BMJ quality & safety
-
BMJ quality & safety · May 2012
Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.
The under-reporting of medication errors can compromise patient safety. A qualitative study was conducted to enhance the understanding of barriers to medication error reporting in healthcare organisations. ⋯ Study results may lead to a better understanding of the barriers to medication error reporting, why these barriers exist and what can be done to successfully overcome them. These results could be used by hospitals to encourage reporting of medication errors and ultimately make organisational changes leading to a reduction in the incidence of medication errors and an improvement in patient safety.
-
BMJ quality & safety · May 2012
Surveillance of unplanned return to the operating theatre in neurosurgery combined with a mortality--morbidity conference: results of a pilot survey.
Unplanned return to the operating theatre (UROT) is a useful trigger tool that could be used to identify surgical adverse events (SAEs). The present study describes the feasibility of SAE surveillance in neurosurgical patients, based on UROT identification, completed with SAE analysis at a morbidity-mortality conference (MMC) meeting. ⋯ UROT related to SAE surveillance in neurosurgical patients was considered feasible. The association of surveillance and MMCs allowed staff to concentrate on the analysis of most frequent or most severe AEs and was a practical and useful tool to stimulate improvement. The impact on healthcare quality of SAE surveillance associated with MMC warrants further research.
-
BMJ quality & safety · May 2012
Do some trusts deliver a consistently better experience for patients? An analysis of patient experience across acute care surveys in English NHS trusts.
Data were used from inpatient, outpatient and accident and emergency surveys in acute trusts in England to examine consistency in patient-reported experience across services, and factors associated with systematic variations in performance. ⋯ The results have significant implications for quality improvement in the NHS. The finding that some NHS providers consistently perform better than others suggests that there are system-wide determinants of patient experience and the potential for learning from innovators. However, there is room for improvement overall. Given the large samples of these surveys, the messages could also have relevance for healthcare systems elsewhere.
-
BMJ quality & safety · Apr 2012
Time to accelerate integration of human factors and ergonomics in patient safety.
Progress toward improving patient safety has been slow despite engagement of the health care community in improvement efforts. A potential reason for this sluggish pace is the inadequate integration of human factors and ergonomics principles and methods in these efforts. Patient safety problems are complex and rarely caused by one factor or component of a work system. ⋯ We provide examples of how human factors and ergonomics principles and methods have improved both care processes and patient outcomes. We provide five major recommendations to better integrate human factors and ergonomics in patient safety improvement efforts: build capacity among health care workers to understand human factors and ergonomics, create market forces that demand the integration of human factors and ergonomics design principles into medical technologies, increase the number of human factors and ergonomic practitioners in health care organizations, expand investments in improvement efforts informed by human factors and ergonomics, and support interdisciplinary research to improve patient safety. In conclusion, human factors and ergonomics must play a more prominent role in health care if we want to increase the pace in improving patient safety.
-
BMJ quality & safety · Apr 2012
Comparative StudyAssessment of adverse events in medical care: lack of consistency between experienced teams using the global trigger tool.
Many patients are harmed as the result of healthcare. A retrospective structured record review is one way to identify adverse events (AEs). One such review approach is the global trigger tool (GTT), a consistent and well-developed method used to detect AEs. The GTT was originally intended to be used for measuring data over time within a single organisation. However, as the method spreads, it is likely that comparisons of GTT safety outcomes between hospitals will occur. ⋯ The results do not encourage the use of the GTT for making comparisons between hospitals. The use of the GTT to this end would require substantial training to achieve better agreement across reviewer teams.