Quality and Safety in Health Care Journal

In an effort to improve patient safety attitudes and skills among third-year medical students, two patient safety training sessions were added to their curriculum, complementing a previously implemented second-year curriculum on quality improvement, patient safety and teamwork.

Safety attitudes and skills were assessed before and after students completed the medicine clerkship training and were compared with historical controls. Students identified and reported on observed safety events, with their reports matched to event type and harm score with contemporaneous safety reports from University of Missouri's Patient Safety Network (PSN). Comparisons were assessed by five internal safety experts using criteria for report submission "worthiness", blame tone, target of blame and presence/strength of proposed solutions.

Students completing the third-year safety booster conferences expressed statistically higher comfort levels with identifying the cause of an error than did the student control group (p<0.05). Medical students proposed safety interventions that were more robust than those suggested by event reporters regarding similar events within our health system (p<0.0001). The worthiness and blame tone of medical student reports were not statistically different than event reports in PSN.

Completion of two 1-h patient safety booster conferences in the third year of medical school led to increased student comfort in safety event analysis. Students documented stronger resolution robustness scores, suggesting similar training should be offered to PSN reporters. Medical students represent an underutilised resource for identifying and proposing solutions for patient safety issues.

To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average.

The method uses routine administrative databases that are available nationally in The Netherlands—the National Medical Registration dataset for the years 2005–2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process.

In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patient's risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005–2007 is 2.3 times the HSMR of the hospital with the lowest value.

Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.

Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance.

To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance.

Independent blinded assessment of these variables in a random, stratified sample of health service organisations.

Acute care: large, medium and small health-service organisations in Australia.

Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system.

Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance.

Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377).

Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

The benefits on clinical practice of a clinical decision support system (CDSS) are predominantly determined by the quality of the clinical rules used in this system. Therefore, it is essential to investigate the performance and potential benefits on quality of care of these rules.

A clinical rule assisting physicians in selecting the appropriate dosage according to renal function of frequently prescribed antimicrobials was developed. In 2004, 1788 patients admitted to the intensive care unit (ICU) for more than 12 h were included in this retrospective study. The actual number of dosage adjustments without the support of the CDSS was compared with the theoretical number of dosage adjustments determined by the clinical rule in patients with moderate (creatinine clearance (Clcreat) 10–50 ml/min) and severe (Clcreat <10 ml/min) renal dysfunction. If dosage adjustment was omitted, the duration of excessive anti-infective dosing and extra drug costs involved was determined.

Dosage adjustment of antimicrobials was omitted in 163 patients (86%) with moderate renal failure and 13 patients (54%) with severe renal failure. Excessive exposure was most frequently detected in patients receiving fluconazole and ciprofloxacin (median duration of 6 days). In our ICU alone, more than 16 000 ($19 000) can be saved annually by adjusting the dosage according to renal function of frequently prescribed antimicrobials.

Despite intensive monitoring of patients in the ICU, dosage adjustment of antimicrobials is often omitted. Implementing this clinical rule has the potential to contribute to a significant improvement in medication safety and is expected to generate substantial savings.

Skilled managers are an important component of quality improvement (QI) infrastructure, but there has been little evaluation of QI infrastructure, which is needed to guide enhancement of this capacity.

Quality managers at 97 acute care hospitals in Ontario, Canada, were surveyed by mail to describe how their roles were integrated with QI performance objectives. Binary and scaled responses were analysed quantitatively, and open-ended responses were analysed thematically.

The response rate was 79.4%. Many QI managers were new to their role and had no support staff despite responsibility for multiple portfolios. Respondents thought that QI objectives should be less reactive to hospital executives or boards, adverse events or demands from government and accreditation bodies, and recommended that dedicated QI managers proactively apply explicit strategic plans and engage executives and clinicians. Findings were consistent regardless of rank, staffing or hospital type. Those with master's training and greater experience were more involved in strategic planning, data analysis and communication.

QI is not well resourced in most acute care hospitals in Ontario. To develop QI capacity, investment and QI training may be required. Research should empirically establish objective performance measures of QI capacity to guide investment and evaluation.

To test the feasibility of applying population impact measures utilising local population data on established interventions for heart failure and diabetes mellitus.

Modelling study.

Registered general practitioner (GP) population in a primary care trust (PCT)

Local data sources included the quality and outcomes framework, chronic disease registers for coronary heart disease and diabetes, hospital episode statistics and a range of published risk data in heart failure and diabetes.

Number of events prevented in the population (NEPP) by increasing the uptake of established interventions expressed as the number of deaths, hospitalisations and cardiovascular events prevented.

Data from 17 GP practices (representing 55% of the PCT GP registered population) were used to derive the NEPP. A 10% increase in the number of eligible patients receiving ACE inhibitors (n = 191) could result in at least 18 fewer deaths (95% CI 9.8 to 27.1) and 32 fewer hospitalisations (95% CI 24.9 to 40.7) for heart failure every year. Only 45% of persons with diabetes with an above target total cholesterol were receiving a statin; increasing this to 75% (additional 921) could lead to 44 (95% CI 15.6 to 73.1) fewer cardiovascular disease (CVD) events over 5 years. Similarly, more rigorous blood pressure control in an additional 662 diabetic patients could result in 26 (95% CI –2.7 to 55.6) fewer CVD events over 5 years. There were differences in the potential impact of these interventions according to subgroups within the PCT, as defined by age and geography (locality).

Local data and published literature estimates can be successfully combined to produce the number of events prevented within a locally defined PCT population (NEPP). Commissioners have shown interest in the utility of such a measure in identifying and quantifying areas for improvement.

Systematic analysis of error recovery can provide hospitals with important information to help them improve their ability to detect and correct errors. Because errors will always crop up and 100% safety can never be achieved, hospitals should be able to prevent patient harm by timely and effective error recovery.

In this study, failed, missed and absent recovery opportunities were identified in 52 medication errors which all resulted in severe patient harm or patient death. For all identified recovery opportunities, the underlying failure factors were identified and classified according to the Eindhoven classification model. Those failure factors represent negative influences on error recovery.

The number of recovery opportunities per error ranged from 0 to 11; on average, 2.4 recovery opportunities were identified. Of 127 identified recovery opportunities, 94 (74%) were planned and 33 (26%) were unplanned or ad hoc. Most failure factors underlying the planned recovery opportunities were organisational failure factors; most failure factors underlying the unplanned recovery opportunities were human failure factors.

From this study, it can be concluded that actual accidents can be used as an alternative data source to near misses for the analysis and understanding of error recovery. By using both sources, hospitals can enhance their resilience by reinforcing the positive influences on error recovery as well as reducing the negative ones. Together with traditional error reduction methodologies, which only concentrate on eliminating failure factors, hospitals thus have numerous opportunities to improve patient safety.

Unsafe medical care may cause substantial morbidity and mortality globally, despite imprecise estimates of the magnitude of the problem. To better understand the extent and nature of the problem of unsafe care, the WHO World Alliance for Patient Safety commissioned an overview of the world's literature on patient safety research.

Major patient safety topics were identified through a consultative and investigative process and were categorised into the framework of structure, process and outcomes of unsafe care. Lead experts examined current evidence and identified major knowledge gaps relating to topics in developing, transitional and developed nations. The report was reviewed by internal and external experts and underwent improvements based on the feedback.

Twenty-three major patient safety topics were examined. Much of the evidence of the outcomes of unsafe care is from developed nations, where prevalence studies demonstrate that between 3% and 16% of hospitalised patients suffer harm from medical care. Data from transitional and developing countries also suggest substantial harm from medical care. However, considerable gaps in knowledge about the structural and process factors that underlie unsafe care globally make solutions difficult to identify, especially in resource-poor settings.

Harm from medical care appears to pose a substantial burden to the world's population. However, much of the evidence base comes from developed nations. Understanding the scope of and solutions for unsafe care for the rest of the world is a critical component of delivering safe, effective care to all of the world's citizens.

The World Alliance for Patient Safety was formed to accelerate worldwide research progress towards measurably improving patient safety. Although rates of adverse events have been studied in industrialised countries, little is known about the rates of adverse events in developing and emerging countries.

To review the literature on patient safety issues in developing and emerging countries, to identify patient safety measures presently used in these countries and to propose a method of measurably improving patient safety measurement in these countries.

Using the Medline database for 1998 to 2007, we identified and reviewed 23 English-language articles that examined patient safety measurement in developing and emerging countries.

Our review included 12 studies that prospectively measured patient safety and 11 studies that retrospectively measured safety. Two studies used measures of structure and the remaining used process measures, outcome measures or both. Whereas a few studies used surveys or direct observation, most studies used chart audits to measure patient safety. Most studies addressed safety at a single facility.

Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.

Few institutions currently track intensive care unit (ICU)-specific medication safety data. A comparison of medication error data for intensive care and general care units may determine if ICU-specific surveillance is needed.

To compare the type, cause, contributing factors, level of staff initiating an error, medication use process node, drug classes and patient outcomes for voluntarily reported medication errors occurring in ICUs and general care units.

Retrospective evaluation of voluntarily reported medication errors over 4.5 years at a 647-bed academic medical centre containing greater than 120 ICU beds. Adult patients with a reported medication error in intensive care and general care units were included. Medication error data were compared for ICUs with general care units.

There were a total of 3252 medication errors reported with 541 and 2711 occurring in ICUs and general care units, respectively. Primary types of medication errors were prescribing in the ICUs and omission in the general care units. Leading causes of medication errors were procedure/protocol not followed and knowledge deficit in the ICU and general care units. More frequently there was no contributing factor identified for medication errors in the ICUs. The top three drugs associated with medication errors in the ICUs were opioid analgesics, β-lactam antimicrobials and blood coagulation modifiers compared with anti-asthma/bronchodilators, narcotic analgesics and vaccines in the general care units. The level of care provided after the error was observation increased/initiated in ICUs and no additional care in general care units. Prolonged hospitalisation was a result of medication errors in 1% of ICU cases and 0.4% of general care unit errors (p = 0.056). Medication errors were associated with harm in 12% and 6% of cases in the ICUs and general care units, respectively (p<0.001).

Type, contributing factors, drug classes and patient outcomes associated with voluntarily reported medication errors differ in intensive care and general care units so it is important to develop surveillance systems that analyse ICU-specific data allowing systematic changes for this patient population.

To describe relationships between teamwork behaviours and errors during neonatal resuscitation.

Trained observers viewed video recordings of neonatal resuscitations (n = 12) for the occurrence of teamwork behaviours and errors. Teamwork state behaviours (such as vigilance and workload management, which extend for some duration) were assessed as the percentage of each resuscitation that the behaviour was observed and correlated with the percentage of observed errors. Teamwork event behaviours (such as information sharing, inquiry and assertion, which occur at specific times) were counted in 20-s intervals before and after resuscitation steps, and a generalised linear mixed model was calculated to evaluate relationships between these behaviours and errors.

Resuscitation teams who were more vigilant committed fewer errors (Spearman's for vigilance and errors = –0.62, 95% CI –0.07 to –0.87, p = 0.031). Assertions were more likely to occur before errors than correct steps (OR = 1.44, 95% CI 1.10 to 1.89, p = 0.008) and teaching/advising occurred less frequently after errors (OR = 0.59, 95% CI 0.37 to 0.94, p = 0.028). Though not statistically significant, there was less information sharing before errors (OR = 0.90, 95% CI 0.77 to 1.05, p = 0.172).

Vigilance is an important behaviour for error management. Assertion may have caused errors, or perhaps was an indicator for some other factor that caused errors. Teams may have preferred to resolve errors directly, rather than using errors as opportunities to teach their teammates. These observations raise important questions about the appropriate use of some teamwork behaviours and how to include them in team training programmes.

A project sponsored by the University Health System Consortium has addressed the inaccuracy and high variability across institutions concerning the use of the failure to rescue (FTR) quality indicator defined by the Agency for Healthcare Research and Quality (AHRQ). Results indicated that of the complications identified by the quality indicator, 29.5% were pre-existing upon hospital admission.

The purpose of our study was to investigate the possible bias to FTR measures by including cases of complications that were pre-existing at admission.

Hospital discharges between 1 January 1996 and 30 September 2007 were retrospectively gathered from administrative databases. Using definitions outlined by the AHRQ and the National Quality Forum (NQF), FTR rates were calculated. Using present on admission coding, FTR rates were recalculated to differentiate between the rates of pre-existing and that of acquired cases.

Using the AHRQ definition, the overall FTR rate was 11.60%. The FTR rate for patients with pre-existing complications was 8.85%, whereas patients with complications acquired during hospitalisation had an FTR rate of 18.46% (p<0.001). The NQF FTR rate was 9.93%. Pre-existing and acquired FTR rates using the NQF measure were 9.42% and 12.77%, respectively (p<0.001).

Current definitions of FTR measures meant to identify inhospital complications appear biased by the inclusion of problems at admission. Furthermore, many patients with these complications are excluded from the algorithms. When taking into account the timing of the "complications", these measures can be useful for internal quality control. However, it should be stressed that the usefulness of the measures to compare institutions will be dependent on coding practices of institutions. Validation using chart review may be required.

Investigation of patient safety incidents has focused on retrospective analyses once incidents have occurred. Prospective risk analysis techniques complement this but have not been widely used in healthcare.

Prospective risk identification of non-operative risks associated with adult elective surgery under general anaesthesia using a customised structured "what if" checklist and development of risk matrix. Prioritisation of recommendations arising by cost, ease and likely speed of implementation.

Groups totalling 20 clinical and administrative healthcare staff involved in peri-operative care and risk experts convened by the UK National Patient Safety Agency.

102 risks were identified and 95 recommendations made. The top 20 recommendations together were judged to encompass about 75% of the total estimated risk attributable to the processes considered. Staffing and organisational issues (21% of total estimated risk) included recommendations for removing distractions from the operating theatre, ensuring the availability of senior anaesthetists and promoting standards and flexible working among theatre staff. Devices and equipment (19% of total estimated risk) could be improved by training and standardisation; airway control and temperature monitoring were identified as two specific areas. Pre-assessment of patients before admission to hospital (12% of estimated risk) could be improved by defining a data set for adequate pre-assessment and making this available throughout the NHS.

This technique can be successfully applied by healthcare staff but expert facilitation of groups is advisable. Such wider-ranging processes can potentially lead to more comprehensive risk reduction than "single-issue" risk alerts.

Implementation of quality improvement programmes may suffer if the stakeholders involved do not share a common understanding of the theory of change or do not accept it as legitimate. We aimed to identify how strategic stakeholders understood and responded to the first phase of the Health Foundation's Safer Patients Initiative, a programme aimed at making hospitals safer for patients in the UK.

Semistructured telephone interviews were conducted with 60 strategic-level hospital stakeholders and with five stakeholders involved in commissioning, designing and introducing the initiative. Analysis was based on the constant comparative method.

The aims of the initiative were seen as legitimate and sound by most hospital stakeholders, and the theory of change was generally understood and accepted, but seven hospital stakeholders were unable to describe it. Although participants had specific doubts, particularly relating to feasibility of implementation and scientific legitimacy of some elements of the initiative, overall there was a broadly shared vision and commitment to the principles and practices associated with the theory of change, and considerable enthusiasm and optimism. Contestations about the legitimacy and relevance of the initiative among front-line staff, local resistance to changes that went against established norms, and resource and structural issues were, however, seen as potentially threatening to implementation.

It is possible to get strategic-level individuals, even when widely dispersed, to understand and agree upon a theory of change that can be used in their organisations. These individuals are also able to recognise the contexts of negotiation in which programmes of change are enacted.