Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes
Conclusions
GPs were not more likely to investigate ‘patients’ with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - May 18, 2017 Category: Health Management Authors: Sheringham, J., Sequeira, R., Myles, J., Hamilton, W., McDonnell, J., Offman, J., Duffy, S., Raine, R. Tags: Original research Source Type: research
Implementation of a structured hospital-wide morbidity and mortality rounds model
Conclusions and relevance
Implementation of a structured model enhanced the quality of M&M rounds with demonstrable policy improvements hospital wide. The OM3 can be feasibly implemented at other hospitals to effectively improve quality of M&M rounds across different specialties. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - May 18, 2017 Category: Health Management Authors: Kwok, E. S. H., Calder, L. A., Barlow-Krelina, E., Mackie, C., Seely, A. J. E., Cwinn, A. A., Worthington, J. R., Frank, J. R. Tags: Original Research Source Type: research
Calibrating how doctors think and seek information to minimise errors in diagnosis
Information gathering is a foundational step of the diagnostic process.1 It is not possible to synthesise clinical information to make a correct diagnosis without adequate data collection related to a patient's history, physical examination, test results or consultations with other clinicians. However, evidence over the last several decades suggests that failures in information gathering are common and feature prominently in analyses of diagnostic errors.2–7 Many information-gathering failures are related to history taking, including asking the right questions, which is sometimes based on certain cues from the patien...
Source: Quality and Safety in Health Care - May 18, 2017 Category: Health Management Authors: Meyer, A. N. D., Singh, H. Tags: Editorials Source Type: research
The evolution of morbidity and mortality conferences
Morbidity and mortality conferences (MMCs) have become a vital element of patient care, sitting at the intersection of medical education, quality improvement and risk management. MMCs may have increased in importance as a staple of safety education since the Accreditation Council for Graduate Medical Education has identified that the discussion and analysis of adverse events in a structured fashion promotes the learning of key quality and safety concepts.1–3 Groups across specialties and disciplines have implemented innovative models of MMCs as a vehicle to engage clinicians in discussions to learn from adverse event...
Source: Quality and Safety in Health Care - May 18, 2017 Category: Health Management Authors: Tad-y, D., Wald, H. L. Tags: Editorials Source Type: research
Abstracts
We describe responses to a data collection system that explicitly sought to promote the use of data about patient safety for improvement, exploring how it intervened in and was influenced by the dynamics of blame. We focus on the NHS Safety Thermometer, a large-scale exercise which introduced an innovative measure of patient safety across multiple clinical settings (Harmfreecare.org 2016; Power et al. 2014). The NHS Safety Thermometer is an improvement tool measuring four common harms: pressure ulcers, falls in care settings, urinary tract infections (UTIs) in patients with a catheter, and venous thromboembolism (VTE). It ...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Armstrong, N., Brewster, L., Tarrant, C., Dixon, R., Willars, J., Power, M., Dixon-Woods, M., Nambiar, B., Hargreaves, D. S., Colbourn, T., Shaw, J., McKillop, A., Sheridan, N., Gray, C. S., Carswell, P., Wodchis, W. P., Denis, J.-L., Baker, G. R., Connol Tags: Abstracts Source Type: research
Erratum: Computerised prescribing for safer medication ordering: still a work in progress
Schiff GD, Hickman T-TT, Volk LA, et al. Computerised prescribing for safer medication ordering: still a work in progress. BMJ Qual Saf 2016;25:315–9. doi:10.1136/bmjqs-2015-004677 The original article is missing several acknowledgements. The amended acknowledgements statement is as below: The authors would like to acknowledge contributions of FDA staff: Carol Holquist, RPh, Office of Regulatory Operations, Office of Generic Drugs; Kendra Worthy PharmD, Division of Medication Error Prevention and Analysis (DMEPA), Office of Medication Error Prevention and Risk Management (OMEPRM), Office of Surveillance and Epidemiol...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Tags: Corrections Source Type: research
Estimating deaths due to medical error: the ongoing controversy and why it matters
One important reason for the widespread attention given to the 1999 US Institute of Medicine (IOM) report To Err Is Human1 lie in its estimate that medical error was to blame for 44 000–98 000 deaths each year in the US hospitals. This striking claim established patient safety as a public concern, strengthened the case for improving the science underlying safety and motivated providers, policymakers, payers and regulators to take safety seriously. Some did express disquiet about the validity of the figures cited,2 including one of the principal investigators of the two studies that provided the data for the...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Shojania, K. G., Dixon-Woods, M. Tags: Viewpoints Source Type: research
The problem with root cause analysis
Introduction Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents,1–3 is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events,1 RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science4 5 that are use...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Peerally, M. F., Carr, S., Waring, J., Dixon-Woods, M. Tags: Open access The problem with... Source Type: research
Reviewing deaths in British and US hospitals: a study of two scales for assessing preventability
Conclusions
The correspondence is high between a Likert and a continuous scale, although the low reliability of both would suggest careful measurement design would be needed to use either scale. Few to no cases are above the threshold when using a balance of probability approach to determining a preventable death, and in any case, there is little evidence supporting anything more than an ordinal correspondence between these reviewer estimates of probability and the true probability. Thus, it would be more defensible to use them as an ordinal measure of the quality of care received by patients who died in the hospital. (Sou...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Manaseki-Holland, S., Lilford, R. J., Bishop, J. R. B., Girling, A. J., Chen, Y.-F., Chilton, P. J., Hofer, T. P., The UK Case Note Review Group, Alner, Bleasdale, Bosanko, Brind, Byatt, Carmalt, Carr, Dharmarajah, Dunstan, Edmunds, Hayat, Heatlie, Ishaq, Tags: Open access Original research Source Type: research
Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains
Conclusions
Across two distinct pharmacy chains, there is a strong and significant association between drug name confusion error rates observed in the real world and those observed in laboratory-based tests of memory and perception. Regulators and drug companies seeking a validated preapproval method for identifying confusing drug names ought to consider using these simple tests. By using a standard battery of memory and perception tests, it should be possible to reduce the number of confusing look-alike and sound-alike drug name pairs that reach the market, which will help protect patients from potentially harmful medicat...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Schroeder, S. R., Salomon, M. M., Galanter, W. L., Schiff, G. D., Vaida, A. J., Gaunt, M. J., Bryson, M. L., Rash, C., Falck, S., Lambert, B. L. Tags: Open access Original research Source Type: research
Six ways not to improve patient flow: a qualitative study
Conclusions
Typically, flawed initiatives focused on too small a segment of the patient journey to properly address the impediments to flow. The proliferation of narrowly focused initiatives, in turn, reflected a decentralised system in which responsibility for flow improvement was fragmented. Thus, initiatives' specific design flaws may have their roots in a deeper problem: the lack of a coherent system-level strategy. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Kreindler, S. A. Tags: Open access Original research Source Type: research
Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?
Conclusions
This study found that the most commonly proposed solutions were weaker actions, which were less likely to decrease event recurrence. These findings support recent attempts to improve the RCA process and to develop guidance for the creation of effective and sustainable solutions to be used by RCA teams. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Kellogg, K. M., Hettinger, Z., Shah, M., Wears, R. L., Sellers, C. R., Squires, M., Fairbanks, R. J. Tags: Editor's choice Original research Source Type: research
Opportunities to improve clinical summaries for patients at hospital discharge
Conclusions
Our study highlights opportunities to improve clinical summaries for guiding patients' postdischarge care. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Sarzynski, E., Hashmi, H., Subramanian, J., Fitzpatrick, L., Polverento, M., Simmons, M., Brooks, K., Given, C. Tags: Original research Source Type: research
Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey
Conclusions
Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Cowling, T. E., Harris, M., Majeed, A. Tags: Open access Original research Source Type: research
Responding to the challenge of look-alike, sound-alike drug names
Despite significant advances in medication safety, errors related to confusion between drug names are a cause of preventable adverse events and serious harm,1 and remain a patient safety priority.2 3 Although drug name confusion is recognised as a factor contributing to error, its minimisation or elimination is a prevailing challenge.4 5 In this issue, Schroeder et al6 postulate that despite industry's efforts to follow regulators' guidance7 on how to review drug names, more objective evidence, in a standardised format, is needed to improve decision-making about the acceptability of a name. To address this concern, the aut...
Source: Quality and Safety in Health Care - April 18, 2017 Category: Health Management Authors: Trbovich, P. L., Hyland, S. Tags: Editorials Source Type: research
