BMJ Quality & Safety最新文献

Background: Medication errors are the leading cause of preventable harm in healthcare. Despite proliferation of medication-related clinical decision support systems (CDSS), current systems have limitations. We therefore developed an indication-based prescribing tool. This performs dose calculations using an underlying formulary and provides patient-specific dosing recommendations. Objectives were to compare the incidence and types of erroneous medication orders, time to prescribe (TTP) and perceived workload using the NASA Task Load Index (TLX), in simulated prescribing tasks with and without this intervention. We also sought to identify the workflow steps most vulnerable to error and to gain participant feedback.

Methods: A simulated, randomised, cross-over exploratory study was conducted at a London NHS Trust. Participants completed five simulated prescribing tasks with, and five without, the intervention. Data collection methods comprised direct observation of prescribing tasks, self-reported task load and semistructured interviews. A concurrent triangulation design combined quantitative and qualitative data.

Results: 24 participants completed a total of 240 medication orders. The intervention was associated with fewer prescribing errors (6.6% of 120 orders) compared with standard practice (28.3% of 120 orders; odds ratio 0.18, p<0.01), a shorter TTP and lower overall NASA-TLX scores (p<0.01). Control arm workflow vulnerabilities included failures in identifying correct doses, applying maximum dose limits and calculating patient-specific dosages. Intervention arm errors primarily stemmed from misidentifying patient-specific information from the medication scenario. Thematic analysis of participant interviews identified six themes: navigating trust and familiarity, addressing challenges and suggestions for improvement, integration of local guidelines and existing CDSS, intervention endorsement, 'search by indication' and targeting specific patient and staff groups.

Conclusion: The intervention represents a promising advancement in medication safety, with implications for enhancing patient safety and efficiency. Further real-world evaluation and development of the system to meet the needs of more diverse patient groups, users and healthcare settings is now required.

Trial registration number: NCT05493072.

Background: Pulmonary embolism (PE) is a potentially deadly disease and a diagnostic challenge in emergency departments (EDs). Established strategies exist for risk stratification and test stewardship for CT pulmonary angiography (CTPA). However, implementation of best practices has proven challenging, and rising CTPA utilisation increases costs, radiation exposure and ED crowding. We created a multimodal quality intervention to reduce excess CTPA studies and increase the use of d-dimer assays prior to CTPA. Balance measures included the rate of positive CTPA studies and ED returns within 72 hours of discharge.

Methods: This was an observational, pre-post interventional design at three EDs. The intervention included an institutional PE diagnostic guideline, educational sessions, an electronic clinical decision support tool and monthly feedback to individual providers. Consecutive patient data were analysed 1 year pre and 1 year post an intervention on 21 November 2021. Analyses used Pearson χ², logistic regression generalised linear models and XmR statistical process control (SPC).

Results: The study included 307 441 patient encounters, with 35 066 PE evaluations. CTPA utilisation decreased from 6.0% to 5.1% (p<0.01) of all patient encounters, and d-dimer use preceding CTPA increased from 36.6% to 56.3% (p<0.01). For both primary measures, SPC charts showed statistically significant special cause variation compared with the pre-intervention data. There was no significant change in the rate of positive CTPA studies (9.3% vs 10.4%, p=0.14) or 72-hour ED returns (3.0 vs 3.1%, p=0.6).

Conclusions: A multimodal intervention was associated with reduced CTPA utilisation and increased use of d-dimer as the initial test in PE diagnosis, without any negative associated impact on balance measures. This strategy could be reproduced and implemented at other institutions looking to change practice.

Background: Given the emphasis on promoting inclusive policies, we investigated the relationship between US hospitals' inclusion efforts for lesbian, gay, bisexual, transgender, queer or questioning, and other sexual and gender-diverse (LGBTQ+) populations and patient satisfaction from 2016 to 2023.

Methods: This retrospective longitudinal observational study analysed 6 years of data between 2016 and 2023 from the Healthcare Equality Index (HEI), which measures hospitals' LGBTQ+ inclusion efforts, and the Hospital Consumer Assessment of Healthcare Providers and Systems, which measures patient satisfaction. Generalised estimating equations (GEE) were used to obtain population-averaged estimates of the association between hospitals' LGBTQ+ inclusion efforts-assessed by (1) their participation and (2) performance in the HEI (range: 0-100)-and patient satisfaction-measured by (1) patients' hospital rating (range: 0-100) and (2) willingness to recommend the hospital (range: 0-100). We accounted for hospital characteristics, including medical teaching status, specialised service capability, hospital size, ownership, system membership, region and metropolitan location.

Results: Compared with hospitals that never participated in the HEI, those that occasionally participated reported a 0.33-point higher patient rating (p=0.019, 95% CI 0.05, 0.60) and a 0.49-point higher patient recommendation score (p=0.011, 95% CI 0.11, 0.87). Those who always participated reported a 1.30-point higher rating (p<0.001, 95% CI 0.89, 1.70) and a 1.90-point higher recommendation score (p<0.001, 95% CI 1.36, 2.44). Among hospitals that participated in the HEI, a 10-point increase in the total HEI score was associated with a 0.10-point increase in patient ratings (p=0.031, 95% CI 0.01, 0.20) and a 0.15-point increase in patient recommendations (p=0.023, 95% CI 0.02, 0.28).

Conclusion: Hospitals engaging in LGBTQ+ inclusion efforts are associated with higher patient satisfaction.

Background: Wrong-drug medication errors are common. Regulators screen drug names for confusability, but screening methods lack empirical validation. Previous work showed that psycholinguistic tests on pairs of drug names are associated with real-world error rates in chain pharmacies. However, regulators evaluate individual names not pairs, and individual names can be confused with multiple drugs (eg, hydroxyzine with hydralazine but also hydrocet, thorazine, hydrochlorothiazide). This study examines whether an individual drug name's performance on psycholinguistic tests correlates with that name's sum total error rate in the real world.

Methods: Nineteen pharmacists and 18 pharmacy technicians completed memory and perception tests assessing confusability of 77 drug names. Tests involved presenting a drug name to participants in conditions that hindered their ability to see, hear or remember the name. Participants typed the name they perceived and selected that name from a menu of alternatives. Error rates on the tests were assessed in relation to real-world rates, as reported by the patient safety organisation associated with a national pharmacy chain in the USA.

Results: Mean error rate on the psycholinguistic tests was positively correlated with the log-adjusted real-world error rate (r=0.50, p<0.0001). Linear and mixed effects logistic regression analyses indicated that the lab-measured error rates significantly predicted the real-world error rates and vice versa.

Conclusions: Lab-based psycholinguistic tests are associated with real-world drug name confusion error rates. Previous work showed that such tests were associated with error rates of specific look-alike sound-alike pairs, and the current work showed that lab-based error rates are also associated with an individual drug's overall error rate. Taken together, these studies validate the use of psycholinguistic tests in assessing the confusability of proposed drug names.

Background: Individuals with sickle cell disease (SCD) experience poor clinical outcomes while transitioning from paediatric to adult care. Standards for SCD transition are needed. We established a Quality Improvement (QI) Collaborative that aimed to improve the quality of care for all young adults with SCD by establishing a standardised SCD transition process. This study evaluates the implementation of the Six Core Elements (6CE) of Health Care Transition, which was a fundamental component of the cluster-randomised Sickle Cell Trevor Thompson Transition Project (ST3P-UP) study.

Methods: A central QI team trained 14 ST3P-UP study sites on QI methodologies, 6CE and Got Transition's process measurement tool (PMT). Site-level QI teams included a transition coordinator, clinic physicians/staff, patients/parents with SCD and community representatives. Sites completed the PMT every 6 months for 54 months and monthly audits of 10 randomly-selected charts to verify readiness/self-care assessments and emergency care plans.

Results: Of a possible 100, the aggregate mean (±SD) PMT score for paediatric clinics was 23.9 (±13.8) at baseline, 95.9 (±6.0) at 24 months and 98.9 (±2.1) at 54 months. The aggregate mean PMT score for adult clinics was 15.0 (±13.5) at baseline, 88.4 (±11.8) at 24 months and 95.8 (±6.8) at 54 months. The overall QI Collaborative PMT score improved by 402%. At baseline, readiness/self-care assessments were current for 38% of paediatric and 20% of adult patients; emergency care plans were current for 20% of paediatric and 3% of adult patients. Paediatric clinics had one median readiness assessment shift (76%) and four median emergency care plan shifts (65%, 77%, 79%, 84%). Adult clinics experienced three median self-care assessment shifts (58%, 63%, 70%) and two median emergency care plan shifts (57%, 70%).

Conclusions: The ST3P-UP QI Collaborative successfully embedded the 6CE of Health Care Transition into routine care and increased administration of assessments and emergency care plans for transition-aged patients with SCD.

Background: Disparities have been identified in many aspects of the cancer care pathway for people from minority ethnic groups (MEGs). Adherence to systemic anticancer therapies (SACTs) has been shown to impact morbidity and mortality, and therefore, inequitable experiences can have a detrimental effect on outcomes.

Objectives: To identify interventions that focused on improving the experiences and clinical outcomes in people from MEG receiving SACT treatments.

Methods: A scoping review was conducted according to Arksey and O'Malley's methodological framework to map the available literature. A comprehensive search was performed using three electronic databases (Medline, Embase and CINAHL). Standard scoping review methodology following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was used. Studies were included that assessed interventions to improve MEG patients' experience with SACT. Study types included in the review were evaluation studies, randomised/non-randomised controlled trials and all observational studies. Exclusion criteria were applied to studies including opinion pieces, literature and systematic reviews, non-English studies, conference abstracts and studies that were not describing an intervention. Independent duplicate screening, study selection, data extraction and quality assessment were undertaken. Results of the studies were synthesised using a published equity framework.

Results: Searches yielded 1356 articles. Nine studies were included after exclusion criteria were applied. Studies described six digital, two in-person and one hybrid intervention employing different research methodologies, ranging from randomised controlled trials (RCTs), feasibility studies and mixed methods studies. The majority of interventions in this study were delivered remotely, using digital platforms such as websites, recorded educational training materials as well as social media. These interventions were conducted in the USA and primarily targeted patients with early breast cancer from African American backgrounds.

Conclusions: This scoping review showed that there has been a very small number of studies investigating interventions to optimise SACT treatment experiences in people from MEG. We found evidence of interventions incorporating the equity domains that reported improved patient engagement and experience. This new knowledge will help to implement future SACT interventions, addressing health inequities across the cancer continuum.