BMJ Quality & Safety最新文献

Background: The way that data are presented can influence quality and safety initiatives. Time-series charts highlight changes but do not clarify whether data lie outside expected variation. Statistical process control (SPC) charts make this distinction and have been demonstrated to be effective in supporting hospital initiatives. To improve the uptake of the SPC methodology by hospitals in England, a training intervention was created. The current study evaluates the effectiveness of that training against the background of a wider national initiative to encourage the adoption of SPC charts.

Methods: A parallel cluster randomised trial was conducted with 16 English NHS hospitals. Half were randomised to the training intervention and half to the control. The primary analysis compares the difference in use of SPC charts within hospital board papers in a postrandomisation period (adjusting for baseline use). Trainees completed feedback forms with Likert scale and open-ended items.

Results: Fifteen hospitals participated across the study arms. SPC chart use increased in both intervention and control hospitals between the baseline and postrandomisation period (29 and 30 percentage points, respectively). There was no statistically significant difference between the intervention and control hospitals in use of SPC charts in the postrandomisation period (average absolute difference 9% (95% CI -34% to 52%). In the feedback forms, 93.9% (n=31/33) of trainees affirmed learning and 97.0% (n=32/33) had formed an intention to change their behaviour.

Conclusions: Control chart use increased in both intervention and control hospitals. This is consistent with a rising tide and/or contamination effect, such that the culture of control chart use is spreading across hospitals in England. Further research is needed to support hospitals implementing SPC training initiatives and to link SPC implementation to quality and safety outcomes. Such research could support future quality and safety initiatives nationally and internationally.

Trial registration number: NCT04977414.

Background: Early mobilisation of intensive care unit (ICU) patients has been recommended in clinical practice guidelines. Therefore, the Japanese universal health insurance system introduced an additional fee for early mobilisation and/or rehabilitation, which can be claimed by hospitals when starting rehabilitation of ICU patients within 48 hours after their ICU admission. However, the effect of this fee is unknown.

Objective: To measure the proportion of ICU patients who received early rehabilitation and the impact on length of ICU stay, the length of hospital stay and discharged to home after the introduction of the financial incentive (additional fee for early mobilisation and/or rehabilitation).

Design/methods: We included patients who were admitted to ICU within 2 days of hospitalisation between April 2016 and January 2020. We conducted interrupted time series analyses to assess the effects of the introduction of the financial incentive.

Results: The proportion of patients who received early rehabilitation immediately increased after the introduction of the financial incentive (rate ratio (RR) 1.293, 95% CI 1.240 to 1.349). The RR for proportion of patients received early rehabilitation was 1.008 (95% CI 1.005 to 1.011) in the period after the introduction of the financial incentive compared with period before its introduction. There was no statistically significant change in the mean length of ICU stay, the mean length of hospital stay and the proportion of patients who were discharged to home.

Conclusion: After the introduction of the financial incentive, the proportion of ICU patients who received early rehabilitation increased. However, the effects of the financial incentive on the length of ICU stay, the length of hospital stay and the proportion of patients who were discharged to home were limited.

Background: Creating and sustaining an institutional climate conducive to patient and health worker safety is a critical element of successful multimodal hand hygiene improvement strategies aimed at achieving best practices. Repeated WHO global surveys indicate that the institutional safety climate consistently ranks the lowest among various interventions.

Methods: To develop an international expert consensus on research agenda priorities related to the role of institutional safety climate within the context of a multimodal hand hygiene improvement strategy, we conducted a structured consensus process involving a purposive sample of international experts. A preliminary list of research priorities was formulated following evidence mapping, and subsequently refined through a modified Delphi consensus process involving two rounds. In round 1, survey respondents were asked to rate the importance of each research priority. In round 2, experts reviewed round 1 ratings to reach a consensus (defined as ≥70% agreement) on the final prioritised items to be included in the research agenda. The research priorities were then reviewed and finalised by members of the WHO Technical Advisory Group on Hand Hygiene Research in Healthcare.

Results: Of the 57 invited participants, 50 completed Delphi round 1 (88%), and 48 completed round 2 (96%). Thirty-six research priority statements were included in round 1 across five thematic categories: (1) safety climate; (2) personal accountability for hand hygiene; (3) leadership; (4) patient participation and empowerment and (5) religion and traditions. In round 1, 75% of the items achieved consensus, with 9 statements carried forward to round 2, leading to a final set of 31 prioritised research statements.

Conclusion: This research agenda can be used by researchers, clinicians, policy-makers and funding bodies to address gaps in hand hygiene improvement within the context of an institutional safety climate, thereby enhancing patient and health worker safety globally.

Background: There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.

Methods: We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.

Results: We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs.

Conclusion: Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

Background: Low-value care (LVC) describes practices that persist in healthcare, despite being ineffective, inefficient or causing harm. Several determinants for the provision of LVC have been identified, but understanding how these factors influence professionals' decisions, individually and jointly, is a necessary next step to guide deimplementation.

Methods: A factorial survey experiment was employed using vignettes that presented hypothetical medical scenarios among 593 Swedish primary care physicians. Each vignette varied systematically by factors such as patient age, patient request for the LVC, physician's perception of this practice, practice cost to the primary care centre and time taken to deliver it. For each scenario, we measured the reported likelihood of providing the LVC. We collected information on the physician's worry about missing a serious illness.

Results: Patient requests and physicians' positive perceptions of the practice were the factors that increased the reported likelihood of providing LVC the most (by 14 and 13 percentage points (pp), respectively). When the LVC was low in cost or not time-consuming, patient requests further boosted the likelihood of provision by 29 and 18 pp. In contrast, credible evidence against the LVC reduced the role of patient requests by 11 pp. Physicians' fear of missing a serious illness was linked with higher reported probability of providing LVC, and the credibility of the evidence against the LVC reduced the role of this concern.

Conclusions: The findings highlight that patient requests enhance the role of many determinants, while the credibility of evidence diminishes the impact of others. Overall, these findings point to the relevance of increased clinician knowledge about LVC, tools for patient communication and the use of decision support tools to reduce the uncertainty in decision-making.

Background: Healthcare-related procedural misadventures remain underreported despite decades of investment in patient safety. International Classification of Diseases, 10th Revision (ICD-10) codes Y62-Y69 capture defined preventable adverse events during medical and surgical care. This study aimed to examine temporal patterns in Y62-Y69-coded events using aggregated, precomputed data from the TriNetX Global Collaborative Network.

Methods: We conducted a retrospective observational study using deidentified electronic health records from the TriNetX platform, encompassing over 135 million patients aged 0-89 (years: 2016-2024). Incidence rates for Y62-Y69-coded events were analysed globally and across four regional networks, USA, Europe-Middle East-Africa (EMEA), Asia-Pacific (APAC) and Latin America (LATAM), with additional sensitivity analyses in cardiovascular (ICD-10: I00-I99) and oncological (ICD-10: C00-D49) cohorts. Temporal trends were explored descriptively using polynomial regression (for visual pattern illustration) and the Mann-Kendall trend test.

Findings: Globally, Y62-Y69 incidence rates increased from 0.04 to 0.09 per 100 000 patients between 2016 and 2024 (125% increase), with inflection in the early postpandemic phase. EMEA exhibited the steepest rise (414%), followed by APAC (225%). The USA showed a non-linear pattern detectable only through polynomial modelling. LATAM and APAC trends lacked statistical significance, likely due to high year-to-year variability. Sensitivity analyses in the disease-specific cohorts reflected similar patterns, reinforcing the consistency of findings.

Interpretation: This is the first global, real-world analysis of ICD-10 Y62-Y69-coded adverse events. The findings reveal a notable postpandemic escalation in procedural harm, underscoring the fragility of safety systems under operational stress. Regional heterogeneity and non-linear trajectories highlight the importance of locally tailored interventions and the need to reinvigorate global patient safety efforts.

Data availability statement: All data were extracted from the TriNetX Global Collaborative Network. Aggregated incidence rates and the R code used for statistical analysis are provided in online supplemental file 2.

Objectives: With the growing adoption of virtual consultations in primary care, the need for tailored metrics to evaluate their safety became increasingly urgent. This systematic review seeks to identify and review existing safety measures that could be used for safety evaluation of virtual consultations in primary care.

Methods: This has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and followed a published protocol. A systematic literature search was performed in Ovid MEDLINE/PubMed, Embase and Cochrane Library databases from 2014 to 2024. Studies comparing virtual consultations with face-to-face consultations in the primary care setting were included. An inductive thematic analysis was performed to systematically extract and group the safety measures into overarching themes, with a narrative synthesis to summarise the results.

Results: A total of 47 studies (31 experimental and 16 observational studies) were included (n=2 223 697 patients). All studies assessed the safety of virtual versus face-to-face consultations via one or both of the following domains: (1) factors that influence the safety of virtual consultations and (2) tangible outcomes of virtual care safety. The former were categorised into provider-related, patient-related and system-related factors. Tangible outcomes were evident through three subthemes-adverse events, health outcomes and patient perception of safety.

Conclusions: This review provides a systematic synthesis of measures for the safety evaluation of virtual consultations. Further research into patient and physician perspectives is needed to identify aspects and indicators not captured in this study, followed by a consensus study to finalise safety metrics. Ultimately, having a robust methodology for safety evaluation of virtual consultations in place will enable safety monitoring, root cause analyses and safety improvement.

Prospero registration number: PROSPERO CRD42023464878.

Background: Prescribed opioids are potent analgesics associated with high safety risks due to their adverse effects, drug-drug and drug-disease interactions and potential for dependency. To support the implementation of prescribing indicators for further interventions, this study examined the prevalence of different types of potentially hazardous opioid prescribing (PHOP) in general practices across England and investigated underlying factors and variation between practices.

Methods: We conducted a cross-sectional study focusing on adults (aged ≥18 years) at risk of triggering 17 PHOP indicators on 1 April 2021, involving 1358 general practices contributing to the Clinical Practice Research Datalink Aurum. PHOP prevalence was calculated by dividing the number of patients triggering an indicator by the total number at risk. Variation was assessed with intraclass correlation coefficients (ICCs), and multilevel mixed-effects logistic regression models identified associated factors, presented as adjusted ORs (aORs) with 95% CIs.

Results: Among 3 121 852 patients observed, 361 505 (11.58%, 95% CI 11.54, 11.62) triggered at least one PHOP indicator, yielding an ICC of 0.07 (95% CI 0.06, 0.07). The prevalence of the 17 PHOP indicators ranged from 1.97% to 32.02%. Significant variability was noted across the 17 indicators, especially for persistent opioid prescriptions in patients with alcohol use issues (ICC 0.08, 95% CI 0.07, 0.09), chronic obstructive pulmonary disease or asthma (ICC 0.08, 95% CI 0.07, 0.09) and hypothyroidism (ICC 0.07, 95% CI 0.06, 0.07). Patients from the most deprived regions (aOR 1.28, 95% CI 1.22, 1.34) and the Northwest of England (aOR 1.73, 95% CI 1.66, 1.81) had a higher risk of PHOP.

Conclusions and relevance: The high prevalence of PHOP, particularly among the most socioeconomically disadvantaged populations, emphasises existing prescribing risks and the need for their appropriate consideration within primary care. The high variation between practices indicates potential for improvement through targeted practice-level intervention.

The continued use of low-value cancer screening practices not only represents healthcare waste but also a potential cascade of invasive diagnostic procedures and patient anxiety and distress. While prior research has shown it takes an average of 15 years to implement evidence-based practices in cancer control, little is known about how long it takes to de-implement low-value cancer screening practices. We reviewed evidence on six United States Preventive Services Task Force 'Grade D' cancer screening practices: (1) cervical cancer screening in women<21 years and >65 years, (2) prostate cancer screening in men≥70 years and (3) ovarian, (4) thyroid, (5) testicular and (6) pancreatic cancer screening in asymptomatic adults. We measured the time from a landmark publication supporting the guideline publication and subsequent de-implementation, defined as a 50% reduction in the use of the practice in routine care. The pace of de-implementation was assessed using nationally representative surveillance systems and peer-reviewed literature from the USA. We found the time to de-implementation of cervical cancer screening was 4 years for women<21 and 16 years for women>65. Prostate screening in men ≥70 has not reached a 50% reduction in use since the 2012 guideline release. We did not identify sufficient evidence to measure the time to de-implementation for ovarian, thyroid, testicular and pancreatic cancer screening in asymptomatic adults. Surveillance of low-value cancer screening is sparse, posing a clear barrier to tracking the de-implementation of these screening practices. Improving the systematic measurement of low-value cancer control practices is imperative for assessing the impact of de-implementation on patient outcomes, healthcare delivery and healthcare costs.

Introduction: Quality improvement (QI) is aimed at improving care. Equity is one of the six domains of healthcare quality, as defined by the Institute of Medicine. If this domain is ignored, QI projects have the potential to maintain or even worsen inequalities.

Aims and objectives: We aimed to understand why, how, for whom and in which contexts QI approaches increase, or do not change health inequalities in healthcare organisations.

Methods: We conducted a realist review by first developing an initial programme theory, then searching MEDLINE, Embase, CINAHL, PsychINFO, Web of Science and Scopus for QI projects that considered health inequalities. Included studies were analysed to generate context-mechanism-outcome configurations (CMOCs) and develop an overall programme theory.

Results: We screened 6259 records. Thirty-six records met our inclusion criteria, the majority of which were from the USA. We developed CMOCs covering four clusters: values and understanding, resources, data, and design. Five of these described circumstances in which QI may increase inequalities and 15 where it may reduce inequalities. We found that QI projects that are values-led and incorporate diverse, patient-led data into design are more likely to address health inequalities. However, when staff and patients cannot engage fully with equity-focused projects, due to practical or technological barriers, QI projects are more likely to worsen inequalities.

Conclusions: The potential for QI projects to positively impact inequalities depends on embedding equity-focused values across organisations, ensuring sufficient and appropriate resources are provided to staff delivering QI, and using diverse disaggregated data alongside considered user involvement to inform and assess the success of QI projects. Policymakers and practitioners should ensure that QI projects are used to address inequalities.