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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. Data sources Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature. Eligibility criteria Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure. Results 5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies). Conclusions The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies. [ABSTRACT FROM AUTHOR]

Introduction: Patient safety problems stemming from healthcare delivery constitute a global public health concern and represent a pervasive barrier to improving care quality and clinical outcomes. However, evidence generation into safety in mental health care, particularly regarding community‐based mental health services, has long fallen behind that of physical health care, forming the focus of fewer research publications and developed largely in isolation from the wider improvement science discipline. We aimed to investigate the state of the field, along with key conceptual and empirical challenges to understanding patient safety in community‐based mental health care. Methods: A narrative review surveyed the literature to appraise the conceptual obstacles to advancing the science of patient safety in community‐based mental health services. Sources were identified through a combination of a systematic search strategy and targeted searches of theoretical and empirical evidence from the fields of mental health care, patient safety and improvement science. Results: Amongst available evidence, challenges in defining safety in the context of community mental health care, evaluating safety in long‐term care journeys and establishing what constitutes a 'preventable' safety problem, were identified. A dominant risk management approach to safety in mental health care, positioning service users as the origin of risk, has seemingly prevented a focus on proactive safety promotion, considering iatrogenic harm and latent system hazards. Conclusion: We propose a wider conceptualization of safety and discuss the next steps for the integration and mobilization of disparate sources of 'safety intelligence', to advance how safety is conceived and addressed within community mental health care. Patient and Public Contribution: This paper was part of a larger research project aimed at understanding and improving patient safety in community‐based mental health care. Although service users, carers and healthcare professionals were not involved as part of this narrative review, the views of these stakeholder groups were central to shaping the wider research project. For a qualitative interview and focus group study conducted alongside this review, interview topic guides were informed by this narrative analysis, designed jointly and piloted with a consultation group of service users and carers with experience of community‐based mental health services for working‐age adults, who advised on key questioning priorities. [ABSTRACT FROM AUTHOR]

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders. [ABSTRACT FROM AUTHOR]

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work. [ABSTRACT FROM AUTHOR]

The article discusses the COVID-19 crisis has placed an enormous strain on hospitals and health systems. Topics include the novelty of the disease led to uncertainty and chaos in health care systems; and the pandemic has created problems with patient safety and health care quality at multiple levels of the system.

Objectives: To assess whether mortality alerts, triggered by sustained higher than expected hospital mortality, are associated with other potential indicators of hospital quality relating to factors of hospital structure, clinical process and patient outcomes. Methods: Cross-sectional study of National Health Service hospital trusts in England (2011–2013) using publicly available hospital measures reflecting organizational structure (mean acute bed occupancy, nurse/bed ratio, training satisfaction and proportion of trusts with low National Health Service Litigation Authority risk assessment or in financial deficit); process (mean proportion of eligible patients who receive percutaneous coronary intervention within 90 minutes) and outcomes (mean patient satisfaction scores, summary measures of hospital mortality and proportion of patients harmed). Mortality alerts were based on hospital administrative data. Results: Mortality alerts were associated with structural indicators and outcome indicators of quality. There was insufficient data to detect an association between mortality alerts and the process indicator. Conclusions: Mortality alerts appear to reflect aspects of quality within an English hospital setting, suggesting that there may be value in a mortality alerting system in highlighting poor hospital quality. [ABSTRACT FROM AUTHOR]

In Part 2 of this two-part contribution made on behalf of the Innovation and Systems Change Working Group of the International Society for Quality in Health Care (ISQua), we continue the argument for refashioning health systems in response to ageing and other pressures. Massive ageing in many countries and accompanying technological, fiscal and systems changes are causing the tectonic plates of healthcare to shift in ways not yet fully appreciated. In response, while things remain uncertain, we nevertheless have to find ways to proceed. We propose a strategy for stakeholders to pursue, of key importance and relevance to the ISQua: to harness flexible standards and external assessment in support of needed change. Depending on how they are used, healthcare standards and accreditation can promote, or hinder, the changes needed to create better healthcare for all in the future. Standards should support people's care needs across the life cycle, including prevention and health promotion. New standards that emphasise better coordination of care, those that address the entire healthcare journey and standards that reflect and predict technological changes and support new models of care can play a part. To take advantage of these opportunities, governance bodies, external assessment agencies and other authorities will need to be less prescriptive and better at developing more flexible standards that apply to the entire health journey, incorporating new definitions of excellence and acceptability. The ISQua welcomes playing a leadership role. [ABSTRACT FROM AUTHOR]

Objective To provide a description of the Imperial College Mortality Surveillance System and subsequent investigations by the Care Quality Commission (CQC) in National Health Service (NHS) hospitals receiving mortality alerts. Background The mortality surveillance system has generated monthly mortality alerts since 2007, on 122 individual diagnosis and surgical procedure groups, using routinely collected hospital administrative data for all English acute NHS hospital trusts. The CQC, the English national regulator, is notified of each alert. This study describes the findings of CQC investigations of alerting trusts. Methods We carried out (1) a descriptive analysis of alerts (2007-2016) and (2) an audit of CQC investigations in a subset of alerts (2011-2013). Results Between April 2007 and October 2016, 860 alerts were generated and 76% (654 alerts) were sent to trusts. Alert volumes varied over time (range: 40-101). Septicaemia (except in labour) was the most commonly alerting group (11.5% alerts sent). We reviewed CQC communications in a subset of 204 alerts from 96 trusts. The CQC investigated 75% (154/204) of alerts. In 90% of these pursued alerts, trusts returned evidence of local case note reviews (140/154). These reviews found areas of care that could be improved in 69% (106/154) of alerts. In 25% (38/154) trusts considered that identified failings in care could have impacted on patient outcomes. The CQC investigations resulted in full trust action plans in 77% (118/154) of all pursued alerts. Conclusion The mortality surveillance system has generated a large number of alerts since 2007. Quality of care problems were found in 69% of alerts with CQC investigations, and one in four trusts reported that failings in care may have an impact on patient outcomes. Identifying whether mortality alerts are the most efficient means to highlight areas of substandard care will require further investigation. [ABSTRACT FROM AUTHOR]

Objective To investigate the association between alerts from a national hospital mortality surveillance system and subsequent trends in relative risk of mortality. Background There is increasing interest in performance monitoring in the NHS. Since 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied. Methods We investigated alerts sent to Acute National Health Service hospital trusts in England in 2011--2013. We examined risk-adjusted mortality (relative risk) for all monitored diagnosis and procedure groups at a hospital trust level for 12 months prior to an alert and 23 months post alert. We used an interrupted time series design with a 9-month lag to estimate a trend prior to a mortality alert and the change in trend after, using generalised estimating equations. Results On average there was a 5% monthly increase in relative risk of mortality during the 12 months prior to an alert (95% CI 4% to 5%). Mortality risk fell, on average by 61% (95% CI 56% to 65%), during the 9-month period immediately following an alert, then levelled to a slow decline, reaching on average the level of expected mortality within 18 months of the alert. Conclusions Our results suggest an association between an alert notification and a reduction in the risk of mortality, although with less lag time than expected. It is difficult to determine any causal association. A proportion of alerts may be triggered by random variation alone and subsequent falls could simply reflect regression to the mean. Findings could also indicate that some hospitals are monitoring their own mortality statistics or other performance information, taking action prior to alert notification. [ABSTRACT FROM AUTHOR]

An editorial is presented on Patient safety suggestions. Topics include "Teaming up" which feature importance of communication over knowledge; "Thinking smarter" include cognitive tasks such as collaboration and examination; and "Communicating with patients" include proper mindful communication with patients.

Background: Accurate assessment of the need for admission is challenging in out-of-hours (OOH) primary care. Understanding more about patient contacts where the decision to continue care in the community may have been incorrect could assist clinicians in assessing clinical risk.Aim: To define the population contacting OOH primary care who are at higher risk of re-presenting to this service and requiring urgent transfer to secondary care within 3 days of their initial contact.Design and Setting: Retrospective service evaluation of 4 years of patient contacts with Oxfordshire OOH primary care.Method: Multivariable logistic regression was used to evaluate demographic and service delivery factors associated with increased risk of delayed escalation to secondary care.Results: Almost 1% of 496 931 patients contacting OOH primary care required escalation to secondary care within 3 days. Of these, 68.5% were initially discharged with no follow-up or advice to contact their GP; 14.7% were initially referred to secondary care. The odds of requiring escalation were increased with age (odds ratio [OR] 1.010; 95% confidence interval [CI] = 1.009 to 1.011; P<0.001), more frequent prior use of the OOH service (OR 1.016; 95% CI = 1.010 to 1.021; P<0.001), and presenting during periods of low call volume (OR 0.880; 95% CI = 0.857 to 0.904; P<0.001).Conclusion: Older, prior users of the service, presenting at less busy times, are at greater risk of requiring secondary care referral from the OOH service within 3 days of their initial contact. These higher-risk patient groups might benefit from active follow-up by the OOH service. [ABSTRACT FROM AUTHOR]

Purpose: Medications are mostly taken in patients’ own homes, increasingly administered by carers, yet studies of medication safety have been largely conducted in the hospital setting. We aimed to review studies of how carers cause and/or prevent medication administration errors (MAEs) within the patient’s home; to identify types, prevalence and causes of these MAEs and any interventions to prevent them. Methods: A narrative systematic review of literature published between 1 Jan 1946 and 23 Sep 2013 was carried out across the databases EMBASE, MEDLINE, PSYCHINFO, COCHRANE and CINAHL. Empirical studies were included where carers were responsible for preventing/causing MAEs in the home and standardised tools used for data extraction and quality assessment. Results: Thirty-six papers met the criteria for narrative review, 33 of which included parents caring for children, two predominantly comprised adult children and spouses caring for older parents/partners, and one focused on paid carers mostly looking after older adults. The carer administration error rate ranged from 1.9 to 33% of medications administered and from 12 to 92.7% of carers administering medication. These included dosage errors, omitted administration, wrong medication and wrong time or route of administration. Contributory factors included individual carer factors (e.g. carer age), environmental factors (e.g. storage), medication factors (e.g. number of medicines), prescription communication factors (e.g. comprehensibility of instructions), psychosocial factors (e.g. carer-to-carer communication), and care-recipient factors (e.g. recipient age). The few interventions effective in preventing MAEs involved carer training and tailored equipment. Conclusion: This review shows that home medication administration errors made by carers are a potentially serious patient safety issue. Carers made similar errors to those made by professionals in other contexts and a wide variety of contributory factors were identified. The home care setting should be a priority for the development of patient safety interventions. [ABSTRACT FROM AUTHOR]

Objective To investigate hospital patients' reports of undesirable events in their health care. Design Cross-sectional mixed methods design. Participants A total of 80 medical and surgical patients (mean age 58, 56 male). Intervention Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed. Main outcome measures Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care. Results In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing ( P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system. Conclusion Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety. [ABSTRACT FROM AUTHOR]

Background In recent years, factors that affect patients' willingness and ability to participate in safety-relevant behaviours have been investigated. However, how trained healthcare professionals or medical students would feel participating in safety-relevant behaviours as a patient in hospital remains largely unexplored. Objectives To investigate medical students' willingness to participate in behaviours related to the quality and safety of their health care. Design A cross-sectional exploratory study using a survey that addressed willingness to participate in different behaviours recommended by current patient safety initiatives. Three types of interactional behaviours (asking factual or challenging questions, notifying doctors or nurses of errors/problems) and three non-interactional behaviours (choosing a hospital based on the safety record, bringing medicines and a list of allergies into hospital, and reporting an error to a national reporting system) were assessed. Participants One hundred and seventy-nine medical students from an inner city London teaching hospital participated in the study. Findings Students' willingness to participate was affected ( P < 0.05) by the action required by the patient and (for interactional behaviours) whether the patient was engaging in the specific action with a doctor or nurse. Students were least willing to ask 'challenging' questions to doctors and nurses and to report errors to a national reporting system. Doctors' and nurses' encouragement appeared to increase self-reported willingness to participate in behaviours where baseline willingness was low. Conclusion Similar to research on lay patient populations; medical students do not view involvement in safety-related behaviours equally. Interventions should be tailored at encouraging students to participate in behaviours they are less inclined to take on an active role in. Future research is required to examine students' motivations for participation in this important but heavily under-researched area. [ABSTRACT FROM AUTHOR]

Objective To examine the potential for using routinely collected administrative data to compare the quality and safety of stroke care at a hospital level, including evaluating any bias due to variations in coding practice. Design A retrospective cohort study of English hospitals' performance against six process and outcome indicators covering the acute care pathway. We used logistic regression to adjust the outcome measures for case mix. Setting Hospitals in England. Participants Stroke patients (ICD-10 I60–I64) admitted to English National Health Service public acute hospitals between April 2009 and March 2010, accounting for 91 936 admissions. Main Outcome Measure The quality and safety were measured using six indicators spanning the hospital care pathway, from timely access to brain scans to emergency readmissions following discharge after stroke. Results There were 182 occurrences of hospitals performing statistically differently from the national average at the 99.8% significance level across the six indicators. Differences in coding practice appeared to only partially explain the variation. Conclusions Hospital administrative data provide a practical and achievable method for evaluating aspects of stroke care across the acute pathway. However, without improvements in coding and further validation, it is unclear whether the cause of the variation is the quality of care or the result of different local care pathways and data coding accuracy. [ABSTRACT FROM AUTHOR]

Objective To evaluate overall performance of English colorectal cancer surgical units identified as outliers for a single quality measure-30 day inhospital mortality. Design 144 542 patients that underwent primary major colorectal cancer resection between 2000/2001 and 2007/2008 in 149 English National Health Service units were included from hospital episodes statistics. Casemix adjusted funnel plots were constructed for 30 day inhospital mortality, length of stay, unplanned readmission within 28 days, reoperation, failure to rescue-surgical (FTR-S) and abdominoperineal excision (APE) rates. Institutional performance was evaluated across all other domains for institutions deemed outliers for 30 day mortality. Outliers were those that lay on or breached 3 SD control limits. 'Acceptable' performance was defined if units appeared under the upper 2 SD limit. Results 5 high mortality outlier (HMO) units and 15 low mortality outlier (LMO) units were identified. Of the five HMO units, two were substandard performance outliers (ie, above 3 SD) on another metric (both on high reoperation rates). A further two HMO institutions exceeded the second but not the third SD limits for substandard performance on other outcome metrics. One of the 15 LMO units exceeded 3 SD for substandard performance (APE rate). One LMO institution exceeded the second but not the third SD control limits for high reoperation rates. Institutional mortality correlated with FTR-S and reoperations (R=0.445, p<0.001 and R=0.191, p<0.020 respectively). Conclusions Performance appraisal in colorectal surgery is complex and dependent on stakeholder perspective. Benchmarking units solely on a single performance measure is over simplistic and potentially hazardous. A global appraisal of institutional outcome is required to contextualise performance. [ABSTRACT FROM AUTHOR]

Purpose This exploratory study sought to explore the patient experience of the surgical journey from decision to operate, to hospitalization, discharge and subsequent recovery. Design Patients attended one of two focus group discussions. Patient sample Seven patients that had undergone surgery for spinal stenosis or disc prolapsed participated, aged between 48-75 years (mean age 59); five were male. Methods Patients' attitudes towards the information and care they received from the point of the decision to operate through to post-operative recovery were explored. Particular attention was paid to patients' information needs, support provided, general understanding of the processes and ways in which care could have been improved. Results Patients identified nine main 'needs' they felt played an integral part in enhancing the patient experience including the need for reduced waiting times, for better information and preparation, to be proactive, to speak up and ask questions, to feel safe and to be treated with dignity and respect; and the need for ongoing support, human contact, and; continuity of care. Conclusion These findings suggest that there are several measures that could be taken to improve the patient's surgical experience. In particular, providing appropriate information to patients in a timely manner and ensuring that support and advice is easily accessible for those patients that need it are key areas for improvement. [ABSTRACT FROM AUTHOR]

Objective To identify strategies to facilitate the sustainability of a quality and safety improvement collaborative: the Safer Patients Initiative (SPI) and its successes. Design A qualitative interview study with a repeated sample at two time points. Setting Twenty organizations participating in the SPI programme in the UK. Participants Twenty principal SPI programme coordinators took part in interviews towards the end of the supported phase of the programme, 12 of which were interviewed again a year later, along with another three replacement programme coordinators, totalling 35 interviewees across the two time points. Main Outcome Measures Programme coordinators' perceptions of facilitating strategies to the sustainability of the collaborative and its gains. Results Qualitative analysis identified three overarching factors for the sustainability of SPI: (i) using programme improvement methodology and measurement of its outcomes; (ii) organizational strategies to ensure sustainability and (iii) alignment of goals with external requirements. Within these were eight themes identified by the coordinators as helping to sustain the efforts of the SPI programme and its successes. Conclusions This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention. [ABSTRACT FROM PUBLISHER]

Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery ( t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care ( t = −2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact. [ABSTRACT FROM AUTHOR]

Objective The aim of this study was to evaluate the influence of various factors on the perceived impact of a patient safety improvement collaborative in the UK, the Safer Patients Initiative (SPI). Study design A cross-sectional survey design was used. Study setting Twenty National Health Service organizations from the UK that participated in the main phase of the SPI programme, which ran from September 2007 to 2008. Participants Senior executive leads, clinical operational leads in the four clinical areas targeted by the programme, programme coordinators and any other staff involved in the SPI (n= 635). Intervention The SPI is a patient safety improvement intervention based on the Breakthrough Series Collaborative model (Institute of Healthcare Improvement, 2004) aimed at improving patient safety in four clinical areas (general ward care, intensive care, perioperative care and pharmacy) through implementing a number of evidence-based clinical practices and a focus on organizational leadership. Outcome measures Participant perceptions of the impact of the programme on their organizations. Results Exploratory regression analysis showed that programme management, the value assigned to programme methodology and length of data collection contributed the largest variance in perceived impact of the SPI followed by perceived support from junior doctors, inter-professional collaboration, difference of the programme from existing safety improvement practices and organizational readiness. Conclusions The resulting model suggests hierarchical importance for a range of variables to support future research concerning the mechanisms by which large-scale organizational programmes, such as the SPI, impact on the care systems they are designed to influence. [ABSTRACT FROM AUTHOR]

To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data. [ABSTRACT FROM AUTHOR]

Diagnostic errors and delays carry potentially grave consequences for patients and feature prominently in studies of adverse events in health care. Diagnostic errors present a particular challenge for error/incident reporting systems because they involve clinical reasoning and are difficult to define precisely. The aim of the present study was to investigate what insights can be gained about diagnostic error from an incident reporting system. Diagnostic errors reported to the UK's National Reporting and Learning System (NRLS) between November 2003 and October 2005 were investigated. We analysed reported level of harm to the patient and incident location and we compared diagnostic with non-diagnostic incidents. We also assessed the quality of reporting in a subset of reports associated with a patient's death. Of 316 589 incidents reported in the period under investigation, 1674 were diagnostic (0.5%). Diagnostic incidents were more likely than other incidents to be associated with moderate or severe harm, or a patient's death and were more likely to occur in a hospital emergency department than other incidents. Diagnostic incidents in emergency departments were more likely to be associated with greater harm than similar incidents in wards. Observed reporting quality (detail; clarity) was very variable. These findings replicate findings from studies in emergency departments and suggest that reporting systems have a role to play in understanding diagnostic errors alongside other sources of error analysis. Accurate and complete reporting of adequate volume enhances the potential contribution of an incident reporting system to understanding diagnostic error. [ABSTRACT FROM AUTHOR]

Rationale and aims In several countries, collaborative improvement programmes involving multiple health care organizations have been developed to address the issue of patient safety and reliability of care at an organization-wide level. In the UK, the Health Foundation's Safer Patients Initiative (SPI) was developed to achieve breakthrough improvement in the quality and safety of care in 24 acute hospital Trusts between 2004 and 2008. Research evidence for the effectiveness of programmes of this type and the mechanisms by which positive outcomes are achieved remains limited. We report a multi-method preliminary study based upon phase 1 of SPI to understand participant's perceptions of the local impact of the programme and to form the basis of future research in this area. Methods Data were collected on the perceived local impact of SPI on a range of clinical, organizational and social dimensions relating to care quality and safety. Data were collected retrospectively from local SPI programme improvement teams using semi-structured interviews and surveys. Qualitative and quantitative analyses were performed, and the results synthesized under common themes and frameworks. Results Specific dimensions of care systems commonly considered to be affected by SPI, included culture, strategic priority, organizational capability and clinical care delivery. Survey data revealed the perceived importance for success of a range of programme components: quality improvement methodology, learning sessions and programme faculty support, along with predefined clinical practice changes. Safety climate and capability dimensions rated as most sensitive to the effects of the SPI programme related to multi-professional engagement and communication, the degree of routine monitoring of care processes and the capacity to evaluate the impact of changes to clinical work systems. Conclusions Study findings support the view that programmes such as SPI have considerable impact upon the cultural, inter-professional, strategic and organizational aspects of care delivery, in addition to clinical working practices. The specific implications for understanding the effects of complex organization-level interventions and future research design are discussed. [ABSTRACT FROM AUTHOR]

The article discusses the risks involved in the medical practice of junior doctors and ways to reduce errors and patient harm. The errors that young doctors make are often the end result from a series of events. Multiple factors, such as system failures and problems within the healthcare organization, contribute to adverse events. Ways doctors can make healthcare safer for patients include asking for help, using clinical guidelines, and checking all results and information. The authors also explain the steps to take after an adverse event has occurred.

Claims for malpractice and medical negligence are a potentially important source of information on the causes of harm to patients and have provided valuable lessons in the past. However today, with many additional sources of information and methods of analysis, the role of claims analysis needs to be reappraised. We consider the role of claims analysis in relation to other methods of studying adverse outcomes, review previous studies of claims and summarize the findings of four recent British specialty claims reviews. Claims analysis has a number of inherent limitations. We suggest that there is now no case for ad hoc claims reviews which rely on data that have been assembled for legal purposes only. Claims review is still potentially useful for rare events or in cases where other sources of data are not available. However, future claims reviews need to meet basic criteria before being undertaken; these include prospective identification of the relevant questions and variables, adequacy and completeness of the data set, availability of expert reviewers and clear protocols for review. [ABSTRACT FROM AUTHOR]

Background: Healthcare is amongst the most complex of human systems. Coordinating activities and integrating newer with older ways of treating patients while delivering high-quality, safe care, is challenging. Three landmark reports in 2018 led by (1) the Lancet Global Health Commission, (2) a coalition of the World Health Organization, the Organisation for Economic Co-operation and Development and the World Bank, and (3) the National Academies of Sciences, Engineering and Medicine of the United States propose that health systems need to tackle care quality, create less harm and provide universal health coverage in all nations, but especially low- and middle-income countries. The objective of this study is to review these reports with the aim of advancing the discussion beyond a conceptual diagnosis of quality gaps into identification of practical opportunities for transforming health systems by 2030.Main Body: We analysed the reports via text-mining techniques and content analyses to derive their key themes and concepts. Initiatives to make progress include better measurement, using the capacities of information and communications technologies, taking a systems view of change, supporting systems to be constantly improving, creating learning health systems and undergirding progress with effective research and evaluation. Our analysis suggests that the world needs to move from 2018, the year of reports, to the 2020s, the decade of action. We propose three initiatives to support this move: first, developing a blueprint for change, modifiable to each country's circumstances, to give effect to the reports' recommendations; second, to make tangible steps to reduce inequities within and across health systems, including redistributing resources to areas of greatest need; and third, learning from what goes right to complement current efforts focused on reducing things going wrong. We provide examples of targeted funding which would have major benefits, reduce inequalities, promote universality and be better at learning from successes as well as failures.Conclusion: The reports contain many recommendations, but lack an integrated, implementable, 10-year action plan for the next decade to give effect to their aims to improve care to the most vulnerable, save lives by providing high-quality healthcare and shift to measuring and ensuring better systems- and patient-level outcomes. This article signals what needs to be done to achieve these aims. [ABSTRACT FROM AUTHOR]

The authors warn health care officials to be cautious about extrapolating the excellent performance of high reliability organisations in meeting the challenges of high reliability operations in health care. They cite some reasons why the original descriptive studies of such organisations do not reflect realities in health care, including the fact that the organisations are solely military. They also argue that examples from other industries should be considered informative and not prescriptive.

Objective: To reduce the incidence of retained vaginal swabs and near misses.Study Design: A review of previous retained swab incidents and near misses in a large maternity unit identified handovers and transfers as a key point of vulnerability. Interventions were introduced to improve communication at handover from the delivery suite to theatre and from theatre to the high dependency unit. Process data was collected to monitor compliance. The outcome measures were the incidence of retained swab never events and the incidence of near misses. Chi-squared analysis was used to test the significance of the results.Results: For transfers from delivery suite to theatre, verbal handover significantly increased from 28.8% to 75.6% (p<0.0001), and written handover significantly increased from 4.4% to 62.9% (p<0.0001). There were 291 transfers to theatre post-intervention: in 88 (30.2%) of these transfers a vaginal swab was already in situ. In 70/88 (79.5%) of cases the presence of the swab was communicated to theatre staff in three ways (verbally, written and transfer of opened swab packets) according to the new policy. In the post-intervention period there were 56 women transferred from theatre to the high-dependency unit with a vaginal pack in situ: 52 (92.9%) of these women had a sticker in place serving as a constant reminder of the presence of the vaginal pack to staff. Following a baseline of four near misses in two months, there has been only one near miss in the 15 months since the interventions were implemented, (33.3% vs. 1.1%, p<0.0001). There have been no retained swab incidents since the project commenced.Conclusions: Simple interventions to improve communication at handover and transfer can reduce the incidence of retained vaginal swabs and near misses. Further work is needed to raise the profile of swab counting in maternity settings: swab counting needs to be the responsibility of all disciplines, not just the responsibility of theatre staff. [ABSTRACT FROM AUTHOR]