BMJ Open Quality最新文献

Engaging caregivers as active partners in care is a cornerstone of Strategic Objective 4 in the WHO's Global Patient Safety Action Plan 2021-2030. Despite its recognised importance, caregiver integration in acute care remains inconsistent, with significant gaps in registration processes, role clarity and institutional support. At Singapore General Hospital (SGH), a 1900-bed academic medical centre, caregiver involvement was previously informal and varied across clinical settings. This hospital-wide quality improvement initiative aimed to improve the caregiver-to-admission ratio from 1:6 to 1:4 within 6 months. Caregiver was defined as a family member formally registered through the hospital's Automated Visitor Management System (AVMS) and oriented to participate in basic patient care. A multidisciplinary team co-designed a scalable intervention through staff engagement and collaboration with the SingHealth Patient Advocacy Network (SPAN). Key strategies included simplified electronic registration, admission-based caregiver orientation, policy revisions to enable overnight stays, bedside education and flexible learning tools. These changes were embedded into clinical workflows and supported by infrastructure enhancements. Between April 2024 and March 2025, admission-to-caregiver ratio improved from 1:6 in the pre-implementation period to 1:4 post-implementation (5512 caregivers across 33 191 admissions pre-implementation vs 9592 caregivers across 38 874 admissions post-implementation). In addition, hospital-wide patient experience indicator from the Service Level Tracking (SLT) dashboard was included as a balancing measure. The percentage of patients and families who responded 'Definitely yes' to recommending SGH to family and friends improved from 81.9% pre-implementation to 85.2% post-implementation. The initiative reflects not only SGH's operational readiness and leadership commitment but also a broader paradigm shift: the healthcare team's growing recognition of the value of partnering with families, and the public's increasing willingness to participate in care even within high-acuity hospital environments. This project exemplifies how aligning systems, mindsets and partnerships can bring the WHO's patient safety goals into practical, sustainable action.

Background: Patients with limited English proficiency (LEP) face significant language barriers in healthcare, leading to poorer clinical outcomes. Professional medical interpreters are essential for equitable, high-quality care. While their use is widely recommended, there is limited understanding of the optimal objective outcome measures to best evaluate interpreter effectiveness in secondary and tertiary care settings.

Methods: A scoping review was conducted which was prospectively registered on the Open Science Framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Four databases (MEDLINE, PubMed, Embase and CINAHL) were searched without date or language limits. We included comparative studies assessing professional medical interpreting services for adult patients with LEP in secondary or tertiary care using objective outcome measures related to clinical outcomes and/or healthcare utilisation. Data extraction included study design, interpreter modalities, outcome measures and adjustments for confounders.

Results: Eleven studies met the inclusion criteria. Most were cohort or cross-sectional studies, predominantly conducted in the USA. The most common outcome measures were clinical, including length of stay (n=8), readmission (n=5) and return emergency visits (n=3). Four studies assessed healthcare utilisation, including outpatient appointment adherence. Results varied: some studies showed reduced length of stay and readmissions with interpreter use, while others found longer stays or no effect. Disease-specific outcomes (e.g., stroke care quality and obstetric indicators) consistently favoured interpreter or health advocate use. Adjustment for confounders was inconsistent with few studies accounting for illness severity.

Conclusion: This review highlights the heterogeneity and limitations in existing outcome measures for evaluating interpreter services. Length of stay and readmission are commonly used but prone to confounding. Disease-specific outcomes may offer greater sensitivity and relevance, especially when adjusted for clinical severity. Future research should prioritise the development of validated, standardised outcome sets that reflect both patient priorities and clinical relevance. These are essential for guiding service improvement and equitable healthcare delivery for LEP populations.

Background: Recruiting participants for injury and violence-related studies can be challenging, and online data collection opportunities can expand reach, offer convenience and extend a sense of safety to potential participants who may be in unsafe situations or do not want to travel to a location due to safety concerns. While increasing accessibility for some participants, online primary data collection presents challenges around potential fraudulent participants. This methodological paper highlights the strategies for preventing and mitigating fraudulent participants in online qualitative data collection, using a recent firearm violence study in a Northeast city as an example.

Purpose: Using a recent data collection effort related to firearm injury as a case study, the purpose of the current methodology paper is to highlight concerns and challenges with online qualitative data collection and provide strategies for preventing, detecting and removing fraudulent participants in qualitative injury and violence prevention research.

Results: Various predata collection activities can promote a study design that deters fraudulent participants, and additional 'in-the-moment' data collection activities can flag potential suspicious participants. Strategies include prescreening participants, requiring video and answers to basic questions relevant to the study topic and confirming certain pieces of information.

Conclusion: Online primary data collection can increase accessibility and support the safety of participants in injury and violence research, and there are considerations around detecting and removing fraudulent participants that researchers should note. Like all methods, a balance exists between study access, aims and resources. Researchers new to online qualitative data collection can use the strategies outlined here.

Background: Increase in life expectancy in Ireland and social isolation has led to an increasing number of people living in residential care facilities (RCFs). Residents are frequently transferred to emergency departments (ED) for a variety of reasons. Studies found that up to 40% of these hospital admissions were deemed inappropriate. An inappropriate admission in previous studies has been defined as a situation in which care in lower cost settings would be as safe and less disruptive than care in higher cost hospital settings.

Methods: A review of a convenience sample of ED attendances to University Hospital Kerry (UHK) found that 50% were inappropriate. A SMART aim in a quality improvement project (QIP) is an aim which is Specific, Measurable, Achievable, Relevant and Time based. The SMART aim of this QIP was to reduce the number of persons residing in RCFs, being inappropriately referred to UHK, from 50% to 30% from March 2024 to May 2025.Quality improvement (QI) measures included the standardisation of terminology through the workings of the palliative frailty multidisciplinary team, development of a communication document on resuscitation status and treatment escalation preferences, and the implementation of an advanced nurse practitioner (ANP) palliative care service for RCFs supported by a palliative medicine physician. Education was integral in this QIP.

Results: QI measures resulted in a reduction in monthly ED attendances of RCF residents from a median of 82 to 50. Inappropriate attendances reduced from 50% to 31%. Stakeholders' feedback on the new service was overwhelmingly positive. The project resulted in financial savings for the health service.

Conclusion: Integration of the geriatric and palliative medicine services with staff of RCFs allowed for sharing of knowledge, standardisation of terminology and development of alternative models of care and pathways to access specialties. The introduction of a designated ANP palliative care service for RCFs has been essential in helping residents to receive the right care, in the right place, at the right time.

Advanced chronic kidney disease (CKD) is commonly associated with disturbances in acid-base balance. Studies have shown that correcting metabolic acidosis in CKD offers several clinical benefits, including slower disease progression and reduced mortality. Acidosis can be addressed with oral sodium bicarbonate, an easy-to-administer and relatively inexpensive treatment compared with novel drugs such as sodium-glucose co-transporter-2 -(SGLT-2) inhibitors. Although sodium bicarbonate is frequently prescribed in CKD, less attention is paid as to whether serum bicarbonate levels are adequately optimised. This project aimed to increase the proportion of advanced CKD patients with serum bicarbonate levels within the normal range.Retrospective data collection was conducted at our tertiary renal centre to establish baseline bicarbonate levels and assess prescribing practices for sodium bicarbonate. Quality improvement (QI) methodology was then applied to implement a series of interventions designed to increase awareness of acidosis and to promote the appropriate use of oral sodium bicarbonate.Results from baseline data collection showed that 94% of patients had a serum bicarbonate level checked within the previous 6 months. However, only 46% of patients had levels within the optimal range. Although initial improvement was noted following our first intervention, this was not sustained through subsequent QI cycles, and the proportion of patients with optimal bicarbonate levels remained largely unchanged by the end of the project.Optimising serum bicarbonate is an important component of the management of advanced CKD. While this project led to increased awareness and short-term gains, further work is required to achieve lasting improvements and embed change into routine practice.

Introduction: Diagnostic errors significantly contribute to adverse events, patient harm and malpractice claims. While most research focuses on physicians, allied health professionals (AHPs) also play a critical role in diagnostic processes. Existing studies, primarily based on medical-record reviews, often overlook communication gaps and team dynamics affecting diagnostic accuracy. This study aims to (1) describe the overall characteristics and patterns of diagnostic errors reported in the national adverse-event database and (2) compare the clinical features, diagnostic processes and contributing factors between cases involving physicians and those involving AHPs.

Methods: We examined diagnostic-error reports from 1631 hospitals in the Japan Council for Quality Healthcare database (2010-2023). Cases were identified using predefined keywords, and two independent physicians assessed them using the Revised Safer Dx Instrument and Diagnostic Error Evaluation and Research (DEER) taxonomy. Contributing factors were analysed, and statistical methods explored error patterns and stakeholder comparisons.

Results: Among 147 654 event reports, 445 cases involved diagnostic errors. The most common errors occurred in diagnostic testing, assessment and follow-up, particularly misinterpretation of pathological or radiological reports on new injuries during hospitalisation. Physicians were the primary responsible providers (79.3%), while nurses were involved in 19.3% of cases. DEER taxonomy analysis revealed that nurses were more associated with errors in presentation, history-taking and physical examination (p<0.001). Additionally, patient-related factors, observation, reporting and training played a significantly greater role in errors involving nurses than physicians (p<0.001).

Discussion: By leveraging expert-assessed unstructured data, this study provides a broader perspective on diagnostic safety. Findings highlight the critical role of AHPs in diagnostic errors. Our study underscores the need for targeted, profession-specific interventions embedded within broader interprofessional initiatives to effectively reduce diagnostic errors and enhance patient safety.

Procedural sedation and analgesia (PSA) is generally considered safe, yet fatal events remain poorly characterised across procedures and specialties. We retrospectively reviewed the Japan Council for Quality Health Care nationwide adverse-event database (2012-2021), searching narrative reports with 40 Japanese keywords for sedation terms and drug names. Only reports in which PSA was deemed the primary cause of death were included; non-procedural sedation, planned general anaesthesia and procedure-induced injuries were excluded. Among 10 011 reports identified via keyword search, 805 described deaths and 23 were attributed to PSA. Fatalities clustered in gastroenterology (73.9%), particularly endoscopic retrograde cholangiopancreatography (ERCP; 34.8%). Most cases were high-risk patients aged 70-89 years (65.2%) and retrospectively classified as American Society of Anesthesiologists Physical Status III/IV (87%), yet no anaesthetist involvement was documented. Oxygen desaturation was the earliest sign of deterioration (56.5%), and capnography was not documented in any case. When PSA fatalities in Japan are examined across procedures and specialties, gastrointestinal interventions-especially ERCP-predominate in our cohort; however, the absence of procedure-specific denominators warrants cautious interpretation. Targeted safety measures, in line with current national sedation guidelines, including enhanced presedation evaluation, anaesthetist involvement for high-risk patients and routine capnography, may help to reduce PSA-related mortality.

Importance: Healthcare providers (HCPs) working in intensive care units (ICUs) face high levels of stress, burnout and emotional exhaustion. There is limited research on interventions that foster resilience and connection among interdisciplinary ICU teams. Storytelling, particularly through ICU patient survivorship narratives, may offer a novel approach to improving team morale, reducing burnout and enhancing workplace belongingness.

Objectives: To explore the impact of ICU survivor stories on the interdisciplinary ICU team's perceptions of their role in survivorship, resilience, burnout and sense of belonging at work.

Design, setting and participants: This qualitative study used a cross-sectional survey and focus group design at a large academic hospital. Participants included 39 members of the ICU interdisciplinary team who reviewed ICU survivor profiles and completed a survey. A subset of participants engaged in focus groups.

Analysis: Survey data were analysed using descriptive statistics. Open-ended survey responses and focus group transcripts underwent thematic analysis using descriptive and in vivo coding, followed by consensus-based theme development.

Results: All survey items had mean scores above 3.0, indicating overall agreement with the positive impact of the survivor profiles. Six key themes emerged from qualitative analysis: validation and closure, learning and growth, gratitude, team building and collaboration, burnout and sense of belonging. Participants reported that the profiles provided emotional closure, reinforced the value of their work and fostered interdisciplinary appreciation. Some participants noted disparities in recognition across disciplines, highlighting opportunities for more inclusive team-building strategies.

Conclusions: ICU survivor stories may serve as a meaningful intervention to support emotional well-being, reduce burnout and enhance team cohesion among critical care providers. These narratives offer a humanising perspective on patient recovery and may help staff reconnect with the purpose behind their work. Future research should explore the long-term impact of such interventions and their potential to improve both provider well-being and patient care outcomes.

Objective: To evaluate the safety of implementing structured medication optimisation reviews (SMORs) for patients with atrial fibrillation (AF) prescribed direct oral anticoagulants (DOACs). SMORs aimed to improve quality of care and facilitate large-scale alignment with national prescribing guidance (to switch patients onto edoxaban).

Intervention: Complex intervention including a SMOR embedded within primary care electronic patient records alongside clinical decision support tools.

Design: Doubly robust difference-in-difference analysis using linked electronic health records, comparing changes in prescribing and bleeding admissions in patients undergoing SMOR with those in patients not reviewed.

Setting: Sefton (intervention area) and Liverpool (comparator area) in the Northwest of England.

Participants: All patients with AF prescribed a DOAC in 2022.

Main outcomes and measures: Proportion of patients prescribed apixaban, proportion of patients prescribed edoxaban and rate of emergency hospital admissions for bleeding-related events.

Results: The proportion of patients in Sefton prescribed edoxaban increased from 19% to 35%; 13% (95% CI 11% to 14%) of the increase was associated with the SMOR. There was an 11-percentage point decrease in patients prescribed apixaban (95% CI -12% to -10%). Undergoing review was associated with a non-significant reduction in the risk of bleeding admissions (eight fewer admissions per 1000 people reviewed per year; 95% CI -22 to 6).

Conclusions: SMORs can be delivered at scale and used to switch medications for a large proportion of people. There was no evidence of an increased risk of admissions for bleeding complications in AF patients following a large-scale switch from apixaban to edoxaban supported by SMORs. Such reviews could improve prescribing quality and patient safety by ensuring patients are on the most appropriate dose and choice of DOAC and lead to cost savings to health services (by facilitating a switch to a better value product) while not increasing risks for patients.

Background: The concept of care left undone has been extensively studied among nurses, limited research has examined how physicians experience and respond when care is left undone. Understanding physicians' perspectives is needed for developing more comprehensive strategies to enhance care quality and safety.

Objective: To explore how physicians conceptualise, experience and manage care left undone.

Methods: A qualitative study was conducted using semi-structured interviews with 12 physicians active in a tertiary teaching hospital. Thematic analysis was guided by existing literature on missed care but allowed inductive insights to emerge from the data.

Results: Physicians were generally unfamiliar with the term 'care left undone', yet readily identified with the phenomenon when described, conceptualising it as a routine aspect of clinical practice shaped by time scarcity, competing demands and professional judgement. High workload, understaffing and a multitude of responsibilities were identified as main antecedents of care left undone. Omissions most frequently involved administrative tasks, psychosocial support and communication, which were deprioritised relative to diagnostic and therapeutic tasks to mitigate any negative effects on patient outcomes. Strategies to navigate care left undone included implicit triage and task delegation, often framed as expressions of clinical expertise rather than deficiencies. Reported consequences included compromised patient safety, disrupted continuity of care and adverse emotional and professional impacts on physicians, such as moral distress and burnout. Proposed solutions were identified at the organisational (eg, staffing, workload reduction, supportive environment), interpersonal (eg, enhanced collaboration) and patient levels (eg, health literacy and engagement). A cross-cutting meta-theme of professional identity and role boundaries shaped how physicians perceived, rationalised and responded to care left undone, highlighting the need for interdisciplinary, context-sensitive interventions.

Conclusion: Care left undone is a relevant yet underexplored phenomenon among physicians active in acute care hospitals. Addressing care left undone requires profession-sensitive approaches that account for differences in role structure, decision-making autonomy and identity. Quality improvement initiatives should include physicians in the co-design of interventions to ensure they reflect clinical realities and foster engagement.