Quality Lines

David P Stevens, Editor

Two original papers and two commentaries in this issue of QSHC highlight how system hierarchy inhibits identification of risk in both educational and research settings. A report authored by three medical students reminds the reader that because students and trainees are on the frontlines of patient care, they frequently observe near misses that—if candidly addressed—could serve both to make patient care safer but also to provide valuable learning opportunities. The medical hierarchy complicates the ability of these junior members of the care enterprise to assert their concerns. Addressing the complex issue of assertiveness in these hierarchies by junior colleagues deserves explicit attention by our teaching hospitals and systems. A second commentary suggests that near misses may be pervasive in clinical research settings. The authors propose a formal near-miss reporting system for clinical research settings that may promote both safer care and better research. Just as students and junior doctors are mindful of the inhibitory hierarchies in teaching settings, the role of hierarchy in clinical research settings affects all health professionals—nurses, pharmacists, and clerical personnel—who are in a position to discern a high risk clinical environment.
See p 272, 229, 228 and 271

Many recently reclassified Non-Prescription Medications (NPM, also called "over-the-counter medications" in North America) are of increasing potency compared with earlier NPM medicines. Hence the consequences of inappropriate supply or use are potentially more serious. This UK study observed that pharmacists’ consultations for these medicines were frequently not guideline-compliant. The consequences of inappropriate supply and use of NPMs are relatively unknown, but need to be explored as medicine reclassification will result in greater volumes of potent medicines being supplied from community pharmacies, and non-pharmacy retail outlets.
See p 244

A retrospective analysis of the effect of time of day on provider reported anaesthetic adverse events shows an increased risk of adverse events for patients anesthetized at the end of the work day compared to the beginning of the day. Although this may result from patient-related issues, medical care delivery factors such as case load, fatigue, and care transitions may also be influencing the rate of adverse events for cases that start in the late afternoon.
See p 258

One of the most complex settings in health care is the intensive care unit (ICU). Prevention and the relief of suffering easily can get caught in the web of complicated treatment, multidirectional communication, and individual preferences. This report describes the use of an iterative process to develop a "bundle" of indicators for improvement in the quality of palliative care in the ICU. The feasibility of the bundle was successfully demonstrated by pilot testing in 19 ICUs. This work offers opportunities for further improvement in clinician-patient communication as well as other important components of palliative care in this setting.
See p 264

The QSHC homepage has had a facelift. We have been particularly interested in enhancing its function, for example, by pruning little-used functions and adding new shortcuts. Dom Mitchell, Web Administrator for BMJ Journals, provides a walk through the functionality of the homepage. QSHC is committed to helping our readers make full use of this resource. As always, we are open to additional suggestions for its improvement.
See p 226

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