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ChrisHartman: IHI Scientific Advisory Group http://bit.ly/c7rlrP

IHI’s work is guided by a Scientific Advisory Group, an independent group of advisors chartered by IHI’s Board of Directors, which provides expert review and guidance to improve the rigor and credibility of IHI’s results-oriented programs and activities.

Objectives

To examine the role of microsystem characteristics in the translation of an evidence-based intervention (the Diabetes Prevention Initiative (DPI)) into practice in a community-health centre (CHC).

Design

Case study.

Analysis

Constant comparative method of qualitative analysis.

Setting

Community-health centre in a mid-sized city in the USA.

Participants

27 administrators, clinicians and staff of a community-health centre implementing a DPI.

Main outcome measures

Perceptions of microsystem characteristics that influence the implementation of this initiative.

Results

Five characteristics of high-performing microsystems were reflected, but not maximised, in the implementation of the DPI. First, there was no universally shared definition of the desired purpose of the DPI. Second, investment in quality improvement (QI) was strong, yet sustainability remained a concern, since efforts were dependent upon external grant support. Third, lack of cohesiveness between the initiative planning team and the rest of the organisation served to both facilitate and constrain implementation. Fourth, administrators showed both support for new initiatives and a lack of strategic vision for QI. Fifth, this initiative substantially strained already-stretched role definitions.

Conclusions

Translation of the DPI in this CHC was constrained by the lack of a cohesive QI infrastructure and incomplete alignment with characteristics of high-performing microsystems. The findings suggest an important role for microsystem characteristics in the process of implementing evidence-based interventions. Enhancing the level of microsystem performance of CHCs is essential to informing efforts to improve quality of care in this critical safety-net system.

Objectives

To undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including a new patient held record) published in April 2007.

Methods

A multimethod study comprising semistructured interviews in 20 acute trusts and a telephone/email survey of general practitioners (GPs).

Results

The authors found a high degree of consensus concerning a number of problems in the management of anticoagulation services. Consultant haematologists and chief pharmacists expressed concern about the level of competence of junior medical and nursing staff and the quality of patient discharge from general inpatient wards. Patients were regularly discharged before being stabilised on Warfarin, pre-discharge information was not always given, patient-held records were not reliably completed nor follow-up arrangements made. At the ward level, there was some confusion about the responsibility for completing the yellow book on discharge and little awareness of the role of GPs in providing a monitoring service. GPs were largely dissatisfied with the quality of discharge information.

Conclusion

The baseline data present a significant cause for concern in the management of warfarin prior to the publication of the NPSA safety alert.

Introduction

Telephone consulting is increasingly used to improve access to care and optimise resources for day-time work. However, there remains a debate about how such consultations differ from face-to-face consultations in terms of content quality and/or safety. To investigate this, a comparison of family doctors' telephone and face-to-face consultations was conducted.

Methods

106 audio-recordings (from 19 doctors in nine practices) of telephone and face-to-face consultations, stratified at doctor level, were compared using the Roter Interaction Analysis Scale (RIAS) (content measure), the OPTION (observing patient involvement in decision making scale) and a modified scale based on the Royal College of General Practitioners (RCGP) consultation assessment instrument (measuring quality and safety). Patient satisfaction and enablement were measured using validated instruments. The Roter Interaction Analysis Scale scores were compared by multiple linear regression adjusting for covariates; other continuous measures by 2 and Student t tests and binary measures as odds ratios.

Results

Telephone consultations were shorter (4.6 vs 9.7 min, p<0.001), presented fewer problems (1.2 vs 1.8, p<0.001) and included less data gathering, counselling/advice and rapport building (all p<0.001) than face-to-face consultations. These differences remained significant when consultation length and number of problems were taken into account. Telephone consultations were judged less likely to include sufficient information to exclude important serious illnesses. Patient involvement and satisfaction outcomes were similar in both consultation types.

Conclusion

Although telephone consultations are convenient and judged satisfactory by patients and doctors, they may compromise patient safety more than face-to-face consultations and further research is required to elucidate this. Telephone consultations may be more suited to follow-up and management of long-term conditions than for in-hours acute management.

Objectives

To systematically review the peer-reviewed literature on interruptions in healthcare settings to determine the state of the science and to identify the gaps in research.

Methods

Inclusion criteria were determined, and the online databases PubMed and Web of Knowledge-CrossSearch were searched.

Results

Thirty-three papers were reviewed. Several important findings were identified: (1) interruptions occur frequently in all healthcare settings, (2) an important gap exists: only seven studies examined outcomes related to interruptions, (3) interruptions in healthcare have only been studied from the viewpoint of the person being interrupted and (4) few studies explicitly or implicitly examined the cognitive implications of interruptions.

Conclusions

The high frequency of interruptions coupled with information content may simply be indicative of the high need for constant communication and coordination in healthcare. Many interruptions may be necessary for safe, high-quality care; thus, trying to eliminate all interruptions is unwise. That said, there may be situations, such as during high-risk procedures, when limiting interruptions may be warranted. Taking a complex sociotechnical systems approach will help researchers view interruptions more holistically and will result in more comprehensive studies that take into account the complexity of interruptions and the many variables in healthcare settings.

Background

Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients' Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding ‘readiness’ at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative.

Materials and methods

A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI.

Conclusions

This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

Introduction

This paper expands the analogy between motor racing team pit stops and patient handovers. Previous studies demonstrated how the handover of patients following surgery could be improved by learning from a motor racing team. This has been extended to include contributions from several motor racing teams, and by examining transfers at several different interfaces at a non-specialist UK teaching hospital.

Methods

Letters of invitation were sent to the technical managers of nine Formula 1 motor racing teams. Semistructured interviews were carried out at a UK teaching hospital with 10 clinical staff involved in the handover of patients from surgery to recovery and intensive care.

Results

Three themes emerged from the motor racing responses; (1) proactive learning with briefings and checklists to prevent errors; (2) active management using technology to transfer information, and (3) post hoc learning from the storage and analysis of electronic data records. The eight healthcare themes were: historical working practice; problems during transfer; poor awareness of handover protocols; poor team coordination; time pressure; lack of consistency in handover practice; poor communication of important information; and awareness that handover was a potential threat to patient safety.

Conclusions

The lessons from motor racing can be applied to healthcare for proactive planning, active management and post hoc learning. Other high-risk industries see standardisation of working practices, interpersonal communication, consistency and continuous development as fundamental for success. The application of these concepts would result in improvements in the quality and safety of the patient handover process.

Background

Intrathecal administration of vincristine is a rare event but catastrophic for the patient, family and clinical team involved. Analysis of this source of harm shows it to be a classic systems error which has proved intractable for nearly 40 years. Failure to learn from history, communicate safety solutions nationally and internationally, create safety agencies which effectively and reliably prevent adverse events, conduct investigations and enquiries which fully reveals how to mitigate system error, develop robust physical design solutions to prevent harm to patients, make effective solutions universal and preparing for the unexpected are all major challenges.

Conclusions

The elimination of rare yet catastrophic errors like this remains one of the tests of whether we can make healthcare safer. In this paper, we discuss why effective learning has been so slow and illustrate lessons for other fields of patient safety.

Background

Safety rules continue growing rapidly, as if constraining human behaviour was the unique avenue for reaching ultimate safety. Safety rules are essential for a safe system, but their multiplication can have counterproductive effects.

Objective

To monitor, in an anaesthesia ward, compliance with a process-oriented safety rule, and understand barriers and facilitators which help and hinder physicians from following guidelines.

Methods

The rule stipulated that the day before surgery anaesthetists had to record in the patient's file the drugs to be used for the anaesthesia (induction, maintenance, airway control). Compliance was assessed before introduction of the rule, immediately after, at 6 months and at 12 months. All medical staff were blinded to the protocol.

Results

717 patient records were included. The results showed an initial compliance with policy, reaching 86% for some items (never 100%). Reduction began within 6 months and returned almost to initial levels within a year. One individual showed poor compliance throughout the study but even initially compliant doctors experienced a reduction. Compliance was higher for complex surgery but lower for unscheduled surgery and when job pressure was greater.

Conclusions

Compliance eroded over time. A major trigger of erosion seemed to be lack of continued compliance by a senior member of staff. Rules and procedures constitute fragile safety barriers, and it may be better to forego introducing a new safety rule if it is not considered as a priority by staff and is therefore vulnerable to sacrifice in case of conflict with competitive demands.

Background

Cross-fertilisation of ideas across industries, settings and contexts potentially improves learning by providing fresh insights into error pathways.

Objectives and hypotheses

To investigate six cases of human error drawn from disasters in the space, shipping, aviation, mining, rail and nuclear industries, and to apprehend similarities and differences in the antecedents to errors, the way they manifest, the course of events and the way they are tackled. The extent to which human intervention can exacerbate the problems by introducing new errors, how the cases are resolved and the lessons learnt were examined.

Design, setting and participants

Exemplar disaster events drawn from a very large sample of human errors.

Results

It is possible to identify and model a generic disaster pathway that applies across several industries, including healthcare.

Conclusions

Despite differences between industries, it is clear that learning from disasters in other industries may provide important insights on how to prevent or ameliorate them in healthcare.

Objective

To compare the incidence and severity rating of dose prescribing errors before and after the implementation of a commercially available electronic prescribing system at a tertiary care children's hospital.

Methods

Dose errors were identified using prescription review to detect errors. Severity rating was determined by five judges using a validated, reliable scoring tool. The mean score for each error was used as an index of severity.

Results

Dose prescribing errors occurred in 88 of the 3939 (2.2%) items prescribed for outpatients and inpatients, and on discharge prescriptions prior to the implementation of electronic prescribing (EP). After EP, there were 57 dose errors in 4784 (1.2%) items prescribed (1% absolute reduction (p<0.001 2 test; 95% CI of difference in proportions –1.6% to –0.5%)). A decrease in the severity rating of dose errors was also seen: dose errors with potentially minor outcomes 35/3939 (0.89%) pre vs 21/4784 (0.44%) post (95% CI of difference in proportions –0.8% to –0.11%, p=0.009 2 test); moderate outcome 46/3939 (1.17%) pre vs 33/4784 (0.69%) post (95% CI of difference in proportions –0.91% to –0.08, p=0.019, 2 test); severe outcome: 7/3939 (0.18%) pre vs 3/4784 (0.06%) post (95% CI of difference in proportions –0.31% to +0.04, p=0.11, 2 test).

Conclusion

Electronic prescribing appears to reduce rates of dosing errors in paediatrics, but larger studies are required to assess the effect on the severity of these errors and in different settings.

Objective

To investigate the overall probability of error in preparing and administering intravenous medicines; to identify at which stage of the process an error is most likely to occur; and to determine the impact of error correction on the error probability.

Design

Systematic review and random-effects Bayesian conditional independence modelling.

Methods

Medline and EMBASE were searched for studies on intravenous medicines. The error rates of each stage were extracted. These, expert estimates, and error rates from generic tasks, were used in a Bayesian conditional independence model to find error ‘hot-spots.’ The main outcome measure was the probability of at least one error occurring during intravenous therapy.

Results

Nine published studies were identified for inclusion in the systematic review and meta-analysis. The overall probability of making at least one error in intravenous therapy was 0.73 (95% credible interval (CrI) 0.54 to 0.90). If error-checking was introduced at each stage of the process, the overall rate fell to 0.22 (95% CrI 0.14 to 0.31). Errors were most likely in the reconstitution step. Removing the reconstitution step by providing preprepared injections would reduce the overall error rate to 0.17 (95% CrI 0.09 to 0.27).

Conclusions

Intravenous therapy is complex and error-prone. Error-checking at each stage could reduce the error probability. The use of preprepared injections may help by eliminating errors in the reconstitution of drug and diluent. However, it will be important to ensure that benefits are not outweighed by practical disadvantages such as an increase in selection errors.

Aim

The goal of this project was to improve unit-based safety culture through implementation of a multidisciplinary (pharmacy, nursing, medicine) teamwork and communication intervention.

Method

The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture was used to determine the impact of the training with a before–after design.

Results

Surveys were returned from 454 healthcare staff before the training and 368 staff 1 year later. Five of eleven safety culture subscales showed significant improvement. Nurses perceived a stronger safety culture than physicians or pharmacists.

Conclusion

While it is difficult to isolate the effects of the team training intervention from other events occurring during the year between training and postevaluation, overall the intervention seems to have improved the safety culture on these medical units.

Background

While many residency programmes have implemented quality improvement (QI) training programmes, few have been rigorously evaluated.

Methods

Residents at the authors' institution participated in a required course, the Quality Assessment and Improvement Curriculum during two 1-month-long rotations. The American Board of Internal Medicine (ABIM) Practice Improvement Module (PIM) was used to guide residents through chart reviews for quality measures, surveys of patient satisfaction and an assessment of clinic systems. Residents received 12 h of training in QI skills (ie, using Plan–Do–Study–Act cycles). Residents worked in groups to test the effect of a small QI project of their choosing. Residents completed the Quality Improvement Knowledge Assessment Tool (QIKAT) to assess QI knowledge, and a self assessment of QI skills. Third-year residents who did not participate in the curriculum served as a historical control group.

Results

87% (26/30) of PGY2s (intervention group) and 83% (24/29) of PGY3 residents (historical controls) completed the self assessment and QIKAT. PGY2 residents showed a significant improvement in QIKAT scores (Pre: 6.98 (6.23 to 7.72) vs Post: 9.70 (8.92 to 10.50); p<0.001) and all 12 QI skills. In addition, the post-PGY2 intervention group outperformed the PGY3 historical control group in QIKAT scores (PGY2 Post-9.59 (8.82 to 10.36) vs PGY3 Control 7.34 (6.48 to 8.20); p<0.001) and all QI skills.

Conclusion

A QI curriculum using the ABIM PIMs and small-group, resident chosen QI projects can result in improvements in resident knowledge and self-assessed skills in QI. The use of a historical control group was a helpful way to account for the effects of accumulating experience in the pre-post evaluation of this curriculum.

Problem

Medical nutrition therapy is an important component of glycaemic management in hospitalised patients with diabetes; however, there is a lack of information guiding the ordering of specific meal plans in this setting.

Setting

University-affiliated academic medical centre.

Methods

An administrative decision to gradually replace standard consistent-carbohydrate (CCMP) (standard group) with patient-controlled meal plans (patient-controlled group) presented the opportunity to compare menu selection, adherence to CCMP, glycaemic control and satisfaction as a quality-improvement initiative. Information was obtained from consecutive inpatients with diabetes admitted to units receiving standard (n=30) or patient-controlled meal plans (n=43). Patients received the meal plan according to unit location.

Results

No group differences were observed in adherence to CCMP (70% vs 64%, p=0.1), mean capillary blood glucose (CBG) or hyperglycaemia frequency (CBG>180 mg/dl). Hypoglycaemia (CBG<70 mg/dl) occurred more frequently in the patient-controlled group (0.39 vs 3.23%, p=0.04). There were no episodes of severe hypoglycaemia (CBG<40 mg/dl) in either group. The patient-controlled group reported a greater satisfaction and had more opportunities for nutrition education, with a demonstrated improvement in adherence to CCMP following targeted education in six of nine patients with available menu data.

Conclusions

The standard group experienced less hypoglycaemia and required less clinician oversight. The patient-controlled group allowed for identification of patients who would benefit from education, required more oversight by nutrition services and reported greater satisfaction with their meal plan. Both meal plans may be appropriate for inpatients with diabetes, provided that a sufficient review is available for patients who make inappropriate selections with the patient-controlled meal plan.

Background

Communication is problematic in healthcare. The Veterans Health Administration is implementing Medical Team Training. The authors describe results of the first 32 of 130 sites to undergo the programme. This report is unique; it provides aggregate results of a crew resource-management programme for numerous facilities.

Methods

Facilities were taught medical team training and implemented briefings, debriefings and other projects. The authors coached teams through consultative phone interviews over a year. Implementation teams self-reported implementation and rated programme impact: 1=‘no impact’ and 5=‘significant impact.’ We used logistic regression to examine implementation of briefing/debriefing.

Results

Ninety-seven per cent of facilities implemented briefings and debriefings, and all implemented an additional project. As of the final interview, 73% of OR and 67% of ICU implementation teams self-reported and rated staff impact 4–5. Eighty-six per cent of OR and 82% of ICU implementation teams self-reported and rated patient impact 4–5. Improved teamwork was reported by 84% of OR and 75% of ICU implementation teams. Efficiency improvements were reported by 94% of OR implementation teams. Almost all facilities (97%) reported a success story or avoiding an undesirable event. Sites with lower volume were more likely to conduct briefings/debriefings in all cases for all surgical services (p=0.03).

Conclusions

Sites are implementing the programme with a positive impact on patients and staff, and improving teamwork, efficiency and safety. A unique feature of the programme is that implementation was facilitated through follow-up support. This may have contributed to the early success of the programme.