journal
https://read.qxmd.com/read/38071526/retrospective-cohort-study-of-wrong-patient-imaging-order-errors-how-many-reach-the-patient
#21
JOURNAL ARTICLE
Jerard Z Kneifati-Hayek, Elias Geist, Jo R Applebaum, Alexis K Dal Col, Hojjat Salmasian, Clyde B Schechter, Noémie Elhadad, Joshua Weintraub, Jason S Adelman
Studying near-miss errors is essential to preventing errors from reaching patients. When an error is committed, it may be intercepted (near-miss) or it will reach the patient; estimates of the proportion that reach the patient vary widely. To better understand this relationship, we conducted a retrospective cohort study using two objective measures to identify wrong-patient imaging order errors involving radiation, estimating the proportion of errors that are intercepted and those that reach the patient. This study was conducted at a large integrated healthcare system using data from 1 January to 31 December 2019...
January 19, 2024: BMJ Quality & Safety
https://read.qxmd.com/read/38135496/identifying-patients-with-additional-needs-isn-t-enough-to-improve-care-harnessing-the-benefits-and-avoiding-the-pitfalls-of-classification
#22
EDITORIAL
Natalie Armstrong, Elizabeth Sutton, Sarah Chew, Carolyn Tarrant
No abstract text is available yet for this article.
December 22, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38124225/our-mission-and-how-we-hope-to-move-the-field-forward-statement-from-the-bmj-quality-safety-senior-editorial-team-2023
#23
EDITORIAL
John Browne, Bryony Dean Franklin, Eric J Thomas, Perla J Marang-van de Mheen
No abstract text is available yet for this article.
December 14, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38097250/quality-and-safety-in-the-literature-january-2024
#24
JOURNAL ARTICLE
Sonali Vaid, Ashwin Gupta, Nathan Houchens
No abstract text is available yet for this article.
December 14, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38124229/using-patient-and-carer-perspectives-to-improve-medication-safety-at-transitions-of-care
#25
EDITORIAL
Sara Garfield, Mike Etkind, Bryony Dean Franklin
No abstract text is available yet for this article.
December 13, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38124136/how-to-co-design-a-prototype-of-a-clinical-practice-tool-a-framework-with-practical-guidance-and-a-case-study
#26
JOURNAL ARTICLE
Matthew Woodward, Mary Dixon-Woods, Wendy Randall, Caroline Walker, Chloe Hughes, Sarah Blackwell, Louise Dewick, Rachna Bahl, Tim Draycott, Cathy Winter, Akbar Ansari, Alison Powell, Janet Willars, Imogen A F Brown, Annabelle Olsson, Natalie Richards, Joann Leeding, Lisa Hinton, Jenni Burt, Giulia Maistrello, Charlotte Davies, Jan W van der Scheer
Clinical tools for use in practice-such as medicine reconciliation charts, diagnosis support tools and track-and-trigger charts-are endemic in healthcare, but relatively little attention is given to how to optimise their design. User-centred design approaches and co-design principles offer potential for improving usability and acceptability of clinical tools, but limited practical guidance is currently available. We propose a framework (FRamework for co-dESign of Clinical practice tOols or 'FRESCO') offering practical guidance based on user-centred methods and co-design principles, organised in five steps: (1) establish a multidisciplinary advisory group; (2) develop initial drafts of the prototype; (3) conduct think-aloud usability evaluations; (4) test in clinical simulations; (5) generate a final prototype informed by workshops...
December 12, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38071590/equitable-and-accessible-informed-healthcare-consent-process-for-people-with-intellectual-disability-a-systematic-literature-review
#27
JOURNAL ARTICLE
Manjekah Dunn, Iva Strnadová, Jackie Leach Scully, Jennifer Hansen, Julie Loblinzk, Skie Sarfaraz, Chloe Molnar, Elizabeth Emma Palmer
OBJECTIVE: To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible. DATA SOURCES: Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals. ELIGIBILITY CRITERIA: Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability...
December 9, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38071586/a-realist-review-of-medication-optimisation-of-community-dwelling-service-users-with-serious-mental-illness
#28
JOURNAL ARTICLE
Jo Howe, Maura MacPhee, Claire Duddy, Hafsah Habib, Geoff Wong, Simon Jacklin, Sheri Oduola, Rachel Upthegrove, Max Carlish, Katherine Allen, Emma Patterson, Ian Maidment
BACKGROUND: Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI...
December 7, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/36788035/patient-safety-and-hospital-visiting-at-the-end-of-life-during-covid-19-restrictions-in-aotearoa-new-zealand-a-qualitative-study
#29
JOURNAL ARTICLE
Aileen Collier, Deborah Balmer, Eileen Gilder, Rachael Parke
BACKGROUND: Visiting restrictions were enacted in Aotearoa New Zealand to reduce transmission of COVID-19 and protect the healthcare system. This research aimed to investigate the experiences of families and clinicians of hospital visiting for people with palliative and end-of-life care needs during restrictions. METHODS: Semistructured interviews were completed between March and October 2021 with family members and clinicians who had personally experienced enactment of visiting restrictions during pandemic restrictions...
December 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050180/quality-and-reporting-of-large-scale-improvement-programmes-a-review-of-maternity-initiatives-in-the-english-nhs-2010-2023
#30
JOURNAL ARTICLE
James McGowan, Bothaina Attal, Isla Kuhn, Lisa Hinton, Tim Draycott, Graham P Martin, Mary Dixon-Woods
BACKGROUND: Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. AIM: To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment...
November 29, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050158/health-services-under-pressure-a-scoping-review-and-development-of-a-taxonomy-of-adaptive-strategies
#31
JOURNAL ARTICLE
Bethan Page, Dulcie Irving, Rene Amalberti, Charles Vincent
OBJECTIVE: The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments. DESIGN: In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised...
November 29, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050161/patient-safety-in-remote-primary-care-encounters-multimethod-qualitative-study-combining-safety-i-and-safety-ii-analysis
#32
JOURNAL ARTICLE
Rebecca Payne, Aileen Clarke, Nadia Swann, Jackie van Dael, Natassia Brenman, Rebecca Rosen, Adam Mackridge, Lucy Moore, Asli Kalin, Emma Ladds, Nina Hemmings, Sarah Rybczynska-Bunt, Stuart Faulkner, Isabel Hanson, Sophie Spitters, Sietse Wieringa, Francesca H Dakin, Sara E Shaw, Joseph Wherton, Richard Byng, Laiba Husain, Trisha Greenhalgh
BACKGROUND: Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE: UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS: Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis)...
November 28, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050151/connecting-pathogen-transmission-and-healthcare-worker-cognition-a-cognitive-task-analysis-of-infection-prevention-and-control-practices-during-simulated-patient-care
#33
JOURNAL ARTICLE
Joel M Mumma, Bradley W Weaver, Jill S Morgan, Golpar Ghassemian, Paige R Gannon, Kylie B Burke, Brandon A Berryhill, Rebecca E MacKay, Lindsay Lee, Colleen S Kraft
BACKGROUND: Relatively little is known about the cognitive processes of healthcare workers that mediate between performance-shaping factors (eg, workload, time pressure) and adherence to infection prevention and control (IPC) practices. We taxonomised the cognitive work involved in IPC practices and assessed its role in how pathogens spread. METHODS: Forty-two registered nurses performed patient care tasks in a standardised high-fidelity simulation. Afterwards, participants watched a video of their simulation and described what they were thinking, which we analysed to obtain frequencies of macrocognitive functions (MCFs) in the context of different IPC practices...
November 28, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050114/changing-the-patient-safety-mindset-can-safety-cases-help
#34
EDITORIAL
Mark Sujan, Ibrahim Habli
No abstract text is available yet for this article.
November 24, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/38050138/grand-rounds-in-methodology-key-considerations-for-implementing-machine-learning-solutions-in-quality-improvement-initiatives
#35
JOURNAL ARTICLE
Amol A Verma, Patricia Trbovich, Muhammad Mamdani, Kaveh G Shojania
Machine learning (ML) solutions are increasingly entering healthcare. They are complex, sociotechnical systems that include data inputs, ML models, technical infrastructure and human interactions. They have promise for improving care across a wide range of clinical applications but if poorly implemented, they may disrupt clinical workflows, exacerbate inequities in care and harm patients. Many aspects of ML solutions are similar to other digital technologies, which have well-established approaches to implementation...
November 23, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/37945341/why-is-safety-in-intrapartum-electronic-fetal-monitoring-so-hard-a-qualitative-study-combining-human-factors-ergonomics-and-social-science-analysis
#36
JOURNAL ARTICLE
Guillaume Lamé, Elisa Giulia Liberati, Aneurin Canham, Jenni Burt, Lisa Hinton, Tim Draycott, Cathy Winter, Francesca Helen Dakin, Natalie Richards, Lucy Miller, Janet Willars, Mary Dixon-Woods
BACKGROUND: Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk. METHODS: Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings...
November 9, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/37940414/talking-about-falls-a-qualitative-exploration-of-spoken-communication-of-patients-fall-risks-in-hospitals-and-implications-for-multifactorial-approaches-to-fall-prevention
#37
JOURNAL ARTICLE
Lynn McVey, Natasha Alvarado, Frances Healey, Jane Montague, Chris Todd, Hadar Zaman, Dawn Dowding, Alison Lynch, Basma Issa, Rebecca Randell
BACKGROUND: Inpatient falls are the most common safety incident reported by hospitals worldwide. Traditionally, responses have been guided by categorising patients' levels of fall risk, but multifactorial approaches are now recommended. These target individual, modifiable fall risk factors, requiring clear communication between multidisciplinary team members. Spoken communication is an important channel, but little is known about its form in this context. We aim to address this by exploring spoken communication between hospital staff about fall prevention and how this supports multifactorial fall prevention practice...
November 8, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/37931935/effect-of-implementing-a-heart-failure-admission-care-bundle-on-hospital-readmission-and-mortality-rates-interrupted-time-series-study
#38
JOURNAL ARTICLE
Thomas Woodcock, Dionne Matthew, Raffaele Palladino, Mable Nakubulwa, Trish Winn, Hugh Bethell, Stephen Hiles, Susan Moggan, Jackie Dowell, Paul Sullivan, Derek Bell, Martin R Cowie
This study aimed to evaluate the impact of developing and implementing a care bundle intervention to improve care for patients with acute heart failure admitted to a large London hospital. The intervention comprised three elements, targeted within 24 hours of admission: N-terminal pro-B-type natriuretic peptide (NT-proBNP) test, transthoracic Doppler two-dimensional echocardiography and specialist review by cardiology team. The SHIFT-Evidence approach to quality improvement was used. During implementation, July 2015-July 2017, 1169 patients received the intervention...
November 5, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/37923372/identifying-and-mapping-measures-of-medication-safety-during-transfer-of-care-in-a-digital-era-a-scoping-literature-review
#39
JOURNAL ARTICLE
Catherine Leon, Helen Hogan, Yogini H Jani
BACKGROUND: Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. OBJECTIVES: To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. METHODS: Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care...
November 3, 2023: BMJ Quality & Safety
https://read.qxmd.com/read/37880148/time-to-treat-the-climate-and-nature-crisis-as-one-indivisible-global-health-emergency
#40
EDITORIAL
Chris Zielinski
No abstract text is available yet for this article.
October 25, 2023: BMJ Quality & Safety
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