Journals

To assess the quality and impact of medication safety outputs issued by the National Patient Safety Agency (NPSA) to the NHS in England and Wales.

A multi-method study comprising (1) focus groups and interviews with NHS Chief Pharmacists and (2) an electronic survey of medical, nursing and clinical governance directors.

Acute sector respondents agreed that the medication outputs had a major impact on patient safety. Pharmacists welcomed national support for medication safety improvement, despite the resulting workload. Medical Directors were much less likely to be aware of alerts and Rapid Response Reports (RRRs) than their nursing and clinical governance colleagues. One key finding was the inability of around half of NHS trusts to communicate effectively and reliably with their junior doctors.

Medication alerts issued by the NPSA have stimulated significant work to improve medication safety and are believed to have had an important impact on patient safety.

Research in healthcare has long been very well regulated, but this is rarely the case for improvement activities. Improvement activities are activities which use data to assess the current situation to identify areas for improvement. Solutions are then developed and implemented, and later evaluated to measure their success and sustainability. There has been much discussion in the literature as to whether, like research activities, improvement activities should undergo independent ethical review. In fact, most healthcare organisations in Australia struggle with how best to manage improvement activities, despite the 2003 publication of the National Health and Medical Research Council guidelines on this subject.

At The Children's Hospital at Westmead, the authors take the view supported by others that ethical review is necessary and so have developed a process which utilises the unique skills available in the Clinical Governance Unit to ensure improvement activities are reviewed for ethical considerations in an effective and efficient manner and implemented a database to approve, monitor and report on improvement activities. This has resulted in staff being increasingly satisfied with the turnaround time for approval of improvement activities they are undertaking as well as for the methodological support provided. The authors have experienced a dramatic increase in the number of improvement activities being recorded and ethically reviewed.

In 2005, The Joint Commission included medication reconciliation as a National Patient Safety Goal to reduce medication errors related to omissions, duplications and interactions. Hospitals continue to struggle to implement successful programmes that meet these objectives.

The authors used improvement methods and reliability principles to develop and implement a process for medication reconciliation completion at admission at a large, paediatric medical centre. Medication reconciliation was defined as recording a complete and accurate list of each patient's medications within 20 min of admission by the nurse and reconciliation of those medications within 24 h of admission by the physician. Interventions focused on five main areas: leadership and support from senior physicians and nurses to sustain a culture of safety; simplification and standardisation of the electronic medication reconciliation application; clarifying roles and responsibilities; creating a highly reliable and visible system; and sustainability.

At baseline, only 62% of patients had their medications reconciled within 24 h of admission. Over a 9-month period, ≥90% medication reconciliation was achieved within 24 h of admission. These results have been sustained for 27 months.

Through the use of improvement methods and reliability science, a sustainable process for medical reconciliation completion at admission was successfully achieved at a large, busy academic children's hospital.

To evaluate the effectiveness of two pressure-ulcer screening tools against clinical judgement in preventing pressure ulcers.

A single blind randomised controlled trial.

A large metropolitan tertiary hospital.

1231 patients admitted to internal medicine or oncology wards. Patients were excluded if their hospital stay was expected to be 2 days or less.

Participants allocated to either a Waterlow (n=410) or Ramstadius (n=411) screening tool group or to a clinical judgement group (n=410) where no formal risk screening instrument was used.

Incidence of hospital acquired pressure ulcers ascertained by regular direct observation. Use of any devices for the prevention of pressure ulcers, documentation of a pressure plan and any dietetic or specialist skin integrity review were recorded.

On admission, 71 (5.8%) patients had an existing pressure ulcer. The incidence of hospital-acquired pressure ulcers was similar between groups (clinical judgement 28/410 (6.8%); Waterlow 31/411 (7.5%); Ramstadius 22/410 (5.4%), p=0.44). Significant associations with pressure injury in regression modelling included requiring a dietetic referral, being admitted from a location other than home and age over 65 years.

The authors found no evidence to show that two common pressure-ulcer risk-assessment tools are superior to clinical judgement to prevent pressure injury. Resources associated with use of these tools might be better spent on careful daily skin inspection and improving management targetted at specific risks.

The trial was registered with the Australian and New Zealand Clinicat Trials Registry (ACTRN 12608000541303).

To investigate internal consistency and factor structure of a questionnaire measuring learning capacity based on Senge's theory of the five disciplines of a learning organisation: Personal Mastery, Mental Models, Shared Vision, Team Learning, and Systems Thinking.

Cross-sectional study.

Substance-abuse treatment centres (SATCs) in The Netherlands.

A total of 293 SATC employees from outpatient and inpatient treatment departments, financial and human resources departments.

Psychometric properties of the Questionnaire for Learning Organizations (QLO), including factor structure, internal consistency, and interscale correlations.

A five-factor model representing the five disciplines of Senge showed good fit. The scales for Personal Mastery, Shared Vision and Team Learning had good internal consistency, but the scales for Systems Thinking and Mental Models had low internal consistency.

The proposed five-factor structure was confirmed in the QLO, which makes it a promising instrument to assess learning capacity in teams. The Systems Thinking and the Mental Models scales have to be revised. Future research should be aimed at testing criterion and discriminatory validity.

Patient record review of hospitalised patients is by far the most applied method to assess adverse events (AEs) in hospitals. The diligence with which information is recorded may influence the visibility of AEs. On the other hand, poor quality of the information in patient records may be a cause or a consequence of poor quality of care and may thus be associated with higher rates of AEs. The objective of this study was to assess the relation between the quality of patient records and the occurrence of AEs.

In this study, 7926 hospital admissions of 21 Dutch hospitals were analysed with a structured record review method. The occurrence of AEs, the presence of patient information and the quality of the present information (completeness, readability and adequacy) were assessed. Their association was analysed using multilevel logistic regression analyses.

The absence of record components was associated with lower rates of AEs, suggesting that missing record components lead to an underassessment of AEs in record-review studies. In contrast, poor quality of the information present in patient records was associated with higher rates of AEs, implying that the quality of the present patient information is a predictor of the quality of care.

Evidence-based standards and a (electronic) format for record keeping are necessary for standardisation of recording patient information. This will improve the completeness, readability, accessibility, accuracy and exchange of patient information between healthcare providers and institutions. Better registration of patient information will benefit the quality of the healthcare process and will reduce the risk of AEs.

The purpose of this study was to evaluate the impact of a patient-safety curriculum administered during a paediatric clerkship on medical students' attitudes towards patient safety.

Medical students viewed an online video introducing them to systems-based analyses of medical errors. Faculty presented an example of a medication administration error and demonstrated use of the Learning From Defects tool to investigate the defect. Student groups identified and then analysed medication errors during their clinical rotation using the Learning From Defects framework to organise and present their findings. Outcomes included patient safety attitudinal changes, as measured by questions derived from the Safety Attitudes Questionnaire.

108 students completed the curriculum between July 2008 and July 2009. All student groups (25 total) identified, analysed and presented patient safety concerns. Curriculum effectiveness was demonstrated by significant changes on questionnaire items related to patient safety attitudes. The majority of students felt that the curriculum was relevant to their clinical rotation and should remain part of the clerkship.

An active learning curriculum integrated into a clinical clerkship can change learners' attitudes towards patient safety. Students found the curriculum relevant and recommended its continuation.

The paper explores which type of quality aspects (structure, process, outcome) most strongly determines patients' overall assessment of healthcare, and whether there is a variation between different types of patient groups in this respect.

Secondary analyses were undertaken on survey data from patients who underwent hip or knee surgery, cataract surgery, patients suffering from varicose veins, spinal disc herniation or rheumatoid arthritis. In these analyses, the patient-given global rating served as the dependent variable, and experiences regarding structure (waiting times, continuity of care), process (doctor–patient communication and information) and outcome aspects (improvement or worsening of symptoms) served as independent variables.

Experiences regarding process aspects explained most of the variance in the global rating (16.4–23.3%), followed by structure aspects (8.1–21.0%). Experiences regarding outcome did not explain much variance in the global rating in any of the patient groups (5.3–13.5%). The patient groups did not differ with respect to the type of quality aspects that most predicted the overall assessment.

Improving process and structure aspects of healthcare is most likely to increase patients' overall evaluation of the quality of care as expressed in a global rating. A more sophisticated method of patient reported outcome measurement, with pre- and post-treatment questionnaires and the inclusion of quality-of-life criteria, might lead to higher associations between outcome and the overall evaluation of the received care.

Quality and safety improvement programmes advance the standard of care delivered by health organisations but have been shown to be less effective than anticipated. Implementing improvement programmes require a greater understanding of the impact of the social context and strategies that engage staff.

To investigate factors that shaped the development of interprofessional improvement initiatives in a health organisation.

Data are drawn from a large-scale longitudinal action research study examining interprofessional learning and practice. The setting is an autonomous bounded health jurisdiction in Australia. Within the study, health professionals have conceptualised more than 111 interprofessional improvement projects, of which 76 have evolved into ongoing activities. Textual data were analysed using emergent coding and descriptive statistics.

Initiatives were shaped by six determinants: site receptivity; team issues; leadership; impact on healthcare relations; impact on quality and safety issues; and extent to which the projects became institutionally embedded. Initiatives that engaged participants and progressed were characterised by and displayed flexible leadership, and ongoing refinement and maturity over time. The local organisational context and initiatives coevolved.

Improvement initiatives are necessary for improved quality of care and patient safety but are difficult to implement and sustain. The factors identified to develop them are constantly under challenge in health services. Improving healthcare quality will, in part, depend upon the ability to provide more flexible and supportive social contexts.

A growing body of peer-reviewed studies demonstrate the importance of safety culture in healthcare safety improvement, but little attention has focused on developing a common set of definitions, dimensions and measures.

Specific objectives of this literature review include: summarising definitions of safety culture and safety climate, identifying theories, dimensions and measures of safety culture in healthcare, and reviewing progress in improving safety culture.

Peer-reviewed, English-language articles published from 1980 to 2009 pertaining to safety culture in healthcare were reviewed. One hundred and thirty-nine studies were included in this review.

Results suggest that there is disagreement among researchers as to how safety culture should be defined, as well as whether or not safety culture is intrinsically diverse from the concept of safety climate. This variance extends into the dimensions and measurement of safety culture, and interventions to influence culture change.

Most studies utilise quantitative surveys to measure safety culture, and propose improvements in safety by implementing multifaceted interventions targeting several dimensions. Conversely, very few studies made their theoretical underpinnings explicit. Moving forward, a common set of definitions and dimensions will enable researchers to better share information and strategies to improve safety culture in healthcare, building momentum in this rapidly expanding field. Advancing the measurement of safety culture to include both quantitative and qualitative methods should be further explored. Using the expertise of traditional culture experts, anthropologists, more in-depth observational and longitudinal research is needed to move research in this area forward.

To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness.

182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaboratives (QICs) focusing on patient safety and autonomy.

Multiple case before–after study.

75 team leaders completed a written questionnaire at the end of each QIC on achievability and degree of challenge of targets and measurability of progress. Main outcome indicators were collaborative-specific measures (such as prevalence of pressure ulcers).

The degree of effectiveness and percentage of teams realising targets varied between collaboratives. Collaboratives also varied widely in perceived measurability (F=6.798 and p=0.000) and with respect to formulating achievable targets (F=6.566 and p=0.000). The Problem Behaviour collaborative scored significantly lower than all other collaboratives on both dimensions. The collaborative on Autonomy and control scored significantly lower on measurability than the other collaboratives. Topics for which there are best practices and evidence of effective interventions do not necessarily score higher on effectiveness, measurability, achievable and challenging targets.

The effectiveness of a QIC is associated with the efforts of programme managers to create conditions that provide insight into which changes in processes of care and in client outcomes have been made. Measurability is not an inherent property of the improvement topic. Rather, creating measurability and formulating challenging and achievable targets is one of the crucial tasks for programme managers of QICs.

In recent years, there has been increased focus on the importance of professionalism among medical students, residents and practising physicians, as well as the interaction between individual behaviours and the practice environment.

Recognising the need to better understand how organisations advance professional behaviours, the authors undertook an exploratory, qualitative study. This study consisted of screening interviews with 30 organisations. Staff and an expert advisory committee developed criteria to select 10 organisations for further study. The authors then conducted in-depth interviews with two leaders from each of the 10 organisations.

Qualitative analysis revealed several key findings, including diversity in the language that organisations used regarding professionalism, and the professional behaviours that they chose to promote. Despite this diversity, all organisations shared a common strategy of clearly articulating their values and reinforcing these values. This reinforcement occurred through the provision of aligned organisational systems and structures, and the cultivation of strong interpersonal relationships. To better illustrate these findings, the authors provide several examples that demonstrate how organisational leaders use values to cultivate professional behaviour in their organisations.

Developing and updating high-quality guidelines requires substantial time and resources. To reduce duplication of effort and enhance efficiency, we developed a process for guideline adaptation and assessed initial perceptions of its feasibility and usefulness.

Based on preliminary developments and empirical studies, a series of meetings with guideline experts were organised to define a process for guideline adaptation (ADAPTE) and to develop a manual and a toolkit made available on a website (http://www.adapte.org). Potential users, guideline developers and implementers, were invited to register and to complete a questionnaire evaluating their perception about the proposed process.

The ADAPTE process consists of three phases (set-up, adaptation, finalisation), 9 modules and 24 steps. The adaptation phase involves identifying specific clinical questions, searching for, retrieving and assessing available guidelines, and preparing the draft adapted guideline. Among 330 registered individuals (46 countries), 144 completed the questionnaire. A majority found the ADAPTE process clear (78%), comprehensive (69%) and feasible (60%), and the manual useful (79%). However, 21% found the ADAPTE process complex. 44% feared that they will not find appropriate and high-quality source guidelines.

A comprehensive framework for guideline adaptation has been developed to meet the challenges of timely guideline development and implementation. The ADAPTE process generated important interest among guideline developers and implementers. The majority perceived the ADAPTE process to be feasible, useful and leading to improved methodological rigour and guideline quality. However, some de novo development might be needed if no high quality guideline exists for a given topic.

It is widely believed that the emotional climate of surgical team's work may affect patient outcome.

To analyse the relationship between the emotional climate of work and indices of threat to patient outcome.

Interventional study.

Operating rooms in a high-volume thoracic surgery centre from September 2007 to June 2008.

Thoracic surgery operating room teams.

Two 90 min team-skills training sessions focused on findings from a standardised safety-culture survey administered to all participants and highlighting positive and problematic aspects of team skills, communication and leadership.

Relationship of functional or less functional emotional climates of work to indices of threat to patient outcome.

A less functional emotional climate corresponded to more threat to outcome in the sterile surgical environment in the pre-intervention period (p<0.05), but not in the post-intervention or sustaining period of this study. This relationship did not exist in the anaesthesia or circulating environments of the operating room.

The emotional climate of work in the sterile surgical environment appeared to be related to threat to patient outcome prior to, but not after, a team-training intervention. Further study of the relationship between the emotional climate of work and threat to patient outcome using reproducible methods is required.

The medical emergency team (MET) system functions to promptly identify acutely ill patients at-risk for deterioration. Liver transplant (LT) patients are at-risk for serious post-operative complications.

To evaluate the characteristics of MET activations in post-operative LT patients and to compare clinical outcomes with case-matched controls.

Retrospective case–control study of all adult patients receiving LT over a 3-year period. Cases were defined as post-operative LT patients who received a MET activation. Controls were defined as LT patients who did not receive a MET activation during the same period, and were matched for age, sex and pre-operative Model for End-Stage Liver Disease (MELD) score.

We found 10.3% (n=18) of LT patients received a total of 26 MET activations (149.4 per 1000 admissions). The mean (SD) age was 54 (9.5) years and 52% were females. There were no differences in baseline characteristics or underlying liver disease between groups, except pre-operative hepatic encephalopathy was more common among cases (55.6% vs 22.2%, p=0.03). Of the MET activations, respiratory distress was the most common ‘trigger’ (87.7%). In 42.3% (n=11) of the activations, MET criteria had been fulfilled in the 24 h preceding. In these MET activations, patients were characterised as tachypnoeic, hypoxaemic, hypotensive, tachycardic and/or oligo-anuric. MET patients had significantly longer ICU and hospital lengths of stay, along with greater rate of unplanned ICU re-admission (83.3% vs 13.9%, p<0.0001) compared with controls. MET patients also had higher in-hospital and 1-year post-discharge mortality (p=0.10, <0.001, respectively) compared with controls.

LT patients with post-operative complications prompting MET activation had higher morbidity and mortality compared with controls; however, the MET may have been under-utilised and/or delayed. Further prospective multi-centre investigation is warranted.

The objectives of the Breakthrough Series Collaborative are to close the gap between what we know and what we do, and to contribute to continuous quality improvement (CQI) of healthcare through collaborative learning. The improvement efforts are guided by a systematic approach, combining professional and improvement knowledge.

To explore what the improvement teams have learnt from participating in the collaborative and from dealing with promoting and inhibiting factors encountered.

Qualitative interviews with 19 team members were conducted in four focus groups, using the Critical Incident Technique. A critical incident is one that makes significant contributions, either positively or negatively, to an activity.

The elements of a culture of improvement are revealed by the critical incidents, and reflect the eight domains of knowledge, as a product of collaborative learning. The improvement knowledge and skills of individuals are important elements, but not enough to achieve sustainable changes. 90% of the material reflects the need for a system of CQI to solve the problems that organisations experience in trying to make lasting improvements.

A pattern of three success factors for CQI emerges: (1) continuous and reliable information, including measurement, about best and current practice; (2) engagement of everybody in all phases of the improvement work: the patient and family, the leadership, the professional environment and the staff; and (3) an infrastructure based on improvement knowledge, with multidisciplinary teams, available coaching, learning systems and sustainability systems.

The development of a pressure ulcer is an adverse event and is often avoidable if adequate preventive measures are applied. No large-scale data, based on direct patient observations, are available regarding the pressure ulcer preventive interventions used in hospitals.

The aim of this study was to obtain insight into the adequacy of interventions used to prevent pressure ulcers in Belgian hospitals.

A cross-sectional, multi-centre pressure ulcer prevalence study was performed in Belgian hospitals. The methodology used to measure pressure ulcer prevalence was developed by the European Pressure Ulcer Advisory Panel. The data collection instrument includes five categories of data: general data, patient data, risk assessment, skin observation and prevention.

The total sample consisted of 19 968 patients. The overall prevalence of pressure ulcers Category I–IV was 12.1%. Only 10.8% of the patients at risk received fully adequate prevention in bed and while sitting. More than 70% of the patients not at risk received some pressure ulcer prevention while lying or sitting.

Generally, there is a limited use of adequate preventive interventions for pressure ulcers in hospitals, which reflects a rather low quality of preventive care. The implementation of pressure ulcer guidelines requires more attention. The pressure ulcer prevention used in practice should be re-evaluated on a regular basis.

Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective.

Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork.

Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44–0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes.

With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.