Diagnostic delay, a type of diagnostic error, is the failure to establish an accurate and timely diagnosis; diagnostic delay remains a significant source of error in healthcare.1 As in other areas of medicine, there are racial and ethnic disparities in the risk of diagnostic delay; increased risk has been found among marginalised populations in a wide range of conditions, including breast cancer, acute coronary syndrome and even appendicitis in children.2–4 In issue 34:3 of BMJQS, Elena et al present the results of their systematic review of the perspectives of minoritised patients on the causes of diagnostic delay.5 They further map their findings onto an adapted Model of Pathways to Treatment, a conceptual model widely used to describe the diagnostic process.6 Through their work, the authors add voices from marginalised groups to a field of study where patient...

Antimicrobial resistance (AMR) has quietly become a global health crisis, claiming 1.1 million lives annually as of 2021. If left unchecked, the death toll is forecasted to climb to 1.9 million per year by 2050.1Despite the mounting volume of data on the burden of AMR, the global response has been sluggish with limited progress.

Global leaders agree that multi-sectorial and multi-faceted approaches are needed to limit the emergence and spread of AMR. Antimicrobial use is a key driver of AMR, where as much as 50% of use is unnecessary.2 3 In humans, the vast majority of antimicrobial use occurs outside of hospitals, making this setting crucial for antimicrobial stewardship efforts. With the estimated number of global outpatient treatment courses of antimicrobials in the billions,4 curtailing inappropriate prescribing is a daunting task. However, audit and feedback has a robust evidence base and...

Structural and social barriers to healthcare contribute significantly to the poorer health outcomes observed among minoritised ethnic people around the world.1 2 Globally, women who are members of an ethnic group that is a minority in their country of residence have been reported to receive suboptimal maternity care. This can include access challenges, poorer quality of care and support, as well as discrimination.3 4 This global pattern is mirrored in UK maternity services, where black, Asian and minoritised ethnic groups are at greater risk of severe morbidity and death during pregnancy, childbirth and postnatally than their white counterparts.5 Poor maternal outcomes have been attributed to intersecting factors, including social circumstances, cross-cultural communication barriers and organisational factors, which combine to delay help-seeking, reduce access and negatively impact experiences of care.6 7 Poor communication is a persistent...

‘Knowing what you are doing’ is a simple, but elemental value for any (care) professional. Acknowledging that treatments in healthcare can be inherently harmful, and the practice of medicine often involves weighing one harm (the disease) against the other (the treatment), it is obviously vital to know and understand the effects of medical interventions on humans. However, healthcare is becoming increasingly complex, not in the least due to the abundant body of in-depth knowledge that professionals need to weigh into their decisions for patients. Data science is rapidly changing healthcare as we speak, creating tools such as scores,1 2 benchmarks provided by clinical audits3 and guidelines that alter our clinical strategies. Artificial intelligence and machine learning solutions may be less comprehensible than the information provided by, for example, guidelines, but are revolutionising the world and healthcare at an unstoppable speed.4 The...

Vaccination has led to the control of many infectious diseases, reducing morbidity and mortality, and is estimated by the WHO to save between two and three million lives a year globally.1 Many vaccinations are given in infancy to offer protection against diseases such as measles, polio and meningitis. However, low vaccine uptake is a growing concern and has been linked to outbreaks.2 The COVID-19 pandemic appears to have exacerbated vaccine hesitancy, through a growing mistrust of vaccines.3 During the pandemic, many people could also have been reluctant to access healthcare settings due to fear of infection. Relevant to health inequalities, vaccine uptake is often lower in groups considered underserved, such as those from minority ethnic groups, or higher deprivation.3 4 Interventions are needed to increase vaccination rates to avoid preventable disease.

The study by Rosen et al5...

Objective

To evaluate the impact of a personalised audit and feedback prescribing report (AF) and brief educational summary (ES) on empiric treatment of uncomplicated lower urinary tract infections (UTIs) by family physicians (FPs).

Design

Cluster randomised control trial.

Setting

The intervention was conducted in British Columbia, Canada between 23 September 2021 and 28 March 2022.

Participants

We randomised 5073 FPs into a standard AF and ES intervention arm (n=1691), an ES-only arm (n=1691) and a control arm (n=1691).

Interventions

The AF contained personalised and peer-comparison data on first-line antibiotic prescriptions for women with uncomplicated lower UTI and key therapeutic recommendations. The ES contained detailed, evidence-based UTI management recommendations, incorporated regional antibiotic resistance data and recommended nitrofurantoin as a first-line treatment.

Main outcome measures

Nitrofurantoin as first-line pharmacological treatment for uncomplicated lower UTI, analysed using an intention-to-treat approach.

Results

We identified 21 307 cases of uncomplicated lower UTI among the three trial arms during the study period. The impact of receiving both the AF and ES increased the relative probability of prescribing nitrofurantoin as first-line treatment for uncomplicated lower UTI by 28% (OR 1.28; 95% CI 1.07 to 1.52), relative to the delay arm. This translates to additional prescribing of nitrofurantoin as first-line treatment, instead of alternates, in an additional 8.7 cases of uncomplicated UTI per 100 FPs during the 6-month study period.

Conclusion

AF prescribing data with educational materials can improve primary care prescribing of antibiotics for uncomplicated lower UTI.

Trial registration number

NCT05817253.

Background

Ethnic inequities in maternity care persist in England for Black, African, Caribbean and mixed-Black heritage families, resulting in poorer care experiences and health outcomes than other minoritised ethnic groups. Co-production using an integrated care approach is crucial for reducing these disparities and improving care quality and safety. Therefore, this study aimed to understand the alignment of health and local authority professional perspectives with community needs on how to improve maternity experiences for this ethnic group within a London integrated care system (ICS).

Methods

Between March and June 2024, five workshops were conducted with health professionals, local authorities, voluntary, community and social enterprise (VCSE) sector and the public from Black, African, Caribbean and mixed-Black heritage backgrounds across the North West London ICS. Using the nominal group technique (NGT), attendees prioritised ideas to improve the experience of maternity care for families from Black, African, Caribbean and mixed-Black heritage backgrounds, which were thematically synthesised using framework analysis.

Results

Fifty-four attendees, covering primary, secondary, regional and national health professionals, public health teams from three local authorities, VCSE sector and the public, generated 89 potential interventions across 11 themes. All attendees prioritised improving staff knowledge and capacity in culturally competent care and communication. Community-identified needs for advocacy mechanisms and mental health support throughout the maternity pathway were not reflected in professional priorities.

Conclusion

The study highlights the need for an integrated, community-centred approach beyond hospital settings when addressing ethnic inequities in maternity care, recognising key differences between community and professional priorities within an ICS. Leveraging lived experience expertise to lead the NGT community workshops was essential in building trust and buy-in of the overall prioritisation process.

Background

Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.

Objectives

In this scoping review, we explore the circumstances and perceived implications of safety standard workarounds (SSWAs) conducted in the delivery of frontline care.

Method

We searched MEDLINE, CINAHL, PsycINFO and Web of Science for articles reporting on the circumstances and perceived implications of SSWAs in healthcare. Data charting was undertaken by two researchers. A narrative synthesis was developed to produce a summary of findings.

Results

We included 27 papers in the review, which reported on workarounds of 21 safety standards. Over half of the papers (59%) described working around standards related to medicine safety. As medication standards featured frequently in papers, SSWAs were reported to be performed by registered nurses in 67% of papers, doctors in 41% of papers and pharmacists in 19% of papers. Organisational causes were the most prominent reason for workarounds.

Papers reported on the perceived impact of SSWAs for care quality. At times SSWAs were being used to support the delivery of person-centred, timely, efficient and effective care. Implications of SSWAs for safety were diverse. Some papers reported SSWAs had both positive and negative implications for safety simultaneously. SSWAs were reported to be beneficial for patients more often than they were detrimental.

Conclusion

SSWAs are used frequently during the delivery of everyday care, particularly during medication-related processes. These workarounds are often used to balance different risks and, in some circumstances, to achieve safe care.

To improve patient safety, surgeons can continually monitor the surgical outcomes of their patients. To this end, they can use statistical process control tools, which primarily originated in the manufacturing industry and are now widely used in healthcare. These tools belong to a broad family, making it challenging to identify the most suitable methodology to monitor surgical outcomes. The selected tools must balance statistical rigour with surgeon usability, enabling both statistical interpretation of trends over time and comprehensibility for the surgeons, their primary users. On one hand, the observed minus expected (O-E) chart is a simple and intuitive tool that allows surgeons without statistical expertise to view and interpret their activity; however, it may not possess the sophisticated algorithms required to accurately identify important changes in surgical performance. On the other hand, a statistically robust tool like the cumulative sum (CUSUM) method can be helpful but may be too complex for surgeons to interpret and apply in practice without proper statistical training. To address this issue, we developed a new risk-adjusted (RA) O-E CUSUM chart that aims to provide a balanced solution, integrating the visualisation strengths of a user-friendly O-E chart with the statistical interpretation capabilities of a CUSUM chart. With the RA O-E CUSUM chart, surgeons can effectively monitor patients’ outcomes and identify sequences of statistically abnormal changes, indicating either deterioration or improvement in surgical outcomes. They can also quantify potentially preventable or avoidable adverse events during these sequences. Subsequently, surgical teams can try implementing changes to potentially improve their performance and enhance patient safety over time. This paper outlines the methodology for building the tool and provides a concrete example using real surgical data to demonstrate its application.

Previous studies have demonstrated that text message reminders can improve pediatric vaccination rates, including low income & diverse settings such as those served by federally qualified health centers. In this study, we aimed to improve compliance with routine childhood immunizations via a text message intervention in a network of urban, federally qualified health centers at a large academic medical center. We targeted parents or guardians of children aged 0-2 years who were overdue or due within 14 days for at least one routine childhood immunization without a scheduled appointment. In Round 1, two versions of a text were compared to a control (no text). In subsequent Rounds, a new text was compared to a control (no text). In each round the content, wording, and frequency of texts changed. Subjects were randomized to receive a text (treatment group(s)) or to not receive a text (control group) in each round between 2020 and 2022. The primary outcome was whether overdue vaccines had been given by 12 week follow up. The secondary outcome was appointment scheduling within the 72 hours after text messages were sent. In Round 1 (n=1203) no significant differences were found between groups in overdue vaccine administration per group or per patient at follow up, or in appointment scheduling. In Round 2 (n=251) there was no significant difference in vaccine administration per group or per patient. However, significantly more patients in the intervention group scheduled an appointment (9.1% vs. 1.7%, p=0.01). In Round 3 (n=1034), vaccine administration was significantly higher in the intervention group compared to the control overall (7.0% vs. 5.5%, 0.016) and per subject (p=0.02). Significantly more patients in the intervention group scheduled an appointment compared to the control (3.3% vs. 1.2%, p=0.02). We found that text messaging can be an effective intervention to promote health service utilization such as pediatric vaccination rates, which although improved in this study, remain low.

The Oxford Professional Practice Handbook of Quality Improvement in Healthcare1 is the latest in a series of books that will be very familiar to readers in the UK and other parts of the world. Many medical students, practicing doctors and other healthcare professionals will have used the various Oxford Handbooks—including books on Clinical Medicine, General Practice, Emergency Medicine and many more. This new book, focusing on quality improvement in healthcare, is both a welcome addition to the series and evidence of the growing recognition of the importance of understanding quality improvement methods alongside our clinical skills.

As with other books in the series, the book is well signposted, with summary tables, diagrams and examples throughout that make it a very practical resource. Each chapter starts with a summary of the key points, which is useful in signposting the reader to what is to follow. Brief examples and...

Healthcare is at a crossroads. On one hand, health systems are increasingly committed to promote evidence-based practices and reduce wasteful spending. On the other hand, there is a persistent reality of low-value care as demonstrated by procedures, tests and treatments that provide little to no benefit and sometimes even cause harm. Compounding the problem is the increasing availability, complexity and volume of information patients have to grasp when making decisions. While health-seeking behaviours are associated with better patient engagement and better overall outcomes, online health-related information can be a frequent source of misinformation. In the pursuit to decrease low-value care, one critical factor remains consistently underestimated: health literacy (HL).

HL role in low-value care

HL represents the extent to which patients are able to understand and act on health information.1 With rates ranging from 12% in the USA to 53% in European countries over the last...

This edition of BMJ Quality & Safety includes a systematic review on practices to reduce transmission of infections with resistant organisms led by the Agency for Healthcare Research and Quality (AHRQ) as part of the ‘Making Healthcare Safer IV’ initiative.1 The AHRQ team has done a great service to healthcare providers and infection preventionists by summarising the evidence succinctly and in one document. This systematic review focuses on literature on these five safety practices published from 2011 to 2023: universal gloving, contact precautions, cohorting patients, environmental decontamination and patient decolonisation. Included studies took place in inpatient or nursing home settings. The starting place for the review was previously published systematic reviews (n=9), augmented by original research studies not included in these reviews (n=17). Unfortunately, the main finding of this review is that the certainty of evidence that these practices may reduce transmission of infections with multidrug-resistant organisms...

Objective

To (a) examine whether the effect of the Choosing Wisely consumer questions on question-asking and shared decision-making (SDM) outcomes differs based on individuals’ health literacy and (b) explore the relationship between health literacy, question-asking and other decision-making outcomes in the context of low value care.

Methods

Preplanned analysis of randomised trial data comparing: the Choosing Wisely questions, a SDM video, both interventions or control (no intervention). Randomisation was stratified by participant health literacy (‘adequate’ vs ‘limited’), as assessed by the Newest Vital Sign.

Main outcome measures

Self-efficacy to ask questions and be involved in decision-making, and intention to engage in SDM.

Participants

1439 Australian adults, recruited online.

Results

The effects of the Choosing Wisely questions and SDM video did not differ based on participants’ health literacy for most primary or secondary outcomes (all two-way and three-way interactions p>0.05). Compared with individuals with ‘adequate’ health literacy, those with ‘limited’ health literacy had lower knowledge of SDM rights (82.1% vs 89.0%; 95% CI: 3.9% to 9.8%, p<0.001) and less positive attitudes towards SDM (48.3% vs 58.1%; 95% CI: 4.7% to 15.0%, p=0.0002). They were also more likely to indicate they would follow low-value treatment plans without further questioning (7.46/10 vs 6.94/10; 95% CI: 0.33 to 0.72, p<0.001) and generated fewer questions to ask a healthcare provider which aligned with the Choosing Wisely questions (2 (1)=73.79, p<.001). On average, 67.7% of participants with ‘limited’ health literacy indicated that they would use video interventions again compared with 55.7% of individuals with ‘adequate’ health literacy.

Conclusion

Adults with limited health literacy continue to have lower scores on decision-making outcomes in the context of low value care. Ongoing work is needed to develop and test different intervention formats that support people with lower health literacy to engage in question asking and SDM.

Background

Current adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework.

Methods

AEMT was defined as harm resulting from a procedure, treatment or other contact with the healthcare system. The overall crude incidence rate, age-standardised incidence rate and their changes over time were analysed to evaluate temporal trends. Data were stratified by sociodemographic index (SDI) quintiles, age groups and sex to address heterogeneity across and within nations. An age–period–cohort model framework was used to differentiate the contributions of age, period and cohort effects on AEMT incidence changes. The model estimated overall and age-specific annual percentage changes in incidence rates.

Findings

Although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950.

Conclusion

As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.

Background

Proximal femoral fractures in older adults affect prognosis, quality of life and medical expenses. Therefore, identifying patients with an elevated risk for proximal femoral fractures and implementing preventive measures to mitigate their occurrence are crucial.

Objective

This study aimed to develop an accurate in-hospital fracture prediction model that considers patients’ daily conditions and medical procedure status. Additionally, it investigated the changes in their conditions associated with fractures during hospital stays.

Design

A retrospective observational study.

Setting(s)

Acute care hospitals in Japan.

Participants

Participants were 8 514 551 patients from 1321 medical facilities who had been discharged between April 2018 and March 2021 with hip and proximal femoral fractures.

Methods

Logistic regression analysis determined the association between patients’ changes in their ability to transfer at admission and the day before fracture, and proximal femoral fracture during hospital stays.

Results

Patients were classified into fracture and non-fracture groups. The mean ages were 77.4 (SD: 7.7) and 82.6 (SD: 7.8), and the percentages of women were 42.7% and 65.3% in the non-fracture and fracture groups (p<0.01), respectively. Model 4 showed that even if a patient required partial assistance with transfer on the day before the fracture, the fracture risk increased in each category of change in ability to transfer in the following order: ‘declined’, ‘improved’ and ‘no change’.

Conclusions

Patients showing improved ability to transfer during their hospitalisation are at a higher risk for fractures. Monitoring patients’ daily conditions and tracking changes can help prevent fractures during their hospital stays.

Background

Healthcare-associated infections due to multidrug-resistant organisms (MDROs) remain a high priority patient safety topic, despite broad acceptance as standard-of-care safety practices to prevent central line-associated bloodstream infection, catheter-associated urinary tract infection and ventilator-associated pneumonia. Prior editions of Making Healthcare Safer have mixed certainty evidence for various other patient safety practices.

Objectives

As part of Making Healthcare Safer IV, we performed an updated systematic review on the certainty of evidence for the following safety practices at reducing in-facility MDRO infections in adult patients: universal gloving, contact precautions, cohorting, environmental decontamination, patient decolonisation and the adverse effects of isolation.

Methods

We searched PubMed and the Cochrane Library 2011–May 2023 for systematic reviews and original research studies, both randomised and observational. Settings were limited to high-income countries. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. The synthesis of results is narrative. Certainty of evidence was based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework.

Results

Three systematic reviews and three original research studies provided moderate certainty evidence that patient decolonisation reduced MDRO infections, although restricted to certain populations and organisms. One systematic review provided low certainty evidence that universal gloving was beneficial, again limited to certain populations. One systematic review and two original research studies provided low certainty evidence of benefit for environmental decontamination. One systematic review and one new original study provided low certainty evidence of benefit for cohorting in outbreak settings, and very low certainty evidence of benefit in endemic settings. Six original research studies provide mixed evidence for benefit of contact precautions. There is very low certainty evidence of a signal of increased non-infectious adverse events under patients in contact isolation.

Conclusion

In general, the reviewed patient safety practices reduced MDRO infections, but certainty of evidence was low.

PROSPERO registration number

CRD42023444973.

Introduction

Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted.

Objective

The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research.

Methods

We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed.

Results

From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement. Most studies reported activities from multiple categories. Implementation factors included: clinical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities.

Conclusions

The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.

Introduction

Quality measurement that focuses on important processes and outcomes within healthcare is typically seen as an essential feature of well-functioning healthcare systems.1 While outcome measures are concerned with assessing the impact of healthcare interventions (eg, the number of adverse drug events or the average length of stay for inpatients), process measures focus instead on assessing whether elements or steps within healthcare systems are happening as planned (eg, the number of patients seen in a clinic or the proportion of patients receiving a particular intervention). The relationship between processes and outcomes is acknowledged to be complex.2

Many population-based screening programmes, both in the UK and internationally, have as a key performance indicator (KPI) some sort of measure that assesses how many of the population eligible for that screening intervention participate in it (typically referred to as either ‘uptake’ or ‘coverage’). For example, for the...

The Enhancing the Quality and Transparency of Health Research (EQUATOR) Network indexes over 600 reporting guidelines designed to improve the reproducibility of manuscripts across medical fields and study designs. Although several such reporting guidelines touch on adverse events that may occur in the context of a study, there is a large body of research whose primary focus is on adverse events, near-misses and medical errors that do not currently have a dedicated reporting guideline to help set reporting standards and facilitate comparisons across studies. As part of the process prescribed by EQUATOR for developing such a reporting guideline, we performed a needs assessment, evaluating whether existing standards address key features of a proposed reporting guideline in development, entitled Standard Elements in Studies of Adverse Events and Medical Error (SESAME). We evaluated 12 EQUATOR reporting guidelines for the presence of eight key features of SESAME. Five of the 12 failed to include any of these key features. None of the remaining seven incorporated more than four of the eight SESAME key components, confirming the need for a dedicated reporting guideline for studies of adverse events and medical errors.