major barrier towards implementation.6 There...

Deaths from preventable adverse events originating in hospitals

Drs Shojania and Dixon-Woods1 seem to misunderstand the nature of preventable adverse events originating in hospitals as characterised in my study from the Journal of Patient Safety (JPS) in 2013.2 I do not appreciate being lumped in with the study by Makary and Daniel for their criticisms.3 In fact, I wrote a serious criticism on the Makary and Daniel study after it was published.4

Although Makary and Daniel started with almost the same data that I did, they deviated from the method I used and the conclusions I reached. My estimate, based on data available at the time of my review, asserted that approximately 400 000 people die prematurely because of mistakes (preventable lethal events) originating during hospital care. I acknowledged that the deaths of these patients likely involved a basic cause, say cancer or cardiovascular disease, but a preventable adverse event...

Estimating preventable hospital deaths: the authors reply

We thank Dr James for offering further comments on the debate on estimating deaths due to medical error, and for his clarification of the definition used in his Journal of Patient Safety article.1 Dr James' letter reinforces the need for improved consistency, explicitness and reproducibility in measurement of medical error (and harms associated with it) that we called for in our article.2

One area where such clarity is much needed is in what Dr James describes as errors of omission, which by their nature are more difficult to detect than the slips and lapses that have traditionally been the concern of patient safety efforts. He mentions the example of β-blockers as a treatment for patients with heart failure, but this is not a straightforward example of deficient practice. While it is true that some early studies in the 1980s suggested a positive impact, β-blockers...

Digitalisation of medicines: artefact, architecture and time

Digitalization:  ‘The encoding of analogue information into a digital format and the possible subsequent reconfigurations of the socio-technical context of production and consumption of the associated products and services’.1

This edition includes two papers reporting research from a 5-year study of electronic prescribing in English hospitals.2 3 The papers each address a significant safety and quality issue drawing data from the wider study. These issues are the level of coordination and integration that electronic prescribing systems achieve,3 and the emergence of ‘workarounds’ as managers and clinical users adapt electronic prescribing systems’ capabilities to their needs and working environment.2 The risks to patient safety posed by these systems, their implementation and use are further explored in a third associated paper published elsewhere.4

Workarounds were found to be either ‘informal’ or ‘formalised’ practices, the former derived from user...

When patient-centred care is worth doing well: informed consent or shared decision-making

High quality care is patient-centred.1 Efforts to promote patient-centred care in clinical practice should improve quality. Both shared decision-making (SDM) and the process of obtaining informed consent could be expressions of patient-centred care—to the extent that they respond to the advocates' call for ‘nothing about me without me’. In this issue of BMJ Quality and Safety, Shahu et al2 discuss variations in the quality of informed consent procedures, which could, in their view, fail to support patient-centred care in general, and SDM specifically.

Readers interested in advancing this domain of quality may, therefore, be interested in improving the quality of informed consent procedures and promoting the implementation and routine use of SDM. But are these similar practices? Is informed consent a lesser version of SDM, with SDM the ideal expression of patient autonomy and involvement? Or are these different in purpose, process and outcomes?


Nursing skill mix and patient outcomes

In hospitals, the nursing staff typically represent the largest single element of cost, and nursing is frequently treated as a cost centre rather than a core service line. Efforts to contain hospital costs often involve cutting nursing care, reducing the number of nurses or replacing some professional nursing staff with staff such as licensed practical nurses, nurses' aides and other assistive personnel.

Substantial evidence from studies in the USA, Europe and other countries relates lower nurse staffing and higher nurse workloads to adverse patient outcomes such as mortality, infections, falls and longer lengths of stay. Longer stays, which increase hospital costs, may result from increased adverse events lengthening admissions or delays in care due to nurses being unable to complete their work or prepare patients for discharge.1–13

Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England


Substantial sums of money are being invested worldwide in health information technology. Realising benefits and mitigating safety risks is however highly dependent on effective integration of information within systems and/or interfacing to allow information exchange across systems. As part of an English programme of research, we explored the social and technical challenges relating to integration and interfacing experienced by early adopter hospitals of standalone and hospital-wide multimodular integrated electronic prescribing (ePrescribing) systems.


We collected longitudinal qualitative data from six hospitals, which we conceptualised as case studies. We conducted 173 interviews with users, implementers and software suppliers (at up to three different times), 24 observations of system use and strategic meetings, 17 documents relating to implementation plans, and 2 whole-day expert round-table discussions. Data were thematically analysed initially within and then across cases, drawing on perspectives surrounding information infrastructures.


We observed that integration and interfacing problems obstructed effective information transfer in both standalone and multimodular systems, resulting in threats to patient safety emerging from the lack of availability of timely information and duplicate data entry. Interfacing problems were immediately evident in some standalone systems where users had to cope with multiple log-ins, and this did not attenuate over time. Multimodular systems appeared at first sight to obviate such problems. However, with these systems, there was a perceived lack of data coherence across modules resulting in challenges in presenting a comprehensive overview of the patient record, this possibly resulting from the piecemeal implementation of modules with different functionalities. Although it was possible to access data from some primary care systems, we found poor two-way transfer of data between hospitals and primary care necessitating workarounds, which in turn led to the opportunity for new errors associated with duplicate and manual information transfer. Extending ePrescribing to include modules with other clinically important information needed to support care was still an aspiration in most sites, although some advanced multimodular systems had begun implementing this functionality. Multimodular systems were, however, seen as being difficult to interface with external systems.


The decision to pursue a strategy of purchasing standalone systems and then interfacing these, or one of buying hospital-wide multimodular systems, is a pivotal one for hospitals in realising the vision of achieving a fully integrated digital record, and this should be predicated on a clear appreciation of the relative trade-offs between these choices. While multimodular systems offered somewhat better usability, standalone systems provided greater flexibility and opportunity for innovation, particularly in relation to interoperability with external systems and in relation to customisability to the needs of different user groups.

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals


Concerns with the usability of electronic prescribing (ePrescribing) systems can lead to the development of workarounds by users.


To investigate the types of workarounds users employed, the underlying reasons offered and implications for care provision and patient safety.


We collected a large qualitative data set, comprising interviews, observations and project documents, as part of an evaluation of ePrescribing systems in five English hospitals, which we conceptualised as case studies. Data were collected at up to three different time points throughout implementation and adoption. Thematic analysis involving deductive and inductive approaches was facilitated by NVivo 10.


Our data set consisted of 173 interviews, 24 rounds of observation and 17 documents. Participating hospitals were at various stages of implementing a range of systems with differing functionalities. We identified two types of workarounds: informal and formal. The former were informal practices employed by users not approved by management, which were introduced because of perceived changes to professional roles, issues with system usability and performance and challenges relating to the inaccessibility of hardware. The latter were formalised practices that were promoted by management and occurred when systems posed threats to patient safety and organisational functioning. Both types of workarounds involved using paper and other software systems as intermediaries, which often created new risks relating to a lack of efficient transfer of real-time information between different users.


Assessing formal and informal workarounds employed by users should be part of routine organisational implementation strategies of major health information technology initiatives. Workarounds can create new risks and present new opportunities for improvement in system design and integration.

Beyond hand hygiene: a qualitative study of the everyday work of preventing cross-contamination on hospital wards


Hospital-acquired infections are the most common adverse event for inpatients worldwide. Efforts to prevent microbial cross-contamination currently focus on hand hygiene and use of personal protective equipment (PPE), with variable success. Better understanding is needed of infection prevention and control (IPC) in routine clinical practice.


We report on an interventionist video-reflexive ethnography study that explored how healthcare workers performed IPC in three wards in two hospitals in New South Wales, Australia: an intensive care unit and two general surgical wards. We conducted 46 semistructured interviews, 24 weeks of fieldwork (observation and videoing) and 22 reflexive sessions with a total of 177 participants (medical, nursing, allied health, clerical and cleaning staff, and medical and nursing students). We performed a postintervention analysis, using a modified grounded theory approach, to account for the range of IPC practices identified by participants.


We found that healthcare workers' routine IPC work goes beyond hand hygiene and PPE. It also involves, for instance, the distribution of team members during rounds, the choreography of performing aseptic procedures and moving ‘from clean to dirty’ when examining patients. We account for these practices as the logistical work of moving bodies and objects across boundaries, especially from contaminated to clean/vulnerable spaces, while restricting the movement of micro-organisms through cleaning, applying barriers and buffers, and trajectory planning.


Attention to the logistics of moving people and objects around healthcare spaces, especially into vulnerable areas, allows for a more comprehensive approach to IPC through better contextualisation of hand hygiene and PPE protocols, better identification of transmission risks, and the design and promotion of a wider range of preventive strategies and solutions.