BMJ Quality & Safety最新文献

BackgroundThe Organisation for Economic Co-operation and Development (OECD) Patient-Reported Indicator Surveys (PaRIS) initiative aims to support countries in improving care for people living with chronic conditions by collecting information on how people experience the quality and performance of primary and (generalist) ambulatory care services. This paper presents the development of the conceptual framework that underpins the rationale for and the instrumentation of the PaRIS survey.

Methods: The guidance of an international expert taskforce and the OECD Health Care Quality Indicators framework (2015) provided initial specifications for the framework. Relevant conceptual models and frameworks were then identified from searches in bibliographic databases (Medline, EMBASE and the Health Management Information Consortium). A draft framework was developed through narrative review. The final version was codeveloped following the participation of an international Patient advisory Panel, an international Technical Advisory Community and online international workshops with patient representatives.

Results: 85 conceptual models and frameworks were identified through searches. The final framework maps relationships between the following domains (and subdomains): patient-reported outcomes (symptoms, functioning, self-reported health status, health-related quality of life); patient-reported experiences of care (access, comprehensiveness, continuity, coordination, patient safety, person centeredness, self-management support, trust, overall perceived quality of care); health and care capabilities; health behaviours (physical activity, diet, tobacco and alcohol consumption), sociodemographic characteristics and self-reported chronic conditions; delivery system characteristics (clinic, main healthcare professional); health system, policy and context.

Discussion: The PaRIS conceptual framework has been developed through a systematic, accountable and inclusive process. It serves as the basis for the development of the indicators and survey instruments as well as for the generation of specific hypotheses to guide the analysis and interpretation of the findings.

Background: In 2017, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network conducted a cluster randomised controlled trial (cRCT) at 26 Australian and New Zealand hospitals to improve bronchiolitis care. Findings demonstrated that targeted interventions significantly improved adherence with five evidence-based low-value bronchiolitis practices (no chest radiography, salbutamol, glucocorticoids, antibiotics and epinephrine) in the first 24 hours of hospitalisation (adjusted risk difference, 14.1%; 95% CI: 6.5% to 21.7%; p<0.001). During the intervention year (2017), intervention hospital (n=13) compliance was 85.1% (95% CI: 82.6% to 89.7%). This study aimed to determine if improvements in bronchiolitis management were sustained at intervention hospitals 2 years post-trial completion.

Methods: International, multicentre follow-up study of hospitals in Australia and New Zealand that participated in a cRCT of de-implementation of low-value bronchiolitis practices, 1 year (2018) and 2 years (2019) post-trial completion, obtained retrospectively from medical audits. Sustainability was defined a priori as no more than a <7% decrease to any level of improvement in adherence for all five low-value practices (composite outcome) from the cRCT intervention year.

Results: Of the 26 hospitals, 11 intervention and 10 control hospitals agreed to participate in the follow-up study. Data were collected on 3299 infants with bronchiolitis 1 year (intervention and control hospitals) and 1689 infants 2 years post-trial (intervention hospitals). Adherence with no use of the five low-value practices 2 years post-trial completion was 80.9% (adjusted predicted adherence, 80.8%, 95% CI: 77.4% to 84.2%; estimated risk difference from cRCT outcome -3.9%, 95% CI: -8.6% to 0.8%) at intervention hospitals, fulfilling the a priori definition of sustainability.

Discussion: Targeted interventions, delivered over one bronchiolitis season, resulted in sustained improvements in bronchiolitis management in infants 2 years later. This follow-up study provides evidence for sustainability in de-implementing low-value care in bronchiolitis management.

Trial registration details: Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.

Introduction: Machine translation of patient-specific information could mitigate language barriers if sufficiently accurate and non-harmful and may be particularly useful in healthcare encounters when professional translators are not readily available. We evaluated the translation accuracy and potential for harm of ChatGPT-4 and Google Translate in translating from English to Spanish, Chinese and Russian.

Methods: We used ChatGPT-4 and Google Translate to translate 50 sets (316 sentences) of deidentified, patient-specific, clinician free-text emergency department instructions into Spanish, Chinese and Russian. These were then back-translated into English by professional translators and double-coded by physicians for accuracy and potential for clinical harm.

Results: At the sentence level, we found that both tools were ≥90% accurate in translating English to Spanish (accuracy: GPT 97%, Google Translate 96%) and English to Chinese (accuracy: GPT 95%; Google Translate 90%); neither tool performed as well in translating English to Russian (accuracy: GPT 89%; Google Translate 80%). At the instruction set level, 16%, 24% and 56% of Spanish, Chinese and Russian GPT-translated instruction sets contained at least one inaccuracy. For Google Translate, 24%, 56% and 66% of Spanish, Chinese and Russian translations contained at least one inaccuracy. The potential for harm due to inaccurate translations was ≤1% for both tools in all languages at the sentence level and ≤6% at the instruction set level. GPT was significantly more accurate than Google Translate in Chinese and Russian at the sentence level; the potential for harm was similar.

Conclusion: These results support the potential of machine translation tools to mitigate gaps in translation services for low-stakes written communication from English to Spanish, while also strengthening the case for caution and for professional oversight in non-low-risk communication. Further research is needed to evaluate machine translation for other languages and more technical content.

Background: Access to electronic health records (EHRs) has the potential to improve the quality of care. Clinical notes, free-text entries documenting clinicians' observations and decisions, are central to EHRs. Sharing these notes may reduce information asymmetry, enhance transparency and empower patients. However, their impact on care quality remains unclear.

Aim: To assess the impact of sharing clinical notes online with patients on the domains of quality as defined by the Institute of Medicine (ie, patient-centredness, effectiveness, efficiency, safety, timeliness and equity).

Methodology: A systematic review was conducted with no time limit, using CINAHL, Cochrane, OVID Embase, HMIC, Medline/PubMed and PsycINFO. A narrative synthesis method was employed to extract the study characteristics, and reported outcomes were organised using the six IOM quality domains. The risk of bias of included studies was assessed using the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool.

Results: Nineteen studies involving 203 152 participants met inclusion criteria. Outcomes included patient-centredness (n=16), patient safety (n=14), equity (n=6), efficiency (n=4), timeliness (n=0) and effectiveness (n=0). Patient-centredness studies reported high satisfaction (n=6), increased engagement (n=11) and stronger patient-provider trust (n=7). Patient safety studies noted improvements in medication adherence (n=4) and note accuracy (n=5), alongside privacy concerns (n=5). Equity studies found benefits for minority (n=3) and less-educated patients (n=2), with one reporting equitable outcomes (n=1). No significant changes in efficiency were observed (n=4).

Discussion: Online sharing of clinical notes with patients positively impacted self-reported patient-centredness and patient safety, particularly benefiting underserved populations. However, privacy concerns must be effectively addressed, and robust safeguarding is essential to mitigate confidentiality issues. Further research is needed to evaluate the long-term impact on timeliness, effectiveness and efficiency of care.

Introduction: Non-adherence to cardiovascular disease and diabetes treatments contributes to suboptimal clinical outcomes and higher cost. The initial medication adherence (IMA) intervention is a multidisciplinary primary care (PC) intervention based on shared decision-making (SDM). The IMA-cluster-randomised controlled trial (cRCT) study evaluated the impact of the IMA intervention on medication initiation, secondary adherence and clinical outcomes compared with usual care (UC).

Methods: This was a pragmatic cRCT with a hybrid effectiveness-implementation design which randomised 24 PC centres in Spain to intervention or UC. Patients receiving a new prescription of antihypertensive, lipid-lowering, antiplatelet and/or oral/injectable antidiabetic medication at the intervention centres (March 2022-September 2022) were attended by general practitioners (GPs), nurses and community pharmacists who had been trained in SDM and given decision aids (leaflets and website). Real-world data from prescription and dispensing records-used to assess medication initiation and secondary adherence (correct dosing and continued use)-and clinical outcome data from electronic health records were collected up to 18 months after initial prescription and analysed using multilevel regression models.

Results: Overall, 4910 prescriptions were issued to 3629 patients (Intervention=2148; UC=1481) by 150 GPs (Intervention=91; UC=59). No differences were detected between groups in medication initiation or secondary adherence. Among clinical outcomes, only blood pressure outcomes favoured the IMA intervention, reflecting a small but clinically meaningful improvement.

Conclusions: The IMA intervention had limited overall impact, with no effect on adherence, but showed potential benefits in blood pressure. However, SDM, as an ethically grounded approach, may enhance patients and professional experiences, supporting its consideration for broader implementation. Future efforts should prioritise these benefits by investing in professional training and patient support, addressing implementation challenges and deepening understanding of SDM effects, which would warrant further evaluation.

Trial registration number: NCT05026775.

Background: Surgical errors in ophthalmology can have devastating consequences. We developed an artificial intelligence (AI)-based surgical safety system to prevent errors in patient identification, surgical laterality and intraocular lens (IOL) selection. This study aimed to evaluate its effectiveness in real-world ophthalmic surgical settings.

Methods: In this retrospective observational before-and-after implementation study, we analysed 37 529 ophthalmic surgeries (18 767 pre-implementation, 18 762 post implementation) performed at Tsukazaki Hospital, Japan, between 1 March 2019 and 31 March 2024. The AI system, integrated with the WHO surgical safety checklist, was implemented for patient identification, surgical laterality verification and IOL authentication.

Results: Post implementation, five medical errors (0.027%) occurred, with four in non-authenticated cases (where the AI system was not fully implemented or properly used), compared with one (0.0053%) pre-implementation (p=0.125). Of the four non-authenticated errors, two were laterality errors during the initial implementation period and two were IOL implantation errors involving unlearned IOLs (7.3% of cases) due to delayed AI updates. The AI system identified 30 near misses (0.16%) post implementation, vs 9 (0.048%) pre-implementation (p=0.00067), surgical laterality errors/near misses occurred at 0.039% (7/18 762) and IOL recognition at 0.29% (28/9713). The system achieved>99% implementation after 3 months. Authentication performance metrics showed high efficiency: facial recognition (1.13 attempts, 11.8 s), surgical laterality (1.05 attempts, 3.10 s) and IOL recognition (1.15 attempts, 8.57 s). Cost-benefit analysis revealed potential benefits ranging from US$181 946.94 to US$2 769 129.12 in conservative and intermediate scenarios, respectively.

Conclusions: The AI-based surgical safety system significantly increased near miss detection and showed potential economic benefits. However, errors in non-authenticated cases underscore the importance of consistent system use and integration with existing safety protocols. These findings emphasise that while AI can enhance surgical safety, its effectiveness depends on proper implementation and continuous refinement.

Introduction: The vital role of medical workforce well-being for improving patient experience and population health while assuring safety and reducing costs is recognised internationally. Yet the persistence of poor well-being outcomes suggests that current support initiatives are suboptimal. The aim of this research study was to work with, and learn from, diverse hospital settings to understand how to optimise strategies to improve doctors' well-being and reduce negative impacts on the workforce and patient care.

Methods: Realist evaluation consistent with the Realist And Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II quality standards. Realist interviews (n=124) with doctors, well-being intervention implementers/practitioners and leaders in eight hospital settings (England) were analysed using realist logic.

Results: There were four key findings, underpinned by 21 context-mechanism-outcome configurations: (1) solutions needed to align with problems, to support doctor well-being and avoid harm to doctors; (2) doctors needed to be involved in creating solutions to their well-being problems; (3) doctors often did not know what support was available to help them with well-being problems and (4) there were physical and psychological barriers to accessing well-being support.

Discussion and conclusion: Doctors are mandated to 'first, do no harm' to their patients, and the same consideration should be extended to doctors themselves. Since doctors can be harmed by poorly designed or implemented well-being interventions, new approaches need careful planning and evaluation. Our research identified many ineffective or harmful interventions that could be stopped. The findings are likely transferable to other settings and countries, given the realist approach leading to principles and causal explanations.