Between 1996 and 2005 in the UK, the Serious Hazards of Transfusion (SHOT) scheme has reported 105 deaths and 296 patients developing major morbidity due to transfusion. Accurate patient identification and monitoring of patients during blood transfusion are vital in ensuring patient safety, and national guidelines have been in place since 1999. There have been numerous initiatives in the UK in recent years promoting safe and appropriate use of blood and this paper reports the results of the 2005 National Comparative Audit of transfusion practice, and compares this audit with previous audits and survey results.
The 2005 audit consisted of two parts looking at organisational factors and bedside practice. To enable comparison with previous audits and surveys the 2005 data have been limited to English NHS sites (217 sites for organisational, 211 sites for bedside practice).
Hospital transfusion committees were well established by 2003 though hospital transfusion teams have lagged behind. 86% of hospitals reported having established teams by 2005 although only 52% reported having all essential elements of the team in place. Only 38% reported having trained at least half of their nurses in blood transfusion. Bedside practice has improved, although in 2005, 6% of patients receiving a blood transfusion had no identification wristband in place, and in 9% of those who did, the details were incomplete. Observation of vital signs during transfusions has also improved, although in 2005, 13% of patients receiving a transfusion had had no observations recorded.
This paper document the progress that has been made in the UK in establishing an effective infrastructure for the support of safe transfusion practice, and the measurable improvements in bedside transfusion practice. There remain, however, many areas of poor practice, and the improvements have not been seen across all hospitals. It is still too early to say whether progress made is being translated into a reduction in serious transfusion errors at the bedside. Further progress needs to be made.
Studies suggest that there is a need to improve the way we deliver care at the end of life. Based on recommendations from end-of-life experts, metrics were identified to measure the quality of dying in Dunedin Hospital.
A retrospective observational study was performed to assess the care provided to patients who died in the hospital in 2003.
Dunedin Hospital is a 350-bed tertiary care teaching hospital located in the South Island of New Zealand.
Medical records of 200 consecutive decedents were reviewed to evaluate communication, interventions, and symptom control during their terminal hospitalisation.
Mean hospital length-of-stay was 8 days; 38 patients (19%) died following an ICU admission. There was documentation of end-of-life discussion with either the patient or the family in 164 patients (82%). 74% had a DNR order. Pain status was documented in 140 patients (70%); 134 of these patients were pain-free.
Overall, the results suggest that the ideals in end-of-life care pertaining to pain control, communication and avoidance of unnecessary interventions were achieved in a majority of the decedents during the study period. The socialised healthcare system, the availability of resources, societal expectations and a lack of a litigious environment are theorised to positively influence end-of-life care delivery in New Zealand.
Most studies of healthcare complications identify surgery as a major contributor to the overall burden of complicated care that leads to injury or death. Indeed, surgical adverse events account for one-half to three-quarters of all adverse events in these studies. Despite the intensive current focus on improving medical quality and safety, only a minority of quality improvement efforts are focused on surgery. This study reports on the development and testing of a Trigger Tool to detect adverse events among patients undergoing inpatient surgery.
Rather than relying on traditional voluntary reporting for safety outcome measures such as incident reports, surgical peer review, or morbidity and mortality conferences, the Institute for Healthcare Improvement (IHI) has employed a new method for the detection of surgical adverse events (SAEs). This approach, commonly referred to as the "Trigger Tool", identifies adverse events using a form of retrospective record review that has been developed and implemented in many areas of care.
During a 12-month IHI Perioperative Safety Collaborative, 11 hospitals voluntarily submitted data from surgical inpatient record reviews. In 854 patients, 138 SAEs were detected in 125 records for a rate of 16 SAEs per 100 patients or 14.6% of patients; 61 (44%) of these events contributed to increased length of stay or readmission and 12 (8.7%) events required life-saving intervention or resulted in permanent harm or death. Hospital review teams reported verbally that most of the events identified during the Trigger Tool review process had not been detected or reported via any other existing mechanism.
The IHI Surgical Trigger Tool may offer a practical, easy-to-use approach to detecting safety problems in patients undergoing surgery; it can be the basis not only for estimating the frequency of adverse events in an organisation, but also determining the impact of interventions that focus on reducing adverse events in surgical patients.
In Sweden, patient malpractice claims are handled administratively and compensated if an independent physician review confirms patient injury resulting from medical error. Full access to all malpractice claims and hospital discharge data for the country provided a unique opportunity to assess the validity of patient claims as indicators of medical error and patient injury.
To determine: (1) the percentage of patient malpractice claims validated by independent physician review, (2) actual malpractice claims rates (claims frequency ÷ clinical volume) and (3) differences between Swedish and other national malpractice claims rates.
Swedish national malpractice claims and hospital discharge data were combined, and malpractice claims rates were determined by county, hospital, hospital department, surgical procedure, patient age and sex and compared with published studies on medical error and malpractice.
From 1997 to 2004, there were 23 364 inpatient malpractice claims filed by Swedish patients treated at hospitals reporting 11 514 798 discharges. The overall claims rate, 0.20%, was stable over the period of study and was similar to that found in other tort and administrative compensation systems. Over this 8-year period, 49.5% (range 47.0–52.6%) of filed claims were judged valid and eligible for compensation. Claims rates varied significantly across hospitals; surgical specialties accounted for 46% of discharges, but 88% of claims. There were also large differences in claims rates for procedures.
Patient-generated malpractice claims, as collected in the Swedish malpractice insurance system and adjusted for clinical volumes, have a high validity, as assessed by standardised physician review, and provide unique new information on malpractice risks, preventable medical errors and patient injuries. Systematic collection and analysis of patient-generated quality of care complaints should be encouraged, regardless of the malpractice compensation system in use.
The National Institute for Health and Clinical Excellence (NICE) issued guidance on surgical techniques for tonsillectomy during a national audit of surgical practice and postoperative complications.
To assess the impact of the guidance on tonsillectomy practice and outcomes.
An interrupted time-series analysis of routinely collected Hospital Episodes Statistics data, and an analysis of longitudinal trends in surgical technique using data from the National Prospective Tonsillectomy Audit.
Patients undergoing tonsillectomy in English NHS hospitals between January 2002 and December 2004.
Postoperative haemorrhage within 28 days.
The rate of haemorrhage increased by 0.5% per year from 2002, reaching 6.4% when the guidance was published. After publication, the rate of haemorrhage fell immediately to 5.7% (difference 0.7%: 95% CI –1.3% to 0.0%) and the rate of increase appeared to have stopped. Data from the National Prospective Tonsillectomy Audit showed that the fall coincided with a shift in surgical techniques, which was consistent with the guidance.
NICE guidance influenced surgical tonsillectomy technique and in turn produced an immediate fall in postoperative haemorrhage. The ongoing national audit and strong support from the surgical specialist association may have aided its implementation.
Among adult general medical inpatients, there are numerous interventions whose benefits outweigh their risks. However, there are no published reports describing the overall use of such proven interventions in this population.
To determine implementation rates of a broad range of interventions while accounting for valid reasons for non-use, predictors of implementation and feasibility of generating new indices to describe quality of care.
Based on a review of current practice guidelines and clinical trials related to five common conditions, implementation rates of 17 interventions were assessed retrospectively. Subjects were a complete sample of 150 adults with target medical conditions discharged from general medical units at an urban community hospital.
The Ideal Intervention Index (3I), which described the proportion of ideal intervention opportunities that were implemented, was 0.74 (95% CI 0.70 to 0.78). The Justified Non-Use Index (JNUI), which described the proportion of all the interventions not implemented that were justified by a valid reason for non-use, was 0.49 (95% CI 0.41 to 0.55). Smoking cessation therapy in high-risk patients had the lowest indices (3I 0.30, 95% CI 0.00 to 0.60; JNUI 0.00), and aspirin for secondary stroke prevention had the highest (3I 1.0; JNUI 1.0).
Overall, proven interventions are underused among the patients studied, and the reasons for non-use are frequently not readily discernible. There is potential for improvement, but research is required to further investigate reasons for non-use. It is feasible to measure implementation rates of proven interventions as an indicator of quality of care using the indices developed.
To test the validity, reliability and discriminating capacity of an instrument to assess team climate, the Team Climate Inventory (TCI), in a sample of Dutch hospital teams. The TCI is based on a four-factor theory of team climate for innovation.
Validation study.
Hospital teams in The Netherlands.
424 healthcare professionals; 355 nurses working in 22 nursing teams and 69 nurses and doctors working in 14 quality-improvement teams.
Exploratory and confirmatory factor analyses, Pearson’s product moment correlations, internal homogeneity of the TCI scales based on Cronbach alpha, and the TCI capability to discriminate between two types of healthcare teams, namely nursing teams and quality-improvement teams.
The validity test revealed the TCI’s five-factor structure and moderate data fit. The Cronbach alphas of the five scales showed acceptable reliabilities. The TCI discriminated between nursing teams and quality-improvement teams. The mean scores of quality-improvement teams were all significantly higher than those of the nursing teams.
Patient care teams are essential for high-quality patient care, and team climate is an important characteristic of successful teams. This study shows that the TCI is a valid, reliable and discriminating self-report measure of team climate in hospital teams. The TCI can be used as a quality-improvement tool or in quality-of-care research.
To compare the accuracy in recording of pressure-ulcer prevalence and prevention before and after implementing an electronic health record (EHR) with templates for pressure-ulcer assessment.
All inpatients at the departments of surgery, medicine and geriatrics were inspected for the presence of pressure ulcers, according to the European Pressure Ulcer Advisory Panel—methodology, during 1 day in 2002 (n = 357) and repeated in 2006 (n = 343). The corresponding patient records were audited retrospectively for the presence of documentation on pressure ulcers.
In 2002, the prevalence of pressure ulcers obtained by auditing paper-based patient records (n = 413) was 14.3%, compared with 33.3% in physical inspection (n = 357). The largest difference was seen in the geriatric department, where records revealed 22.9% pressure ulcers and skin inspection 59.3%. Four years later, after the implementation of the EHR, there were 20.7% recorded pressure ulcers and 30.0% found by physical examination of patients. The accuracy of the prevalence data had improved most in the geriatric department, where the EHR showed 48.1% and physical examination 43.2% pressure ulcers. Corresponding figures in the surgical department were 22.2% and 14.1%, and in the medical department 29.9% and 10.2%, respectively.
The patients received pressure-reducing equipment to a higher degree (51.6%) than documented in the patient record (7.9%) in 2006.
The accuracy in pressure-ulcer recording improved in the EHR compared with the paper-based health record. However, there were still deficiencies, which mean that patient records did not serve as a valid source of information on pressure-ulcer prevalence and prevention.
Most medication error studies come from inpatient settings. There is limited information about medication errors in primary care settings.
To describe medication errors reported by family physicians and their office staff and to estimate their preventability using currently available electronic prescribing and monitoring tools.
In two error reporting studies conducted by the American Academy of Family Physicians (AAFP) National Research Network (NRN), 1265 medical errors were voluntarily reported by >440 primary care clinicians and staff from 52 physician offices. The 194 error reports related to medications were abstracted and analysed using a medication error coding tool—Medication Error Types, Reasons, and Informatics Preventability (METRIP).
Type, severity and preventability of medication errors and associated adverse drug events (ADEs).
126 (70%) of the medication errors were prescribing errors, 17 (10%) were medication administration errors, 17 (10%) documentation errors, 13 (7%) dispensing errors and 5 (3%) were monitoring errors. ADEs resulted from 16% of reported medication errors. The severity of harm from reported errors were: prevented and did not reach patients, (72, 41%), reached patients but did not require monitoring (63, 35%), reached patients and required monitoring (15, 8%), reached patients and required intervention (23, 13%) and reached patients and resulted in hospitalisation (5, 3%). No deaths were reported. Of the errors that were prevented from reaching patients, 29 (40%) were prevented by pharmacists, 14 (19%) by physicians, 12 (17%) by patients and 5 (7%) by nurses. 102 (57%) of the reported errors might have been prevented with enhanced electronic prescribing and monitoring tools.
Most medication errors reported from US family physician offices were related to prescribing errors and more than half of the errors reached patients. The errors were prevented by pharmacists, patients and physicians. More than half of the errors could be prevented by electronic tools.
Measurement of the quality of healthcare is a first step for quality improvement. To measure quality of healthcare, a set of quality indicators is needed. We describe the adaptation of a set of systematically developed US quality indicators for healthcare for vulnerable elders in The Netherlands. We also compare the US and the Dutch set to see if quality indicators can be transferred between countries, as has been done in two studies in the UK, with mixed results.
108 US quality indicators on GP care for vulnerable elders, covering eight conditions, were assessed by a panel of nine clinical experts in The Netherlands. A modified version of the RAND/UCLA appropriateness method was used. The panel members received US literature reviews, extended with more recent and Dutch literature, summarising the evidence for each quality indicator.
72 indicators (67% of US set) were (nearly) identical in the Dutch and US sets. For some conditions, this percentage was much lower. For undernutrition, only half of the US indicators were included in the Dutch set. For depression, many indicators were discarded or changed in a significant way, with the result that only five of the original 17 indicators (29%) are the same in the Dutch and the US set.
Quality indicators can be transferred between countries, but with caution, because in two of the three studies on transferring indicators between the US and Europe, 33–44% of the indicators were discarded. For some conditions in the current study, this percentage is much higher. For undernutrition, there is hardly any evidence, and differences between the indicator sets can be attributed to differences in expert opinion between the countries. For depression, it seems that different evidence is considered important in the US and in The Netherlands, of which the Dutch body of knowledge is not known in the US.
Clinical guidelines aim to improve the safety and quality of patient care by providing clinicians with graded recommendations based on evidence of best practice.
To evaluate the effects of the introduction of clinical guidelines for allied health professionals, and to estimate the effectiveness of the guideline dissemination and implementation strategies used.
A comprehensive search of six electronic databases to June 2006 and the Cochrane Effective Practice and Organisation of Care database was conducted. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies were included if the intervention was aimed at implementing guidelines in the allied health professions. Articles were screened for eligibility and their methodological quality was assessed; data were extracted independently by two reviewers.
Fourteen studies met the inclusion criteria. The methodological quality varied greatly, with the proportion of quality criteria met ranging from 0 to 6 out of seven. In most studies, the effects reported for patient and process outcomes were small and in favour of the intervention group. Of the 14 included studies, 10 focused on educational interventions. Six of the 14 studies used a single intervention strategy and seven used a multi-faceted implementation strategy. One study compared both single and multi-faceted strategies. Multi-faceted interventions were no more effective than single intervention strategies and effects of the same strategy varied across trials.
There is no evidence to support a set guideline implementation strategy for allied health professionals. When implementing clinical guidelines it is important to first identify specific barriers to change using theoretical frameworks of behaviour change and then develop strategies that deal with these barriers. When measuring the effectiveness of these strategies, professionals should consider the use of both patient and process outcomes and choose outcomes that reflect their aims.
Monitoring the effect of service changes on quality of care is essential. By using statistical process control (SPC) charts, this study aimed to explore the relationship between changes in the structure of stroke services and the process of care.
Prospectively acquired data on the process of acute stroke care from three hospitals admitting 2962 patients (July 2001 to June 2004) were charted retrospectively on SPC charts for individual values (I charts) to determine whether or not "special cause variation" followed known changes in stroke service structure and publication of the Medical Research Council (MRC) Heart Protection Study. Unexpected signals of special cause variation were identified and reasons for observed patterns were sought by discussion with clinical teams.
Improved brain imaging provision was followed by a reduction in time to imaging and earlier prescription of aspirin for ischaemic stroke. The MRC Heart Protection Study was followed by increased statin prescription. However, increasing beds allocated to stroke had no influence on the proportion of patients receiving stroke unit care. Some unexpected signals of special cause variation could be plausibly explained (eg, breakdown of brain scanner), but others could not. Anecdotal evidence from healthcare professionals suggests that charts may be acceptable in clinical practice.
SPC charts have the potential to provide valuable insights into the impact of changes in structure of services and of clinical evidence on the process of stroke care. In the present study, the charts were generally well received by healthcare professionals.
Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries.
Jeder Fehler Zaehlt (JFZ;
The incident reporting system received 199 reports in the 17 months following its launch, of which 188 were classifiable. Of these, 72.9% were classified as process errors and 26.1% as knowledge/skills errors. The most frequently reported process errors were treatment errors (32.2%), communication errors (12.6%) and investigation errors (8.5%). Of the classified errors, 41.5% were associated with harm to the patient. More than 300 comments were made, mostly by anonymous users of the system.
JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.