Opportunities for incident reporting. Response to: 'The problem with incident reporting by Macrae et al
Macrae highlights well-discussed challenges of using safety incident reporting systems as a source of learning and improvement in healthcare.1 Our research group has analysed over 50 000 free-text reports from primary care submitted to the England and Wales National Reporting and Learning System, and developed a mixed methods approach to identify learning from these reports.2 We agree that simply aiming for a greater number of reports to remedy problems arising from under-reporting is not desirable. There is, however, an opportunity to target specific discipline or professional groups to stimulate a culture of reporti...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Williams, H., Cooper, A., Carson-Stevens, A. Tags: BMJQS Noteworthy articles Correspondence Source Type: research
Response to letter from Youngson et al
We thank Professor Youngson et al1 for their interest in our work2 and their comments calling for greater standardisation in medical non-technical skills (NTS) teaching. We are pleased that Professor Youngson agrees with our conclusion about the need for better cooperation and communication between specialties on how such training and assessment should be carried out. We are also delighted to acknowledge the important work being carried out by the Royal College of Surgeons (Edinburgh) (RCSEd) and the University of Aberdeen on the development of Non-Technical Skills for Surgeons (NOTSS), and are of course aware of the paper...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Greig, P., Higham, H., Vaux, E. Tags: BMJQS Noteworthy articles Correspondence Source Type: research
Response to: 'Mapping search terms to review goals is essential by Geiger et al
Thank you for the opportunity to respond to the letter to the editor from Geiger et al1 and discuss aspects of our systematic review.2 We acknowledge that the authors of the letter have made a substantial contribution to the body of knowledge of shared decision-making and its measurement. However, we highlight that the conceptual approach to patient participation in our systematic review was reflective of the broad nature of patient participation. As stated in the background,2 the terms ‘patient participation’ and ‘patient centredness’ are often used synonymously. There are a number of concepts that...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Phillips, N. M., Street, M., Haesler, E. Tags: BMJQS Noteworthy articles Correspondence Source Type: research
Response to: 'Lack of standardisation between specialties for human factors content in postgraduate surgical training: an analysis of specialty curricula in the UK by Greig et al
We were very interested to read the article by Greig et al,1 which has identified how poorly non-technical skills appear in a review of 46 postgraduate curricula from all medical specialties. This is similar to work sponsored by the Academy of Medical Royal Colleges and carried out by the Royal College of Surgeons of Edinburgh (RCSEd) in conjunction with the NHS Institute of Innovation and Improvement2 which also demonstrated significant deficiency in identifying patient safety in general and non-technical skills in particular, as part of the requirement for any educational portfolio. This project also provided an online c...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Youngson, G., Paterson-Brown, S., Russ, S. Tags: BMJQS Noteworthy articles Correspondence Source Type: research
Mapping search terms to review goals is essential
Patient participation can be seen as an end in and of itself, and it can be seen as a way to foster further goals like quality and safety in healthcare, adherence and cost-effectiveness. Wide-scale implementation of interventions to increase patient participation without having confidence in its measures means being unable to determine if implementation was successful or the desired outcome was achieved. Therefore, we were pleased to see a review of measures assessing patient participation in healthcare. However, we have some major concerns about the conceptual approach, the method and the conclusions in the review by Phil...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Geiger, F., Clayman, M. L., Scholl, I., Liethmann, K., Kasper, J. Tags: BMJQS Noteworthy articles Correspondence Source Type: research
Meta-analysis of the central line bundle for preventing catheter-related infections: a case study in appraising the evidence in quality improvement
Conclusions
That the central line bundle could receive only a moderate evidence rating may suggest that the GRADE framework, developed mostly for traditional clinical therapies, requires modification for QI interventions. GRADE does not distinguish prospective trials (eg, controlled before-after studies and interrupted time series) from lower-level observational studies. On the other hand, that the two highest quality studies reached different conclusions makes it difficult to conclude that future research would not change the effect estimate, especially given evidence of secular trends and the variability of co-interventi...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Marang-van de Mheen, P. J., van Bodegom-Vos, L. Tags: Systematic review Source Type: research
A systematic review of reliable and valid tools for the measurement of patient participation in healthcare
Conclusion
Few reliable and valid tools for measurement of patient participation in healthcare have been recently developed. Of those reported in this review, the dyadic Observing Patient Involvement in Decision Making (dyadic-OPTION) tool presents the most promise for measuring core components of patient participation. There remains a need for further study into valid, reliable and feasible strategies for measuring patient participation as part of continuous quality improvement. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Phillips, N. M., Street, M., Haesler, E. Tags: Systematic review Source Type: research
Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative
Conclusions
This stepwise approach with pre-arrival planning using the Chronic Care Model, followed by standardisation of processes, created a sustainable improvement of timely antibiotic delivery in F&I patients. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Dandoy, C. E., Hariharan, S., Weiss, B., Demmel, K., Timm, N., Chiarenzelli, J., Dewald, M. K., Kennebeck, S., Langworthy, S., Pomales, J., Rineair, S., Sandfoss, E., Volz-Noe, P., Nagarajan, R., Alessandrini, E. Tags: Quality improvement reports Source Type: research
Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human
One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regio...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Mitchell, I., Schuster, A., Smith, K., Pronovost, P., Wu, A. Tags: Original research Source Type: research
"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs
Conclusions
The different frequencies for types of AMC likely reflect differences in how residents and nurses work and disparate professional cultures. But, verbal communication in both groups included important information unlikely to be captured in written handoff tools or the electronic medical record, underscoring the importance of direct communication to ensure safe handoffs. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Bergman, A. A., Flanagan, M. E., Ebright, P. R., O'Brien, C. M., Frankel, R. M. Tags: Editor's choice Original research Source Type: research
"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs
Conclusions
Handoffs are a type of socially constructed work. Questions emerge with some frequency in virtually all handoffs but not in a linear or predictable way. Instead, they arise in the moment, as necessary, and without preplanning. A checklist cannot model this process element because it is a static memory aid and questions occur in a relational context that is emergent. Studying the different functions of questions during end of shift handoffs provides insights into the interface between the technical context in which information is transferred and the social context in which meaning is created. (Source: Quality an...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: O'Brien, C. M., Flanagan, M. E., Bergman, A. A., Ebright, P. R., Frankel, R. M. Tags: Original research Source Type: research
The problem with incident reporting
‘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 series is overseen by Ken Catchpole (Guest Editor) and Kaveh Shojania (Editor-in-Chief). Seminal reports that launched the modern field of patient safety highlighted the importance of learning from critical incidents.1 2 Since then, incident reporting systems have become one of the most widespread safety improvement strategies in healthcare, both within individual or...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Macrae, C. Tags: The problem with... Source Type: research
Advancing the next generation of handover research and practice with cognitive load theory
Introduction Improving patient safety during handovers has become a public health priority.1 Over the past decade, a number of best practices have emerged, which, taken together, represent the first generation of handover interventions. Largely adapted from industries (such as aviation and railroad) in which transition errors have high consequences,2 these first-generation best practices aim to reduce information loss and distortion via structured communication protocols such as face-to-face and written sign-out that use mnemonics and standardised templates, interactive questioning and distraction-free environments.1 These...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Young, J. Q., Wachter, R. M., ten Cate, O., O'Sullivan, P. S., Irby, D. M. Tags: Viewpoints Source Type: research
Can we talk? The art (and science) of handoff conversation
Art and science have their meeting point in method. —Earl Edward George Bulwer-Lytton, Caxtoniana (1875), 303 The handoff or handover of patient care is not just a simple act of communication. It is a complex exchange of patient information that increases the likelihood of safe and effective care. We know that these transfers of care are a vulnerable link in patient care that is associated with preventable adverse events. It is especially concerning that effective handoff communication is not regularly or systematically taught to health professionals. It is the interaction between the ‘sender’ and the &...
Source: Quality and Safety in Health Care - January 18, 2016 Category: Health Management Authors: Johnson, J. K., Arora, V. M. Tags: Editorials Source Type: research
Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): a tool for critical appraisal of quality improvement intervention publications
Conclusions
We developed a ready-to-use, valid and reliable critical appraisal instrument applicable to healthcare QI intervention publications, but recognise scope for continuing refinement. (Source: Quality and Safety in Health Care)
Source: Quality and Safety in Health Care - November 19, 2015 Category: Health Management Authors: Hempel, S., Shekelle, P. G., Liu, J. L., Sherwood Danz, M., Foy, R., Lim, Y.-W., Motala, A., Rubenstein, L. V. Tags: Open access Research and reporting methodology Source Type: research
