BMJ Quality & Safety最新文献

Purpose: This systematic review aims to identify the implementation strategies of financial navigation and systematically synthesise its effects on mitigating financial toxicity among cancer survivors, based on the theoretical framework of implementation science.

Methods: Medline, Web of Science Core Collection, ScienceDirect and ProQuest Health & Medical Collection databases were searched for studies published before 22 August 2023. We sought original research on financial navigation interventions among adult cancer survivors with financial toxicity in healthcare settings. The Revised Cochrane risk-of-bias tool for randomised trials, 2.0 and the Risk Of Bias In Non-randomised Studies of Interventions-I were used to assess the risk of bias in included studies. In addition, the implementation strategies of the included studies were categorised and collated based on Expert Recommendations for Implementing Change, and the Consolidated Framework for Implementation Research was adopted to explain barriers and facilities for implementation.

Results: In total, 6855 records were screened, yielding 14 full-text articles, which were included (3 randomised clinical trials and 11 non-randomised studies). 'Train and educate stakeholders' (n=13 (92.9%)) and 'use evaluative and iterative strategies' (n=12 (85.7%)) were the most common implementation strategies in financial navigation. The feasibility of financial navigation is relatively high, but generally hindered by the health condition of cancer survivors, low willingness to participate and insufficient number of navigators to cover all participants. After the intervention, three of seven studies reported statistically significant mitigations in patient-reported financial toxicity. In studies reporting statistically significant outcomes, 'adapt and tailor to the context' and 'change infrastructure' were proposed as key corresponding recommendations.

Conclusions: Financial navigation is a potentially beneficial intervention for lessening the financial toxicity of cancer survivors, but more high-level evidence is needed for further validation. Financial navigation combined with the theoretical framework of implementation science provides a foundation for the future realisation of the leap from knowledge to practice.

Prospero registration number: CRD42023469114.

Background: Globally, up to 17% of hospitalised people suffer a patient safety incident. Learning from adverse events through patient safety investigation is critical to prevention; however, their utility is still questioned. Two key investigation outputs include identifying contributing factors (CFs) and proposing recommendations to prevent future occurrences. Criticisms of current methods include incomplete analysis of CFs and weak incident prevention strategies. A proposed solution is systems thinking analysis, which recognises healthcare complexity. However, it is not clear whether such methods are being applied in practice.

Objective: This study aimed to assess current use of systems thinking-based strategies by examining a set of Australian patient safety incident investigations.

Methods: Investigations (n=300) from 56 different Australian health services were deductively analysed. Identified CFs were classified by healthcare system level using a framework combining Systems Engineering Initiative for Patient Safety (SEIPS) principles and AcciMap's hierarchical structure. Recommendation sustainability and effectiveness were classified as weak, medium or strong using US Department of Veteran Affairs' criteria.

Results: 51% of incidents were issues with clinical processes and procedures. The investigations identified CFs that disproportionally focused on the people involved in those processes (n=677, 47%) rather than other system levels and as a consequence, most recommendations were of medium (n=665, 51%) and weak (n=560, 43%) strength. Notably, 10% of investigations lacked any CFs or recommendations.

Conclusion: The focus on individual actions highlighted that simple linear thinking persists in patient safety incident investigations. This study proposes five key areas of effective incident analysis and investigation: a sociotechnical focus; improved data collection techniques; investigative independence; the professionalisation of investigators; and the aggregation of data. Learning from incidents is key to maximising their preventative effectiveness, especially in an increasingly complex healthcare system.

Background: In 2019, NHS England launched the second version of the Saving Babies' Lives Care Bundle (SBLCBv2), recommendations that maternity providers are expected to fully implement, in an ongoing effort to reduce stillbirths and preterm births. Although stillbirth rates have seen an overall significant reduction since the inception of the SBLCB, experiences of maternity care in England are deteriorating. This study aimed to explore service users' experiences of SBLCBv2-informed maternity care to help understand the aspects of care they received positively and those needing improvement.

Methods: This qualitative study captured service users' experiences of receiving maternity care across England between November 2022 and December 2023. Purposive sampling was employed to include service users from diverse backgrounds with a variety of experiences of each element of SBLCBv2. Participants (n=29) were 16 years or older, had given birth within the previous 12 months and could comprehend and speak English. Semi-structured interviews were conducted via video call and the data analysed using reflexive thematic analysis.

Results: Four main themes with nine subthemes were developed: (1) feelings towards measuring and monitoring, (2) the importance of clear communication, (3) healthcare professionals' roles in decision-making and (4) belief in service users, trust in healthcare professionals. Each theme is discussed in relation to the five elements, and the 'Important Principles', of SBLCBv2.

Conclusions: Our findings echo maternity care needs reported elsewhere in the literature, suggesting the interventions introduced in SBLCBv2 are generally acceptable but that information about SBLCBv2 must be personalised, and clearly presented, to each individual. Professionals play an important role in service users' decision-making, and participants' perceptions of how collaborative and supportive professionals were in decision-making processes varied. Believing service users and trusting professionals are of paramount importance for ensuring service users have positive maternity care experiences.

Objective: To evaluate the effectiveness of clinician-directed default nudges for reducing overuse of tests and treatments.

Design: A systematic review was conducted to synthesise evidence from randomised controlled trials examining the effect of clinician-directed default nudges on overuse of tests or treatments, measured as a proportion of encounters or patients. Four databases and three clinical trial registries were searched up to 13 January 2025. Two reviewers screened, extracted data, assessed risk of bias and certainty of evidence using Cochrane guidance. Because there was high clinical heterogeneity, we used the Synthesis Without Meta-analysis guidelines for our overall analysis. A secondary exploratory meta-analysis was performed on a subgroup of default nudge interventions targeting opioid prescriptions.

Results: We included six trials (five cluster randomised trials and one patient randomised trial, n=767 to 21 331). Trials targeted overuse of opioids, antibiotics, high-risk medicines for older patients and imaging during palliative radiotherapy. Lowering default quantities of opioids may cause reductions in opioid overuse, but on one occasion increased overuse. It is unclear if opt-out defaults reduce antibiotic overuse in patients with sepsis eligible for de-escalation or if lowering default doses reduce overuse of high-risk medications in older patients. Reducing the default frequency of imaging probably causes large reductions in unnecessary imaging in people receiving palliative radiotherapy. A subgroup meta-analysis was only possible on one type of default for opioids. A 10-tablet default may reduce overuse of large packs of opioids (risk difference=-14.3%, 95% CI -51.4% to +22.9%, 3 trials, 18 186 encounters, very low certainty evidence).

Conclusions: Clinician-directed default nudges had inconsistent effects on overuse of healthcare, with limited and mostly low certainty evidence. High-quality trials are essential to determine whether default nudges reduce overuse or improve patient outcomes.

Prospero registration number: 42024516423.

Background and objectives: Paediatric medication use is at high risk for errors due to factors such as weight-based dosing and liquid medications. In the outpatient setting, where most children take their medicines, errors are common and can be dangerous. However, errors are not widely measured in this setting. Continuous measurement is the first step towards quality improvement. Our aim was to collaborate with a variety of professional and patient/family key partners to identify types of measures needed to assess paediatric outpatient medication errors, including those that occur in the home.

Methods: We conducted qualitative interviews and concept mapping with parents, pharmacists, paediatricians, nurses, health system leaders and healthcare organisational leaders. Using concept mapping, a multiple-step structured process of surveys, sorting and analysis using multidimensional scaling and hierarchical cluster analysis, participants generated measures and prioritised those they considered most important and feasible to measure in future medication error instruments. At the same time, interviews identified gaps in current measurement approaches and top priorities to fill these gaps. Results were compared during analysis.

Results: Concept mapping participants (n=71) contributed ideas which key partner panel (n=9) mapped into seven clusters: prescribing errors, giving medication/administration, pharmacy dispensing, dosing tools and education, monitoring for problems, error surveillance and family partnership in understanding errors. Interview participants (n=24) highlighted the need for health system measures of safe outpatient medication used for quality improvement, including feasible measures related to home administration, dispensing errors and measures of harm. The ability to segment data by high-risk populations (eg, preferred language) was a priority.

Conclusions: Measures of safe administration at home were the highest priority for parents and healthcare professionals. Development of these measures is critical as no scalable measures for this element of care are available. These and other prioritised measures will likely need to include caregiver report.

Introduction: There is increased recognition that diagnostic errors disproportionately affect marginalised and underserved patient populations in the USA. However, evidence on diagnostic inequities in mental disorders is sparse and not well integrated into the overall diagnostic safety literature.

Objective: We systematically reviewed and narratively synthesised evidence on inequities in diagnosis of mental disorders, guided by the Diagnostic Process Framework developed by The National Academies of Sciences, Engineering, and Medicine.

Methods: We conducted a systematic review and a narrative synthesis. Medline, Embase, PsycInfo and CINAHL were searched for studies published between 2015 and 2024. Studies were eligible if they reported on inequities in the diagnosis of mental disorders and applied a quantitative, qualitative or mixed-methods design. Studies had to be peer reviewed, US based and published in English. The Mixed-Methods Appraisal Tool was used for quality appraisal. Data were analysed with a descriptive intent, and inequities were mapped into the diagnostic process.

Results: 20 studies of varying methodological quality were included. Though not the initial focus, autism spectrum disorder (ASD) emerged as the most studied mental disorder (n=17). Of the diagnostic errors identified, most fell into the category of delayed diagnosis. 11 factors emerged as contributors to diagnostic inequities. Limited health literacy among patients and caregivers was the leading cause of diagnostic error in symptom recognition. Insurance coverage issues delayed patient engagement with the healthcare system. Provider bias during clinical history-taking and interviewing was seen as a key cause of delays and misdiagnoses. Within diagnostic testing and interpretation, culturally inequivalent assessment measures might cause misdiagnosis and delayed diagnosis for Black/African American and Hispanic/Latino patients. The use of medical jargon and lack of qualified language interpreters during communicating the diagnosis were associated with diagnostic errors impacting patients with limited health literacy and low English language proficiency.

Conclusions: Diagnostic inequities in ASD and other mental disorders persist across US patient populations. Multiple factors such as parental health literacy, provider bias and limited access interact and impact the diagnostic process. Addressing these interconnected barriers is essential to ensure timely, accurate and equitable care.

Prospero registration number: CRD42024581271.