BMJ Open Quality最新文献

Background: Human and planetary health are deeply interconnected and endangered by the triple planetary crisis: climate change, biodiversity loss and pollution. Despite proactive measures being pursued to reduce healthcare's overall environmental footprint, relatively few of these are directed at primary care, notwithstanding that it accounts for up to 25% of healthcare's ecological impact. Within Ireland's primary healthcare sector, despite a growing recognition of the importance of environmentally sustainable healthcare, little is known about the perspectives of those healthcare professionals (HCPs) working in the sector to delivering more environmentally sustainable primary care services.

Methods: This qualitative descriptive study explored the knowledge and attitudes of community pharmacists, dentists, general practitioners and practice nurses working in primary care in Ireland, toward planetary health and sustainable healthcare. Semistructured interviews were conducted between May and September 2024 and analysed using inductive qualitative content analysis.

Results: Analysis of interviews (n=20) produced a broad range of insights which were consolidated into three higher order categories. Findings revealed that while HCPs recognised the importance of climate action, many felt unable to translate concern into practical change in primary care due to barriers such as a lack of knowledge, limited guidance and inadequate system-level supports. HCPs emphasised the need for targeted training, access to practical tools and clear leadership from the relevant stakeholders.

Conclusion: This study highlights the urgent need to shift from reliance on individual motivation to practice sustainably, to a coordinated public health response in Ireland. Achieving this requires educational and systemic changes, including supportive policy, incentivisation and practical sustainable interventions, to embed environmental sustainability into routine care.

Background: Obstetrical haemorrhage is a common complication of childbirth, and all patients are at risk for haemorrhage. Mortality attributable to haemorrhage has been decreasing in the USA, but the incidence of haemorrhage has continued to increase. In Ohio, one-third (31%) of all pregnancy-related deaths in 2020 were due to causes other than infection, mental health or embolisms, with 3% of those attributed to haemorrhage. Haemorrhage was the third leading cause of pregnancy-related death in the state from 2008 to 2016.

Methods: Sponsored by the Ohio Department of Children and Youth, the Hemorrhage Quality Improvement Project (QIP) applies the Institute for Healthcare Improvement's methodology to implement structured quality improvement (QI) activities to improve key measures and implement the Alliance for Innovation on Maternal Health's Obstetric Hemorrhage Patient Safety Bundle. Hospitals provided patient data and completed surveys. Data from participating hospitals were used to calculate and monitor improvement in primary process measures (quantitative blood loss and haemorrhage risk assessment).

Results: Across Ohio, 22 delivery hospitals spanning 13 health systems participated in the Hemorrhage QIP pilot. Participating hospitals achieved a statistically significant improvement in all process measures, including quantitative blood loss documentation (both overall and when limited to vaginal deliveries) and in the completion of haemorrhage risk assessment between admission and delivery.

Conclusions: The Hemorrhage QIP demonstrates feasibility of a statewide QI initiative to improve care for women who experience obstetrical haemorrhage. Delivery hospitals have clinical expertise to improve outcomes related to postpartum haemorrhage care. Providing opportunity for peer-to-peer learning, evidence-based resources and QI coaching within a replicable QI project creates an opportunity to reduce preventable morbidity and mortality caused by an obstetric haemorrhage.

Background and objectives: Medication administration errors (MAEs) are frequent and preventable. While the five rights (5R) rule and the double-check are standard practices for safe drug administration, incidents still occur. MAEs involving high-risk drugs such as opioids are a major concern, especially in older patients. To address this, a practical, error-driven training was developed through an opioid Room of Horrors (RoH) to reinforce the 5R rule and the double-check procedure and map risks within the opioid medication-use process, thereby improving the safety of opioid administration. The secondary objective was to evaluate participant satisfaction with the training.

Method: The opioid RoH integrates four errors and four hazards hidden in the opioid medication-use process. Participants, working in pairs, were asked to prepare and administer an opioid to a fictitious patient. Two assessors recorded the number of errors detected and hazards avoided. During the debriefing, assessors reviewed and explained these items to the pair of trainees combined with a refresh on the 5R rule and the double-check process. Detection and avoidance rates were analysed using descriptive statistics. Participants assessed the training through a satisfaction questionnaire.

Results: A total of 86 sessions were conducted, involving 172 participants including nurses, nurse assistants and physicians from a geriatric department. Participants detected errors such as wrong patient (60%), expired drugs (63%), incorrect strength or galenic form (55%) and documented allergy (55%), while most hazards were avoided, except for the correct device, which was used in only 65% of cases. Double-check performance was inefficient mainly focusing on the dose check. Satisfaction was high (9.2/10), and 73% of participants reported a knowledge gain.

Conclusions: The opioid RoH is an effective training to refresh and emphasise the rigorous application of the 5R rules and the double-check procedure to reduce MAEs. Additionally, this simulation showed persistent gaps such as patient identification and double-check failures, highlighting the need to strengthen safety practices through continuous training and institutional-level system improvements in medication administration safety.

Medication reconciliation is the practice of making sure that medication lists are accurate through transitions of care. This is critical to reduce medication prescription medication errors, which can compromise patient safety. Evidence indicates that communication breakdowns account for a sizable portion of prescription errors, highlighting the importance of efficient medication reconciliation.Medication reconciliation has been recognised as an important patient safety measure by Sheikh Shakhbout Medical City (SSMC), a large tertiary hospital in the United Arab Emirates. Senior leadership at SSMC, in an effort to adopt safer practices, decided to increase the outpatient medication reconciliation compliance goal to 92%; however, meeting this new goal proved difficult. According to an analysis of the first two quarters of 2023 performance data, the department of medicine's average outpatient medication reconciliation compliance rate was persistently below the new goal of 92%, at 80%.Over the course of 14 months, from August 2023 to September 2024, 133 328 patient visits were evaluated at the department of medicine outpatient specialty clinics, a busy department serving about 9500 patients each month.This publication's goal is to highlight the quality improvement initiatives that were put in place to increase outpatient medication reconciliation compliance as well as the results of those initiatives. We were able to increase the department of medicine outpatient medication reconciliation compliance rate from an average of 80% in August 2023 to 97% in April through September 2024 by applying critical thinking, technology and human factor principles. This improvement was maintained.This study highlights the need for quality improvement teams using information technology to understand the clinical context and human elements at play. The department of medicine's outpatient medication reconciliation improvement initiative paved the way for possible replication in other departments and healthcare organisations by disseminating the lessons acquired from this quality improvement project throughout the hospital.

Problem: Hospital readmissions following elective colorectal resections remain a persistent challenge, affecting recovery, hospital efficiency and overall quality of surgical care. Readmissions increase morbidity, healthcare costs and may delay ongoing cancer treatment. Within our institution, the colorectal surgical team noted a rise in unplanned readmissions after discharge, prompting structured evaluation.

Background: Colorectal resections form a major component of elective surgical activity at our centre. During early 2024, local Model Health System dashboards showed readmission rates above regional medians for both colonic and rectal resections. These findings, together with governance discussions about potentially preventable readmissions, led to a quality improvement project. National benchmarking data from the Getting It Right First Time programme were used to contextualise performance. These benchmarks are now integrated within the NHS Model Health System, enabling ongoing data-driven monitoring across surgical specialties.

Aim: To evaluate 30-day readmission rates following elective colorectal resections, identify contributory factors, and propose targeted quality improvement measures.

Methods: A retrospective observational review was conducted at Whiston Hospital for patients undergoing elective colorectal resections between July and September 2024. Data included demographics, procedure type, comorbidities, length of stay and 30-day readmissions. Causes of readmission were analysed and compared with national data.

Results: Among 28 patients (mean age 61±14 years; 61% male), the median length of stay was 6 days. The 30-day readmission rate was 14.2%, exceeding national benchmarks. Common causes included urinary retention, intra-abdominal collections, port-site hernia and gastrointestinal symptoms. Readmissions were associated with shorter stays and comorbidities. Model Health System data indicated early improvement in rectal resections but a modest rise in colonic cases.

Conclusion: Readmissions exceeded national averages, emphasising the need for enhanced recovery compliance, prehabilitation, improved discharge planning and early post-discharge follow-up. Continuous benchmarking supports sustainable improvement in outcomes.

Background: End-stage liver disease (ESLD) is a terminal diagnosis with a poor prognosis and an accelerating mortality rate in the UK. Limited research suggests that patients with ESLD have unmet palliative care (PC) needs, likely due to various factors, including difficulty predicting prognosis and lack of clear specialist palliative care (SPC) referral criteria.This quality improvement (QI) project aimed to assess and improve access to PC for inpatients with ESLD and unmet PC needs over a 6-month period using a novel intervention incorporating the Supportive and Palliative Care Indicators Tool for Liver Disease (SPICT).

Methods: The project was conducted at a tertiary centre between 2020 and 2022 with three data cycles: one baseline measurement and two Plan-Do-Study-Act (PDSA) cycles. PDSA cycle 1 involved regular screening of inpatients using the SPICT to trigger SPC referral. PDSA cycle 2 also involved screening using the SPICT, but instead to prompt multidisciplinary meeting (MDM) discussion between hepatology and SPC teams. Outcome measures reflecting holistic aspects of PC were assessed across all cycles.

Results: PDSA cycle 1 demonstrated a significant reduction in patients receiving no PC measures (67% to 26%, p: <0.001) and increased SPC input (32% to 52%, p: 0.04). Community PC referrals also rose significantly (13% to 39%, p: 0.01).PDSA cycle 2 failed to improve measures compared to baseline. Only 42% of eligible patients were discussed in the MDM. Most agreed plans were implemented, but only a minority included SPC review, community PC referral or advanced care planning.

Conclusion: Patients with ESLD continued to have unmet PC needs despite implementing an intervention based on expert guidance. PDSA cycle 1 demonstrated some significant, positive impacts, supporting the clinical utility of the SPICT, but within the context of a small, single-centre QI project with methodological limitations.

Introduction: Healthcare team performance directly impacts the quality and safety of medical care. However, measuring the performance of teams is challenging and requires methodologies to investigate different contributing elements. This study proposes an AI(artificial intelligence)-driven multimodal approach to visualising gaze (ie, joint visual attention) and speech in medical team performance and examines how these might differ across medical expertise, using eye-trackers and our own automatic gaze annotation programme.

Method: Four simulation sessions, two in Japan and another two in the UK, were filmed with eye-trackers worn by a clinician and a nurse. In each site, one session was conducted with an experienced pair (UK_Ex and JP_Ex) and the other with a less experienced pair (UK_LessEx and JP_LessEx). The scenarios were a difficult intubation in Japan and a urine infection, with a family member present, in the UK. The numbers of occurrences and the time lengths of joint attention and individuals' speeches in the four data sets were compared in total and in 15 s time ranges to see the correlations.

Result: The Ex pairs in both contexts paid joint visual attention more frequently and longer and spoke more than the LessEx pairs. In the JP_Ex, the positive correlation was found between the numbers of joint attention and the total speech durations (r=0.81). That indicates the team members verbally coordinated each other's attentional objects, which is termed coregulative attentional engagement. In contrast, in the UK_Ex, the correlation was negative (r=-0.70), where they visually monitored each other's actions while talking to the patient's family, which we call coinfluential attentional engagement. These tendencies were weak in the LessEx pairs.

Conclusion: Although the accuracy of automatic annotation (approximately. 40%-60%) should be improved before applying it to medical training, the research method could provide preliminary insight into elements of good team performance.

Workplace harassment among healthcare workers, particularly nursing students, has reached concerning levels, often resulting in serious consequences. At an acute tertiary teaching hospital in Singapore, reported cases of harassment among nursing students doubled from four in 2019 to eight in 2021. Delayed reporting, often due to a lack of awareness of a structured reporting system, exacerbates the issue. The Clinical Abuse Preventive Education for Students (CAPES) team was formed in January 2022 to empower nursing students to identify, manage and report abusive situations, with its impact evaluated using Kirkpatrick's four-level training evaluation framework.

Methods: Interventions included the development and dissemination of infographic booklets, the establishment of CAPES Buddy for incident reporting and faculty training in psychological support skills. A total of 811 nursing students commenced training under the CAPES initiative between January 2023 and April 2024. Of these, 542 completed both baseline and follow-up surveys, which measured understanding of workplace harassment and confidence in responding. Additionally, 54 faculty members underwent psychological support training to strengthen their ability to support students in crisis.

Results: Following the interventions, nursing students demonstrated a 13.7% increase in their ability to identify harassment and an 18.7% increase in confidence to respond appropriately. Overall, 98% of students demonstrated comprehension of harassment-related issues. These improvements were accompanied by increased reporting and more appropriate triage of harassment cases, with students using CAPES Buddy for complex incidents while clinical instructors managed less severe cases as first-line support. Faculty members also reported enhanced competence in supporting students, contributing to a safer learning environment.

Conclusion: CAPES strengthened students' awareness of workplace harassment and improved their confidence in responding and reporting incidents. While most students found the training relevant and beneficial, delayed reporting remains a challenge. Future work should explore factors contributing to reporting delay such as fear of retaliation or lack of trust in reporting systems and evaluate targeted strategies to address them.

Background: Artificial intelligence (AI)-generated text to video is emerging in medical education, but its effectiveness, accuracy and safety remain uncertain. We aimed to synthesise empirical studies evaluating these tools in learner or patient education.

Methods: A comprehensive search was conducted in MEDLINE/PubMed, Google Scholar, Scopus, Cochrane Review and Web of Science for studies published up to January 2025. Eligible studies evaluated AI-generated text to video for medical or patient education, reporting both quantitative and qualitative outcomes. Two reviewers screened and extracted data. The review adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Out of 103 identified studies, five studies met the inclusion criteria: four evaluated patient education and one evaluated physician training. Clinical areas were ophthalmology (2/5), plastic surgery (1/5), dysphagia rehabilitation (1/5) and neurosurgical training (1/5). In ophthalmology, control materials outperformed AI-generated videos on image/script accuracy (p<0.005), with similar script-image alignment. In dysphagia rehabilitation, a randomised trial reported improvements in swallowing function and related outcomes with an AI-assisted video game intervention (p<0.001). A plastic surgery study reported greater user preference for a video avatar tool compared with a text chatbot (63.5% vs 28.1%). Across the reviewed studies, samples were small and CIs were rarely reported. Outcome measures were heterogeneous, and meta-analysis was not feasible.

Conclusion: AI-generated videos can enhance engagement or selected outcomes in certain contexts, yet concerns about accuracy and inconsistent measurement persist. Current evidence is sparse and mixed. Currently, these tools can complement, rather than replace, standard resources until non-inferiority is demonstrated for the prespecified primary outcomes.

Prospero registration number: CRD42025640042.

Introduction: This quality improvement project was designed to identify perceptions, knowledge and training needs of primary care providers (PCPs) in British Columbia regarding smoking cessation treatment with the intent to improve practices and identify feasible methods to mitigate barriers.

Methods: An integrated knowledge translation approach was used to design, implement and analyse a survey for primary care practitioners in the provincial context of British Columbia. The survey was divided into the four main sections: Demographic Information, Knowledge Assessment, Training Needs and Perception of Barriers. It was distributed through advertisement in e-newsletters for family physicians and nurse practitioners. It is aimed to evaluate and understand PCPs' perceptions of tobacco use disorder and smoking cessation treatment; confidence when providing tobacco use disorder and smoking cessation support and treatment; educational needs and desired supports and barriers to providing and accessing smoking cessation supports and resources.

Results: The survey garnered 198 complete responses from 154 family physicians and 44 nurse practitioners. Findings highlight a need for increased training and resources while exploring desired training content and methods of delivery. Time constraints were identified as the primary barrier to providing smoking cessation intervention, alongside lacking referral pathways, clinical services and support, and compensation. Respondents expressed a desire for 'cheat sheets' with information on smoking cessation resources and best practices, training and education on counselling techniques and vaping cessation guidance, and integrated clinical workflows.

Conclusion: This project emphasises the need for an interdisciplinary approach to smoking cessation centred around integration of resources, training and policies into current workflows (such as electronic medical records or a centralised platform for information). Important gaps have been illuminated in the processes that support smoking cessation in primary care in British Columbia.