BMJ Open Quality最新文献

Background: Individuals with serious mental illness at a Toronto mental health hospital receive interdisciplinary team (IDT) care through a reverse integration model supporting both mental and physical health. Nurses play a central role in this model, yet face barriers including unclear role definitions, limited resources and workflow constraints. Enhancing nursing autonomy and IDT collaboration may improve patient outcomes and workforce retention.

Methods: This quality improvement study aimed to reduce nursing-initiated hospitalist requests by 25% across four pilot units by October 2023. From February to May 2023, 99 nurses completed 1 hour refresher training sessions to strengthen clinical decision-making, clarify scope within the IDT, and improve workflow efficiency. Pre-training and post-training surveys assessed nurses' self-reported knowledge and comfort, and an implementation survey assessed perceived impacts on practice and collaboration. A retrospective electronic health record (EHR) chart review (September 2022-June 2024) evaluated total and declined hospitalist requests (outcome measures), focused nursing assessments (FNAs; process measures) and direct allied health requests (AHRs; balancing measures).

Results: Pre-training and post-training surveys were completed by 69 and 72 nurses, respectively. Mean composite self-reported knowledge scores increased from 3.56 (SD 0.88) pre-training to 4.57 (SD 0.57) post-training (mean difference 1.02; 95% CI 0.77 to 1.26; p<0.001). Implementation surveys indicated improved clinical practice, enhanced IDT collaboration, and strong endorsement of the training. However, nursing-initiated hospitalist requests (monthly mean=339.4) and declined requests (monthly mean=30.6; 9% decline rate) showed no sustained reduction. Common reasons for declined requests included completed assessments (18.8%), duplicate requests (18.8%), and redirected AHRs (13.0%). FNAs (monthly mean=91.77) and AHRs (monthly mean=14.3) remained stable.

Conclusion: Targeted nursing education improved nurses' self-reported knowledge and IDT perceived collaboration but did not reduce hospitalist requests. Sustained impact may require ongoing education, integrated onboarding, EHR workflow enhancements, and clearer role definitions.

Umbilical venous catheters (UVCs) provide essential vascular access for neonates in the neonatal intensive care unit, yet malpositioning and catheter migration can lead to serious complications.We conducted a quality improvement project at Evelina London Children's Hospital, aiming to reduce UVC-related complications by introducing routine monitoring of UVC tip position after insertion using point-of-care ultrasound (POCUS).A retrospective review was carried out to establish a baseline for current UVC practice at a time when tip position was predominantly confirmed by X-ray. During this initial 6-month period, among 28 preterm infants born at less than 30 weeks' gestation, UVC migration occurred in 57% of cases, with two instances of extravasation injury.This was followed by an intervention period, which included a POCUS training programme for medical staff and the introduction of updated local guidelines recommending POCUS assessment of UVC tip position at insertion and routine follow-up between days 3 and 5 after insertion.In a second 6-month period, we prospectively evaluated POCUS use and UVC migration rates among 28 preterm infants with characteristics comparable to the initial cohort.Following the intervention, POCUS use at insertion increased significantly (82% vs 29%), with an improvement in correct UVC placement at insertion (75% vs 40%). At follow-up between days 3 and 5, UVC migration was still observed in 30% of cases.When migration was detected, the UVC was either removed or repositioned if found within the right atrium. Importantly, no extravasation injuries occurred in the post-intervention group.These findings suggest that POCUS can facilitate early detection of UVC migration and optimise initial line placement, with the potential to reduce severe complications. Routine POCUS monitoring is a practicable strategy to improve UVC management and improve the safety of neonatal care.

Objective: To estimate the prevalence of technical errors in the total testing process of pathology tissue specimens.

Design: A systematic review and Meta-analysis of Observational Studies in Epidemiology was performed. Extracted data were pooled using a random-effects model and Grading of Recommendations, Assessment, Development and Evaluation approaches.

Data sources: PubMed, CINAHL, Cochrane Library and Science Direct databases were searched on 29 May 2025 for eligible studies.

Study selection: Peer-reviewed studies published after 2003 that reported technical error prevalence in any aspect of routine tissue collection and processing.

Results: The search returned 30 articles (31 studies), including data from 2 794 987 surgical pathology cases. Pooled effect sizes were calculated for pre-analytic errors at 16.71 per 1000 cases (95% CI 6.42 to 31.67), actively identified errors in the laboratory at 40.17 per 1000 (95% CI 7.04 to 97.61) and reported surgical pathology specimen errors at 4.94 per 1000 (95% CI 1.33 to 10.80). Subgroup analysis showed an occult error prevalence of 2.54 per 1000 cases (95% CI 1.63 to 3.64), and surgical pathology case contamination was 62.23 per 1000 (95% CI 8.22 to 159.33).

Conclusion and relevance: The analysis suggests that tissue processing technical errors are more prevalent than reported. A lack of standardised methods for defining and detecting errors contributes to undocumented and unidentified errors, leaving the true error prevalence unknown. The majority of clinical decisions are based on laboratory results; however, without reliable detection and reporting, errors in vulnerable processes risk compromising patient diagnoses.

Prospero registration number: CRD42024600518.

Objectives: To capture the experiences of people from minoritised groups who self-report healthcare-related harm and their views on contributory factors to the harm.

Design: In-depth one-to-one qualitative interviews, analysed using inductive and deductive methods to explore and then organise factors participants associated with healthcare-related harm and map these factors onto a socioecological framework (SEF).

Setting: People from minoritised groups in the United Kingdom (UK) self-reporting harm arising from the National Health Service (NHS), recruited from community groups, social media and a survey of the general public.

Participants: 48 participants currently minoritised in the UK based on one or more of faith, ethnicity, disability, sexual orientation or gender modality who have experienced harm in the NHS.

Results: Heterogeneous and interacting factors contribute to healthcare-related harms, spanning all five levels of the SEF: individual, interpersonal, community, organisational and societal. Multiple factors from powerlessness and low trust to unwelcoming NHS environments reinforce each other to increase risk of harm in minoritised populations. The SEF helped draw out less visible factors associated with the experience of unsafe care, including a health service designed around the needs of the majority population and societal attitudes to minoritised groups.

Conclusions: Multiple individual factors are already known drivers of disparities in safety among minoritised groups such as language barriers and cultural differences in beliefs. The SEF enabled an expanded view of contributory factors to harm in these groups, thereby providing a wider set of potential interventions to address safety inequities. A narrow focus on improving the quality of interpersonal, relational care is unlikely to have a significant impact on safety improvement in minoritised groups without addressing structural and institutionalised processes that drive discrimination and exclusion.

Background: Challenges in the management of chronic pain have resulted in concerning levels of high-risk opioid prescribing across England, highlighting the importance of personalised care and coordinated working across whole systems.

Aim: Improve management of chronic pain by reducing chronic and high-dose opioid prescribing and increasing awareness and availability of biopsychosocial support.

Methodology: Mobilising activity across the macro, meso and micro levels of the healthcare system in England, the initiative employed a novel 7 Phase Whole System Approach Framework (WSA7), enabling diverse stakeholders to coordinate improvement and learning activity to understand the local problems, coordinate change ideas and consider how to sustain improvement across the pathway of care.

Findings: Predefined national outcomes relating to opioid prescribing were achieved: There was a 5.13% decrease in the rate of chronic opioid prescribing vs baseline, equating to 56 403 fewer people prescribed chronic opioids than would have had the rate remained at baseline levels, preventing between 841 and 910 deaths. Decrease of 20.35% in rate of high-dose prescribing versus baseline, halving the risk of opioid-related death for 16 963 people. Increased availability and awareness of biopsychosocial support; at least 12 093 patients supported to self-manage their pain. 27 integrated care systems (ICSs) fully participated in the initiative, five partially. Successful implementation of the WSA7 (n=19 ICSs) achieved greater sustained improvement vs non-participating ICSs (n=10), ICSs with implementation failure (n=8) and partial implementation (n=5).

Conclusions: Employing the WSA7 created contextual conditions across ICSs that supported and sustained improvement in a complex problem that challenges health and care systems across England.

Aim: This study aimed to explore the barriers to incident reporting among healthcare professionals in a quaternary care hospital in South India.

Methodology: A cross-sectional study was conducted from May to June 2023 among 1784 healthcare professionals selected using systematic random sampling. Data were analysed using descriptive statistics, χ² tests and analysis of variance.

Results: A total of 629 responded (35% response rate): 68 doctors (10%), 435 nurses (69%) and 126 allied health professionals (20%). Incident reporting was highest among allied health professionals (65%), followed by nurses (39%) and doctors (27%). However, nurses reported the highest absolute number of incidents (n=170). Types of incidents most frequently reported included medication related (n=92), patient safety (n=69) and patient care (n=42). The most common barriers were personal, particularly fear of punitive action (66% of allied health professionals, 36% of nurses and 15% of doctors), identity tracking concerns (56%, 40% and 38%, respectively) and perceived lack of anonymity. Differences in perceived barriers across groups were statistically significant (p<0.05).

Conclusion: Individual-level barriers-especially fear of punitive action and lack of anonymity-continue to limit reporting despite established systems. Leadership must foster a non-punitive, confidential culture and improve feedback. While simplifying processes and expanding training may enhance participation, these strategies remain untested at our institution, serving instead as guidance for future quality improvement efforts.

Introduction: The Armed Forces Community (AFC) experience significant health inequalities and barriers to accessing support. Cornwall, England, has one of the highest AFC populations. A social prescribing service, delivered by Active Plus, was developed to improve physical and mental well-being and target wider determinants of health of this population. Uniquely, the service is delivered by social prescribing link workers who are themselves veterans.

Objective: This evaluation aimed to qualitatively explore the experiences of the service users and the social prescribing link workers.

Method: Semistructured interviews of five service users and four social prescribing link workers were conducted online using Google Meet. Service users were sampled to reflect diversity in service branch, age and time since leaving the Armed Forces. Informed consent processes were carried out. Data were transcribed, checked, anonymised and inductively thematically analysed.

Results: Service users had struggled to transition from a military to a civilian identity. Referrals were for mental health, social isolation, housing, finances, physical health and domestic abuse. Having a social prescribing link worker who was a veteran was a crucial component of establishing trust, without the need to explain military culture or experiences. This was instrumental in helping service users engage more fully with the service offered. Service users reported improvements in their living conditions and mental health, were more connected to other people and had a renewed sense of hope and optimism.

Conclusion: This is the first report of experiences of the AFC receiving bespoke social prescribing support. The findings highlight the crucial nature of designing the social prescribing service to resonate with military culture and the difficulties of transitioning to a civilian identity. Service users had improved well-being and were supported with a range of determinants of health. Further research needs to be carried out on other AFC members to confirm the findings.

Background: The COVID-19 pandemic has exacerbated the backlog of elective surgeries across the National Health Service (NHS). This is particularly critical for patients awaiting cardiac surgery, where even short delays can lead to disease progression and increased risk of complications. Enhanced Recovery After Surgery (ERAS) programmes aim to optimise recovery and reduce length of stay, yet their implementation in cardiac surgery remains inconsistent. This quality improvement project sought to improve the implementation of postoperative ERAS principles to increase the timeliness of recovery and enhance intensive care unit (ICU) capacity.

Methods: Time-directed ERAS goals were developed, and a phased educational intervention was implemented through four Plan-Do-Study-Act cycles: (1) introductory teaching and baseline data collection, (2) development of a tool within the electronic patient record to promote real-time implementation of ERAS goals and enable continuous performance monitoring, (3) introduction of an e-learning module and (4) targeted educational interventions. Outcome measures included time to achieve ERAS goals and the proportion of postoperative patients clinically ready for discharge to the ward within 24 and 48 hours. Balancing measures included reintubation and ICU readmission rates.

Results: Implementation of the phased educational intervention led to a sustained reduction in the time required to achieve ERAS goals. The proportion of patients clinically ready for discharge to the ward within 24 and 48 hours increased by 15.6% and 18.0%, respectively, exceeding the project's 5% target. No increase in reintubation or ICU readmission rates was observed, indicating that improvements were achieved safely.

Conclusions: Implementing time-directed ERAS goals through a phased educational intervention increased the timeliness of post-operative recovery after cardiac surgery. This approach has the potential to improve patient flow, enhance ICU capacity and support wider efforts to address elective cardiac surgery backlogs across the NHS.

Objective: To evaluate whether adding a fourth physician to the emergency department night shift would improve metrics.

Methods: This retrospective cohort study used data from the Meir Medical Centre emergency department, 1 January 2021 to 31 May 2023. The study period included adding a fourth physician to the night shift staff in September 2021. Primary and secondary outcomes were time from patient entrance to doctor's examination, time to decision about hospitalisation or discharge and rates of hospitalisation, 1 day hospitalisation and returning patients. Secondary analysis examined the mean and lowest seniority of the staff, and the mean number of patients examined by a physician during night shifts.

Results: After increasing staff, hospitalisation rates decreased minimally from 44% to 42% (p=0.03), whereas 1 day hospitalisation rates increased from 26% to 28% (p=0.006). Paradoxically, time to disposition increased slightly from 4.5 to 4.7 hours (p<0.001). No significant changes were noted in return visit rates or time to first physician encounter.

Discussion: The study did not result in significant impacts on key performance indicators after adding a physician to night shift staffing. Our findings suggest that increasing physician numbers did not significantly improve overall emergency department efficiency. The only benefit observed was a decrease in the number of patients per physician, potentially alleviating individual physician workload.

Conclusions: Adding a physician to the emergency department night shift staff did not result in significant improvements in work efficiency, as measured by the parameters assessed in this study.

Background: MRI uses a magnetic field that can harm patients with metallic implants and eliciting details about implants while entering MRI room is essential. Patient-Reported Experience Measure (PREM) tool takes feedback from patients and checks whether staff have enquired about safety parameters while undergoing the diagnostic test, thereby safeguarding the patients against any potential hazards. Objective of study to develop a context-specific PREM tool for MRI safety through constructive feedback from patients METHODOLOGY: Phase 1 expert group was formed and focused group discussions (FGDs) conducted to develop a Standard Operating Procedure (SOP) and the PREM Questionnaire tool. Phase 2 and phase 3, multiphasic study conducted in 15 hospitals, India with good geographical distribution using purposive sampling. Phase 2 consisted of a pilot study using the PREM tool with a sample size of 213 participants, and phase 3 consisted of a field study with 720 participants.

Results: PREM tool developed with 21 questions based on SOP, findings of FGDs and patient feedback. The internal consistency of the PREM tool was excellent and indicated high reliability and showed that the expert group considered the questions essential. Concerning removing metallic devices before the scan, 100% of participants said yes in the pilot study and 99% in the main study. Lacunae identified in the study included screening using a metal detector, counselling about history of allergy, side effects of contrast agents and claustrophobia, and methods to contact the staff in case of any emergency during the MRI scan. These findings indicate that there is a need to improve safety practices based on feedback from patients using the MRI Safety PREM tool.

Conclusions: MRI Safety PREM tool was developed and validated as a zero-cost patient safety tool. Study participants accepted the PREM questionnaire as a vital tool for patients undergoing MRI to ensure patient safety and improved quality of care.