BMJ Quality & Safety最新文献

Background: Peripheral venous catheters (PVCs) are ubiquitous in hospitals, yet phlebitis remains common despite single-measure prevention. Robust long-term evidence on whether comprehensive bundles sustainably reduce phlebitis is limited. The objective was to determine whether a five-element bundle (Flebitis Zero) reduces PVC-related phlebitis and whether increasing adherence confers incremental benefit.

Methods: A quasiexperimental pre-post study was conducted in 93 Spanish hospitals (2017-2024). PVCs placed in adult medical and surgical wards during 15 consecutive days each year were prospectively audited (78 691 PVCs in 53 121 patients). Daily data included bundle adherence (nine indicators) and phlebitis (Maddox score ≥2). Frequencies, relative risks (RRs) and Mantel-Haenszel χ² trend tests were calculated. A multivariable logistic regression model was employed. The dependent variable was phlebitis incidence; independent variables were bundle adherence, implementation year and inpatient unit. This model identified factors independently associated with phlebitis (p<0.05).

Results: Phlebitis incidence declined from 12.1% to 9.9% over 8 years (18% relative reduction). Seven of nine indicators improved by 5-15 percentage points, including sterile dressing (+9.6 percentage points), hand hygiene (+7 percentage points) and secure fixation (+5.7 percentage points). A clear dose-response emerged: implementing ≥ three measures conferred an additional 17-25% risk reduction versus ≤two measures and fulfilling the four audited actions achieved up to 77% lower risk (RR=0.23; trend χ²= 67.4; p<0.001). Multivariable analysis confirmed full adherence (four measures: aOR=0.612; p<0.001); the implementation year (year 2021: aOR=0.689; p<0.001) and the inpatient unit (surgical: aOR=0.868; p<0.001) independently lowered phlebitis risk.

Conclusions: Incremental adherence to the Flebitis Zero bundle sustainably decreases phlebitis. Achieving at least three measures is the minimum quality target, while full adoption offers maximal protection.

Introduction: Actively engaging patients is essential for diagnostic excellence and patient safety.

Objectives: To (1) identify and synthesise interventions facilitating patient and family engagement (PFE) across the diagnostic process, and (2a) assess patient involvement and (2b) equity considerations in their design or implementation.

Design: This scoping review followed Arksey and O'Malley's framework and PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review) guidelines. An advisory panel guided the review. We searched Medline, Embase, CINAHL, PsycInfo and Northern Light for peer-reviewed literature and conducted grey literature searches using DuckDuckGo and targeted websites. Search terms focused on PFE and diagnostic error. Eligible interventions were published in English between January 1999 and July 2024 and supported PFE in at least one step of the National Academies of Sciences, Engineering, and Medicine (NASEM) diagnostic process. Narrative reviews, case studies and editorials were excluded. Interventions were mapped to the NASEM steps; data were extracted on patient involvement and equity.

Results: Of the 11 630 studies screened, 250 were included, representing 260 interventions. Most (n=213; 85.2%) were from the grey literature, and patients were primary users (n=166; 63.8%). Interventions spanned all diagnostic process steps but were most common in treatment (n=122; 46.9%) and history taking (n=100; 38.5%), with few in referrals (n=10, 3.8%) and physical examinations (n=6, 2.3%). The evidence base was weak: grey literature interventions lacked high-quality studies, and among the 37 peer-reviewed studies, three were randomised controlled trials, each limited by small samples or high attrition. Only 63 interventions (24.2%) were designed with patients, and 48 (18.5%) incorporated equity.

Conclusion: PFE interventions exist across the diagnostic process, but few target referrals and physical examinations. The evidence remains weak, and current interventions cannot be considered effective. Future research should prioritise equity, patient involvement and rigorous evaluation.

Surgical site infections (SSIs), particularly intra-abdominal (IAB) infections, are challenging to identify and remain a resource-intensive focus of infection prevention programmes. Current automated screening measures rely on discrete data from the electronic health record (EHR), such as microbiology results, diagnosis codes and/or return to the operating room. This approach has poor specificity, and therefore surveillance methods depend heavily on additional manual chart review by trained infection preventionists. Large language models (LLMs) offer an opportunity to improve surveillance by synthesising complex clinical documentation alongside structured data elements.We evaluated the performance of a locally hosted LLM (gpt-35-turbo-16k) to improve IAB SSI screening using perioperative clinical notes and microbiology results. The model analysed documentation across the perioperative period (3 days before through 30 days after surgery) to generate case-level SSI summaries and likelihood assessments. We compared the performance of this tool against the current EHR-based screening workflow.Among 1977 abdominal surgical cases, including 56 with confirmed IAB SSIs, the LLM screened 104 cases as high risk, identifying all infections (negative predictive value (NPV) 100%) and achieving a positive predictive value (PPV) of 53.8%. In contrast, the EHR-based workflow identified 288 cases for further review, with a PPV of only 19.4% and the same NPV of 100%. Analysis of 57 224 notes required ~107 million tokens, translating to approximately USD 0.05 per case.An LLM-based approach to SSI surveillance has the potential to substantially improve efficiency while remaining highly accurate and cost-effective. By reducing reliance on manual chart review, this strategy could allow infection preventionists to shift their attention from surveillance toward quality improvement and patient safety initiatives.

Background: Out-of-hours primary care (OOH-PC) services are complex clinical environments where suboptimal care may occur. Clinicians often work under time pressure and with limited access to patients' medical history, increasing the risk of errors such as underestimation of urgency or care needs, potentially resulting in diagnostic delays and inappropriate care pathways. Patient compensation claims represent a valuable source for identifying quality and safety issues that may otherwise remain undetected.

Objective: To identify and categorise harm and failures in Danish OOH-PC by analysing patient compensation claims using the Healthcare Complaints Analysis Tool (HCAT).

Methods: We conducted a retrospective cohort study of patient compensation claims filed with the Danish Patient Compensation Association following OOH-PC contacts. Compensation claims were settled between 2019 and 2023. All claims were analysed using the HCAT framework to classify problem domains, categories, severity and patient-reported harm. A subanalysis of 595 claims with OOH-PC as sole actor was performed to identify harm hot spots (frequent subcategories with high level of harm).

Results: A total of 1162 compensation claims related to OOH-PC were filed; 159 (13.7%) received compensation. Of the 1162 claims, 953 (82.0%) were eligible for analysis with the HCAT. Most problems occurred in the clinical domain (n=753, 67.5%), and the most common category was safety (n=526, 47.1%). Regarding problem severity, 92.4% were classified as medium (n=714) or high (n=317). In terms of patient-reported harm, 30.2% (n=351) of claims described catastrophic harm. Among the 595 claims where OOH-PC was the sole actor, 51% (n=151) of the identified harm hot spots concerned the safety category within the clinical domain.

Conclusion: This study reveals key harm patterns in Danish OOH-PC, with problems concerning the safety problem category as major contributors. Compensation claims revealed overt safety issues, highlighting the need for structured monitoring tools and complementary data sources to enhance patient safety in this high-risk setting.

Background: Ward rounds are an essential activity occurring in hospital settings. Despite their fundamental role in guiding patient care, they have no standardised approach. Implementation of structured interventions during ward rounds was shown to improve outcomes such as efficiency, documentation and communication. Whether these improvements have an impact on clinical outcomes is unclear. Our systematic review assessed whether structured interventions to guide ward rounds affect patient outcomes.

Methods: A systematic search was carried out in May 2023 on Embase, Medline, CINAHL, ERIC, Web of Science Core Collection, the Cochrane Library (Wiley) and Google Scholar, and a backward and forward citation search in January 2024. We included peer-reviewed, original studies assessing the use of structured interventions during bedside ward rounds (BWRs) on clinical outcomes. All inpatient hospital settings where BWRs are performed were included. We excluded papers looking at board, teaching or medication rounds.

Results: Our search strategy yielded 29 studies. Two were randomised controlled trials (RCTs) and 27 were quasi-experimental interventional studies. The majority (79%) were conducted in intensive care units. The main clinical outcomes reported were mortality, infectious complications, length of stay (LOS) and duration of mechanical ventilation (DoMV). Mortality, LOS and rates of urinary tract and central-line associated bloodstream infections did not seem to be affected, positively or negatively, by interventions structuring BWRs, while evidence was conflicting regarding their effects on rates of ventilator-associated pneumonia and DoMV, with a signal towards improved outcomes. Studies were generally of low-to-moderate quality.

Conclusion: The impact of structured interventions during BWRs on clinical outcomes remains inconclusive. Higher quality research focusing on multicentric RCTs or on prospective pre-post trials with concurrent cohorts, matched for key characteristics, is needed.

Prospero registration number: CRD42023412637.

Background: Evaluation of neck trauma is a common reason for emergency department (ED) visits. There are several validated clinical decision rules, such as the National Emergency X-Radiography Utilization Study (NEXUS) Cervical Spine (C-spine) Rule, that can be used to risk stratify these patients and identify low-risk patients who do not require CT imaging. Overutilisation of CT imaging exposes patients to unnecessary radiation, impairs hospital throughput and increases healthcare costs. Various audit-and-feedback strategies have been described in other settings, but it is not known whether these strategies are effective for reducing imaging overutilisation in the ED. Additionally, the effectiveness of face-to-face feedback strategies as compared with digital feedback strategies for addressing this problem has not been previously evaluated. The aim of this study was to compare audit-and-feedback strategies to reduce CT overutilisation in the ED.

Methods: This was a prospective randomised controlled trial, in which emergency medicine clinicians were randomised into three arms to receive digital feedback, hybrid face-to-face/digital feedback or no feedback. Each clinician received three rounds of feedback on patient encounters in which they ordered a CT of the C-spine. Patient encounters were retrospectively reviewed to determine each clinician's overutilisation rate, defined as the percentage of patients who underwent CT of the C-spine despite being classified as low risk by NEXUS criteria.

Results: A total of 78 emergency medicine clinicians were randomised into three arms. Baseline overutilisation rates for each group were 46%-47% of CT of the C-spine studies. After three rounds of audit-and-feedback strategy, the clinicians in the digital feedback group had an overutilisation rate of 33%, compared with 44% in the control group (p=0.020). The hybrid feedback group had an overutilisation rate of 36% (p=0.055 vs control; p=0.577 vs digital feedback). Over the study period, the digital group saw a reduction of 1.26 CT of the C-spine studies per provider per month (p=0.049), and the hybrid feedback group saw a reduction of 1.43 CTs per provider per month (p=0.044).

Conclusion: A digital audit-and-feedback strategy is effective for reducing overutilisation of CT imaging of the C-spine in the ED, while the effectiveness of a hybrid strategy requires further investigation.