The use of verbal orders has been identified as a potential contributor to poor quality and less safe care. As a result, many organisations have encouraged changing the verbal orders process and/or reducing/eliminating verbal orders altogether (Joint Commission (2005), Institute of Medicine (2001), Leapfrog organisation, Institute of Safe Medication Practices). Ironically there is a paucity of research evidence to support the widespread concern over verbal order.
This paper describes the very limited existing research on verbal orders, presents a model of verbal order use identifying potential error trigger points and suggests a verbal order research agenda in order to better understand the nature and extent of the potential patient care safety threat posed by verbal orders.
The use of verbal orders, while essential in some healthcare settings, has been identified as a potential contributor to poor quality and less safe care. Despite the widespread use of verbal orders, little research attention has been paid to understanding and measuring the content of verbal orders or variables related to the context in which verbal orders are made.
This paper first identifies variables related to verbal order content and context, and then provides detailed analyses from two exploratory studies conducted in one community hospital.
The data presented were collected using both a paper-based manual audit, and an analysis of data generated from a computerised order entry system.
Selected analyses focus of variations in types and timing of verbal orders hospital-wide as well as for specific inpatient units, changes in verbal order utilisation following implementation of a computerised provider order entry system, and an analysis of the presence of sound-alike and high-alert medications in verbal orders.
Improving quality of end-of-life care is a key driver of UK policy. The Gold Standards Framework (GSF) for Palliative Care aims to strengthen primary palliative care through facilitating implementation of systematic clinical and organisational processes.
To describe the general practices that participated in the GSF programme in 2003–5 and the changes in process and perception of quality that occurred in the year following entry into the programme, and to identify factors associated with the extent of change.
Participating practices completed a questionnaire at baseline and another approximately 12 months later. Data were derived from categorical questions about the implementation of 35 organisational and clinical processes, and self-rated assessments of quality, associated with palliative care provision.
1305 practices (total registered population almost 10 million). Follow-up questionnaire completed by 955 (73.2%) practices (after mean (SD) 12.8 (2.8) months; median 13 months).
Mean increase in total number of processes implemented (maximum = 35) was 9.6 (95% CI 9.0 to 10.2; p<0.001; baseline: 15.7 (SD 6.4), follow-up: 25.2 (SD 5.2)). Extent of change was largest for practices with low baseline scores. Aspects of process related to coordination and communication showed the greatest change. All dimensions of quality improved following GSF implementation; change was highest for the "quality of palliative care for cancer patients" and "confidence in assessing, recording and addressing the physical and psychosocial areas of patient care".
Implementation of the GSF seems to have resulted in substantial improvements in process and quality of palliative care. Further research is required of the extent to which this has enhanced care (physical, practical and psychological outcomes) for patients and carers.
Healthcare providers work increasingly under a variety of shift work systems to cover the continuous care required by patients. However, the effects of shift work on patient and provider outcomes in healthcare settings has not been systematically evaluated.
To identify and analyse the available evidence on the effect of shift length (8-h vs 12-h shifts) on quality of patient care and healthcare provider outcomes.
Systematic searching of eight online databases, key governmental/organisational websites and academic journals with ancestry search of relevant articles (limited to articles published in English and Spanish).
Of 562 articles that were retrieved from 20 446 titles identified through database and manual searches, 27 satisfied the inclusion criteria, of which 15 were rejected because of low methodological quality. The 12 final studies included cross-sectional/survey (7), before–after (3) and prospective cohort (2) designs. The main primary outcomes evaluated were: (1) quality of patient care and (2) healthcare provider outcomes. The results were equivocal. With respect to the effect of shift length on quality of patient care, two studies found that errors and near errors were associated with working longer shifts, and another study reported decreased patient complications and length of stay with longer shifts. Specific healthcare provider outcomes such as health complaints, well-being, drug and alcohol consumption, stress and job satisfaction were mostly evaluated by single studies and therefore there was insufficient evidence from which to draw conclusions.
Methodological quality of the studies generally was low and results equivocal with insufficient evidence to determine the effects of shift length on quality of patient care and healthcare provider outcomes. Clearly, robust well-designed studies are needed to examine the effect of shift length on patient and healthcare provider outcomes.
The Healthcare Commission, the national regulator for the National Health Service in England, has to assess providers (NHS trusts) on compliance with core standards in a way that targets appropriate local inspection resources.
To develop and evaluate a system for targeting inspections in 2006 of 44 standards in 567 healthcare organisations.
A wide range of available information was structured as a series of indicators (called items) that mapped to the standards. Each item was scored on a common scale (a modified Z-score), and these scores were aggregated to indicate risks of undeclared non-compliance for all trusts and standards. In addition, local qualitative intelligence was coded and scored.
The information sets used comprised 463 875 observations structured in 1689 specific items, drawn from 83 different data streams. Follow-up inspections were undertaken on the 10% of trusts with the highest-risk scores (where the trust had declared compliance with a standard) and an additional 10% of trusts randomly selected from the remainder. The success of the targeting was measured by the number of trust declarations that were "qualified" following inspection. In the risk-based sample, the proportion of inspected standards that were qualified (26%) was significantly higher than in the random sample (13%). The success rate for targeting varied between standards and care sectors.
This innovative approach to using information to target inspection activity achieved its overall aims. The method worked better for some standards and in some settings than for others, and is being improved in the light of experience gained. Such applications are increasingly important as modern regulators strive to be targeted and proportionate in their activities.
In September 2004, 28 published and 17 ongoing clinical management surveys (CMS) of cancer in Australia were identified, describing the clinical management of representative series of cancer patients. The present study assessed the perceived influence of these on clinical practice and the logistical issues involved in conducting a CMS.
Questionnaire sent to a key clinical investigator in each survey.
For the 28 published CMS, respondents (response rate 54%) reported that the CMS were influential in half or more of subsequent changes in the development or implementation of standard protocols, increasing specialist involvement in clinical trials, reducing variability in practice, and providing informed choice for patients. The surveys were regarded as influential in a third to half of noted changes in the use of evidence-based treatments, multidisciplinary care, and standardised collection of data. For CMS in progress, respondents (response rate 65%) reported on objectives and logistical issues, with the need for multiple ethical approvals emerging as a major issue.
CMS of cancer have played a modest but important role in stimulating and supporting improvements in clinical care in Australia. Many Australian surveys have been large and population-based and with high response rates. The recent introduction of a requirement for patient consent by some (but not all) ethical committees greatly increases the difficulties and costs of such surveys.
To evaluate the performance of a trigger tool for identifying adverse drug events (ADEs) among older adults in ambulatory primary care practices.
Manual 12-month retrospective chart review at six practices using a 39-item trigger tool. Patients aged 65 or above with cardiovascular diagnoses were included. Charts with triggers underwent detailed review by a physician and pharmacist to identify ADEs.
Of 1289 charts reviewed, 645 (50%) had at least one trigger. A random sample of 383 of these charts underwent further review (mean 64 charts per practice). Among the 908 triggers in these charts, 232 were deemed to represent ADEs, of which 92 were deemed preventable and 30% of these were severe. The most common triggers and their positive predictive values (PPVs) for ADEs were "Medication stop" (26.3%), "Hospitalisation" (21.8%) and "Emergency Room" visit (14.9%). Only nine of the triggers had PPVs >5%. These nine triggers accounted for 94.4% (219/232) of the ADEs detected.
Trigger tools have a potential role in driving quality improvement in ambulatory primary care. In our study using a 39-item ADE trigger tool, most triggers had very low PPVs. Nine of the 39 triggers accounted for 94.4% of ADEs detected, suggesting the possibility of a much briefer tool. Practical issues related to adoption of such tools by practising physicians should be further explored.
Limited information exists in regard to drug omissions and unjustified medications in the hospital discharge summary (DS).
To evaluate the incidence and types of drug omissions and unjustified medications in the DS, and to assess their potential impact on patient health.
A prospective observational review of the DSs of all patients discharged from our Internal Medicine Department over a 3-month period. Data assessment was made by internists using a structured form.
Of the 577 evaluated DSs, 66% contained at least one inconsistency accounting for a total of 1012 irregularities. There were 393 drug omissions affecting 251 patients, 32% of which were potentially harmful. Seventeen per cent of all medications (619/3691) were unjustified, affecting 318 patients. The unjustified medication was potentially harmful in 16% of cases, occurred significantly more frequent in women than in men (61% vs 50%; p = 0.008) and increased linearly with the number of drugs prescribed (p<0.001). Drug omission had a twofold higher potential to cause harm than unjustified medication.
Drug omissions and unjustified medications are frequent, and systemic changes are required to substantially reduce these inconsistencies.
This study aims at evaluating doctors’ attitudes towards handling medical errors made by their peers.
This cross-sectional questionnaire survey was conducted between April and July 2006 and targeted general practitioners attending continuing medical education programmes in Tehran. A total of 474 doctors were approached, 400 of whom completed the questionnaire. The questionnaire contained a clinical vignette with three hypothetical patient outcomes: near-miss, leading to harm, and leading to death. The participants were asked how they would deal with each case. They were also asked how they would prefer their peers to react when they themselves made a medical error.
The most common attitude toward peers’ medical errors was reporting it to the original doctor and asking them to disclose it to the patient (near-miss: 63.0%; 95% CI 58% to 68%; leading to harm: 70.0%; 95% CI 65.4% to 74.6%; and leading to death: 62.5%; 95% CI 57.5% to 67.5%). In most cases, doctors expected their peers to report their medical errors to them (92.7%; 95% CI 89.7% to 93.0). About 67% of the participating doctors had encountered a peer’s medical error in the past 6 months, although 90% of them had received no or very little training in dealing with this issue.
The most acceptable approach to dealing with a peer’s medical error is to report it to the responsible doctor and encourage them to disclose it to the patient.
Ambulance personnel use wheeled stretchers for moving patients in the out-of-hospital setting. The nature of adverse events and associated injuries occurring during ambulance stretcher operation was characterised.
Data from the United States Food and Drug Administration’s Manufacturer and User Facility Device Experience Database (MAUDE) were used. All adverse events involving ambulance stretchers during the years 1996–2005 were identified. The nature of the event, the method of stretcher handling, the individuals injured and the nature of the resulting injuries were identified.
There were 671 reported adverse events. The most common adverse events were stretcher collapse (54%; 95% CI 50 to 57%), broken, missing or malfunctioning part (28%; 95% CI 25 to 32%) and dropped stretcher (7%; 95% CI 5 to 9%). Adverse events most commonly occurred during unloading of the stretcher from the ambulance (16%; 13 to 19%). Injuries occurred in 121 events (18%; 95% CI 15 to 21%), most often involving sprains/strains (29%), fractures (16%) and lacerations/avulsions (13%). There were three traumatic brain injuries and three deaths. Patients sustained injuries in 52 events (43%), and ambulance personnel sustained injuries in 64 events (53%). More than one individual sustained injuries in 12 events.
Adverse events may occur during ambulance stretcher operation and can result in significant injury to patients and ambulance personnel.
In 2002, the Accreditation Council for Graduate Medical Education (ACGME) introduced a new requirement: residents must demonstrate competency in Practice-Based Learning and Improvement (PBLI). Training in this domain is still not consistently integrated into programmes, with few, if any, adequately going beyond knowledge of basic content and addressing all components of the requirement.
To summarise the implementation of a PBLI curriculum designed to address all components of the requirement and to evaluate the impact on the practice system.
A case-study approach was used for identifying and evaluating the steps for delivering the curriculum, along with the Model for Improvement’s successive Plan–Do–Study–Act (PDSA) cycles (July 2004–May 2006).
Notes from curriculum development meetings, notes and presentation slides made by teams about their projects, resident curriculum exit evaluations curriculum and interviews.
Residents reported high levels of comfort by applying PBLI-related knowledge and skills and that the curriculum improved their ability to do various PBLI tasks. The involvement of multiple stakeholders increased. Twelve of the 15 teams’ suggestions with practical systems-relevant outcomes were implemented and sustained beyond residents’ project periods. While using the traditional PDSA cycles was helpful, there were limitations.
A PBLI curriculum that is centred around practice-based quality improvement projects can fulfil the objectives of this ACGME competency while accomplishing sustained outcomes in quality improvement. A comprehensive curriculum is an investment but offers organisational rewards. We propose a more realistic and informative representation of rapid PDSA cycle changes.
Despite longstanding experimental evidence about effectiveness of academic detailing, transitioning this research-based concept into acceptable primary care quality improvement services has been slow in the USA. The purpose of this study was to describe primary care uptake, retention and response to an academic-detailing-led service in the USA. Exploration of accessible performance indicators of service acceptance, and feasibility of use of an Australian academic detailing service model were secondary objectives.
Over a 29-month period, an academic-detailing-led drug and therapeutics information service was offered to all primary care physicians providing ongoing patient care in Fayette County, Kentucky. Two programmes (on type 2 diabetes management and chronic pain management) incorporating up to four office visits were offered.
102 of 130 (78%) eligible primary care physicians participated in the service, 72% receiving visits for the type 2 diabetes management programme, and 58% the chronic non-malignant pain programme. At all successive encounters, participants expressed a willingness to continue to receive visits. Difficulties were experienced in obtaining appointments for subsequent visits, although on direct enquiry, only one participant explicitly declined further visits. No notable differences existed between physicians accepting visits and those who did not. Across successive visits, passive indicators of satisfaction with the service included: duration of visits, office waiting times, retention of printed materials from one visit to the next, whether physicians wished their extender colleagues to also receive visits, and observed levels of interest and participation within encounters.
Ongoing primary care quality improvement services spearheaded by academic detailing can be acceptable to US primary care physicians in practice.
Drugs are often given intravenously even when the patient is able to swallow and when an oral form would be more cost-effective.
Evaluation of the impact of a multifaceted intervention on the early switch from intravenous to oral administration of proton pump inhibitors (PPI) in a hospital setting. The interrupted time series of intravenous PPI consumption was analysed.
At a French University Hospital, the Drug Committee, composed of multidisciplinary pharmacy and medical staff, addressed the issue of increasing consumption of intravenous PPI drugs (May 2003).
Letters to department heads, academic analyses from members of the Drug Committee, paper reminders at the point of care and audit-feedbacks by pharmacists. Monitoring of consumption and repeated reminder letters were planned.
The consumption of PPI was stable before the first intervention (mean level: 954 units/month). An immediate decrease occurred after the first Drug Committee letter (30% relative reduction, 95% CI –16% to –46%; p<0.001) with a significant trend change during the first multifaceted intervention (–24 units/month, 95% CI –42 to –7; p = 0.007). After the end of the outreach visits (July 2004), the consumptions increased (+32 units/month, 95% CI: 14 to 50, p<0.001). The second intervention had no significant impact.
A complex intervention (audit, feedbacks, outreach visits) had an effect on practice. It was not sustained even after a less resource-intensive intervention. Other types of interventions are needed that could be continuously implemented to improve ordering practices long term.
Enhanced Recovery After Surgery (ERAS) is a perioperative treatment protocol that can improve individual recovery. This allows patients to leave hospital earlier, implying a cost reduction. The programme seems to spread slowly. ERAS was introduced at the Department of Obstetrics and Gynaecology at Akershus University Hospital in 2005. The objective of this study was to monitor changes in the workload and work environment of the ward nursing staff when ERAS was introduced at the department.
A pre-postintervention prospective design was used. Triangulated data were collected immediately before introduction (Phase 1), soon after (Phase 2), and 1 year after introduction (Phase 3). Data sources in all phases were registrations of time spent caring for individual patients during their stay, personnel survey responses and verbal interviews with informants from different staff groups. Patients were included consecutively, the aim being to include a minimum of 40 per phase.
Time registration showed that during the observation period, there was a 28% reduction in mean length of stay (–1.3 days, 95% CI –1.63 to –0.97, p<0.001) and 39% reduction in total time used in nursing activities per stay (–162 min, 95% CI –239.3 to –84.4, p<0.001). The personnel survey had a 100% response rate and presented few changes other than decreasing workload. The interview data from four informants described a successful change.
The findings confirmed the successful introduction of ERAS in the gynaecological department of a large university hospital. The experiences we made indicate that the expected gains of implementing ERAS are achieved without compromising the workload or work environment of ward nursing staff.