Background

Medical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.

Objective

The primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.

Design

Stepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.

Setting

Inpatient oncology, surgery and rehabilitation programmes in four academic hospitals.

Participants

Physicians in participating programmes.

Intervention

Medical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.

Main outcome and measures

The primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.

Results

The adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of ‘Organisational learning’ increased significantly from 35% (26%) to 54% (23%), p=0.00, ‘Response to error’ 37% (24%) to 52% (22%), p=0.025 and ‘Communication about error’ 36% (28%) to 64% (42%), p=0.016 after implementation.

Conclusions and relevance

Medical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.

Trial registration number

NCT05365516.

Objectives

To capture experiences of people self-reporting harm and contrast responses and actions between those who do or do not take formal action.

Design

Semi-structured qualitative interview study.

Setting

People self-reporting harm experienced in the National Health Service (NHS) or their family/friends identified from a general Great British population survey.

Participants

49 participants.

Results

There were commonalities in experiences after harm whether formal action (including making a formal complaint or litigation) was taken or not. Many participants reported raising concerns informally with NHS staff, trying to access explanations or support, but were usually unsuccessful. Decision-making on action was complex. There were multiple reasons for not pursuing formal action, including fears of damaging relationships with clinicians, being occupied coping with the consequences of the harm or not wanting to take action against the NHS. NHS advocacy services were not regarded as helpful. Knowledge of how to proceed and feeling entitled to do so, along with proactive social networks, could facilitate action, but often only after people were spurred on by anger and frustration about not receiving an explanation, apology or support for recovery from the NHS. Those from marginalised groups were more likely to feel disempowered to act or be discouraged by family or social contacts, which could lead to self-distancing and reduced trust in services.

Conclusions

People actively seek resolution and recovery after harm but often face multiple barriers in having their needs for explanations, apologies and support addressed. Open and compassionate engagement, especially with those from more marginalised communities, plus tailored support to address needs, could promote recovery, decrease compounded harm and reduce use of grievance services where other provision may be more helpful.

Background

Increasing age is associated with reductions in kidney function and increasing polypharmacy. Most medicines are eliminated through the kidney, meaning older patients are at risk of medication accumulation and toxicity. This scoping review synthesised: (1) the prevalence at which older patients with reduced kidney function in primary care are exposed to inappropriate prescribing; (2) its associated harms; (3) the reasons for this occurring; and (4) the interventions used to improve prescribing practices.

Methods

This scoping review searched ‘Medline’, ‘Embase’, ‘PsycINFO’, ‘CINAHL’ and ‘Web of Science’ for publications before October 2024. References were managed on EndNote V.X5 and thematic data analysis was undertaken on Microsoft Excel. Common themes were identified, summary statistics were calculated and insights were summarised through a narrative technique.

Results

43 relevant studies explored the scale of inappropriate prescribing, estimating prevalences of patient exposure ranging from 0.6% to 49.1% (median 24.9%). Five studies explored the associated harm from inappropriate prescribing, but only one study assessed harm as a primary outcome. Eight studies that assessed difficulties in following prescribing guidelines in reduced kidney function suggested that a lack of awareness and trusted guidelines are fundamental problems. While 13 studies evaluated interventions for improving prescribing in reduced kidney function, only two demonstrated evidence of effectiveness and only one intervention was theoretically informed.

Conclusions

Despite significant heterogeneity in study characteristics, it is clear that the prevalence of inappropriate prescribing for older people is uncomfortably high. There is a lack of evidence linking this to associated adverse outcomes, as well as identifying the causative issues driving this behaviour and the preventative interventions that could prevent harm.

I have heard faculty members complain, on occasion, that students develop bad habits at these clinics because of inadequate supervision. Certainly the quality of care and the ethics of students ‘practicing’ on those who cannot afford other care should be reviewed.

-E. Poulsen, JAMA (1995)1

Introduction

Student-run clinics (SRCs), in which medical and health professions students take responsibility for operational and logistics management of charitable clinics,2 are a powerful expression of service-based learning: students hone clinical and administrative skills while communities receive essential medical services that might otherwise be unavailable. Yet over the past 20 years, these clinics have begun globalising2–5 and increasing in complexity.5 This is happening within a landscape of limited evidence,5 6 growing concerns about ethics and substandard care,7–13

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