Towards optimising local reviews of severe incidents in maternity care: messages from a comparison of local and external reviews
Conclusions
The quality of local reviews can clearly be improved. Very few of the reviews involved patients. Local reviews should be multidisciplinary, generate an action plan, and the implementation of recommendations should be audited. Improvements in local reviews may be achieved by standardised training or development of national protocols. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - March 19, 2017 Category: Journals (General) Authors: Shah, A., Kemp, B., Sellers, S., Hinton, L., O'Connor, M., Brocklehurst, P., Kurinczuk, J., Knight, M. Tags: Open access Original research Source Type: research
When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship
Conclusions
Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient–doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations—non-white, those with poorer self-reported health and those with fewer years of formal education—may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - March 19, 2017 Category: Journals (General) Authors: Bell, S. K., Mejilla, R., Anselmo, M., Darer, J. D., Elmore, J. G., Leveille, S., Ngo, L., Ralston, J. D., Delbanco, T., Walker, J. Tags: Original research Source Type: research
Triggering safer general practice care
We know for sure that healthcare does good things for a lot of people and that for some, it harms—sometimes concurrently with providing benefits. Quite likely doctors have known this for millennia, inspiring the caution in the Hippocratic oath to ‘first do no harm’. Clinically grounded medical researchers know that medicine is complicated and that things can sometimes go wrong despite the best efforts of conscientious and well-intentioned clinicians. To minimise people's exposure to healthcare that harms them, while maximising their exposure to healthcare that helps, a diverse armamentarium has developed ...
Source: BMJ Quality and Safety - March 19, 2017 Category: Journals (General) Authors: Dovey, S. M., Leitch, S. Tags: Editorials Source Type: research
Opening up to Open Notes and adding the patient to the team
This issue of BMJ Quality & Safety features a paper by Bell et al1 that follows up on the original ‘Open Notes’ experiment with providing patients electronic access to their primary care providers' notes. In the first report,2 the intervention was well received by the patients and did not provoke the anticipated adverse impacts feared by physicians. The current paper explores the effect of Open Notes on trust within the doctor/patient relationship, again finding generally positive responses from patients and doctors. Most patients indicated that they accessed notes to better understand and learn more about ...
Source: BMJ Quality and Safety - March 19, 2017 Category: Journals (General) Authors: Goldzweig, C. L. Tags: Editor's choice Editorials Source Type: research
Response to: 'Supporting adherence for people starting a new medication for a long-term condition through community pharmacies: a pragmatic randomised controlled trial of the New Medicine Service by Elliott et al
The literature concerning the effectiveness of community pharmacy-based interventions is notable for its lack of high quality randomised studies. The publication by Elliott et al1 of a randomised controlled trial (RCT) examining the effectiveness of the New Medicine Service (NMS—a service designed to improve adherence to newly prescribed medications for long-term conditions) is therefore welcome. The paper states that ‘the study is reported according to Consolidated Standards of Reporting Trials (CONSORT) criteria’. The CONSORT statement is ‘an evidence-based, minimum set of recommendations for repo...
Source: BMJ Quality and Safety - March 19, 2017 Category: Journals (General) Authors: Bush, J. Tags: PostScript Source Type: research
Learning from incidents in healthcare: the journey, not the arrival, matters
Introduction Incident reporting is widely recognised as an important method for improving safety in healthcare, and many countries have established their own incident reporting systems.1 However, the actual value of these systems is increasingly subject to debate.2 Reporting systems, both local and national, are overwhelmed by the volume of reports and fall short in defining recommendations for improving healthcare safety: ‘We collect too much and do too little’.3 The purpose of these systems is also under debate. The UK, for example, struggles to clarify whether incident reports should be used to help healthca...
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Leistikow, I., Mulder, S., Vesseur, J., Robben, P. Tags: Open access Viewpoints Source Type: research
Re-examining high reliability: actively organising for safety
In the 15 years since To Err is Human was published,1 the US healthcare industry has worked diligently to improve patient safety. Although progress has been made in reducing hospital-acquired conditions2 and, in some cases, rates of surgical mortality,3 healthcare has not achieved broad reductions for most patient harms. In recent years, healthcare has borrowed ideas from industries that have strong safety records, including teamwork and error reporting from aviation, and process improvement techniques from manufacturing. Healthcare's latest patient safety push is to encourage hospitals to become a ‘high reliabi...
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Sutcliffe, K. M., Paine, L., Pronovost, P. J. Tags: Viewpoints Source Type: research
Improving feedback on junior doctors prescribing errors: mixed-methods evaluation of a quality improvement project
Conclusion
Findings suggest improved experiences around feedback. However, attempts to produce a measurable reduction in prescribing errors are likely to need a multifaceted approach of which feedback should form part. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Reynolds, M., Jheeta, S., Benn, J., Sanghera, I., Jacklin, A., Ingle, D., Franklin, B. D. Tags: Open access Quality improvement reports Source Type: research
Revisiting the panculture
Traditionally, generations of physicians have been taught that the evaluation of the febrile hospitalised patient consists of the ‘panculture;’ that is, microbiological culture of blood, urine, sputum or stool in search of an offending pathogen. Often, these laboratory tests are paired with complementary imaging such as chest or abdominal X-rays in order to elucidate sources of infection. Indeed, it is hard to find a ‘competent’ physician that has not developed this repertoire during the course of their practice. Although well established in clinical parlance, the term panculture was formally introd...
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Vaughn, V. M., Chopra, V. Tags: The problem with... Source Type: research
Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives
Conclusions
We found no association between results of the HSOPS and catheter-associated infection rates when measured at baseline and postintervention in two successful large national collaboratives focused on prevention of CLABSI and CAUTI. These results suggest that it may be possible to improve CLABSI and CAUTI rates without making significant changes in safety culture, particularly as measured by instruments like HSOPS. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Meddings, J., Reichert, H., Greene, M. T., Safdar, N., Krein, S. L., Olmsted, R. N., Watson, S. R., Edson, B., Albert Lesher, M., Saint, S. Tags: Open access Original research Source Type: research
A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement
Conclusions
The information contained in patients’ drug allergy lists needs to be regularly updated. Most of the drug allergy alerts were overridden, with the majority of alert overrides in the subsample considered appropriate. Some of the rules for these alerts should be carefully reviewed and modified, or removed. Further research is needed to understand providers’ overriding of alerts that warned against the risk of ‘anaphylaxis’, which are more concerning with respect to patient safety. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Slight, S. P., Beeler, P. E., Seger, D. L., Amato, M. G., Her, Q. L., Swerdloff, M., Dalleur, O., Nanji, K. C., Cho, I., Maniam, N., Eguale, T., Fiskio, J. M., Dykes, P. C., Bates, D. W. Tags: Original research Source Type: research
Information transfer in multidisciplinary operating room teams: a simulation-based observational study
Conclusions
While our study supports the value of formal team communications during precase briefing, sign in and time out in the Surgical Safety Checklist, our findings suggest suboptimal transmission of information between team members and unequal contributions of information by different professional groups. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Cumin, D., Skilton, C., Weller, J. Tags: Original research Source Type: research
Variations by state in physician disciplinary actions by US medical licensure boards
Conclusions
There is a significant, fourfold variation in the annual rate of medical board physician disciplinary action by state in the USA. When indicated, state medical boards should consider policies aimed at improving standardisation and coordination to provide consistent supervision to physicians and ensure public safety. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Harris, J. A., Byhoff, E. Tags: Original research Source Type: research
The denominator problem: national hospital quality measures for acute myocardial infarction
Conclusions
Exclusion from AMI measures varied substantially among hospitals, sample sizes were very small for some measures (PCI and ACE inhibitor measures) and measures often excluded high-risk populations. This has implications for the representativeness and comparability of the measures and provides insight for future measure development. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Bruckel, J., Liu, X., Hohmann, S. F., Karson, A. S., Mort, E., Shahian, D. M. Tags: Editor's choice Original research Source Type: research
Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study
Conclusions
The implementation of the Surgical Safety Checklist represents a global concern in patient safety research. Yet how teams huddle for the checks has to be acknowledged as an issue in its own right. Appropriate mobilisation practices can help bringing fuller teams together, which has direct relevance to team training. (Source: BMJ Quality and Safety)
Source: BMJ Quality and Safety - February 15, 2017 Category: Journals (General) Authors: Korkiakangas, T. Tags: Original research Source Type: research
