23,475 research outputs found
Protocol for the 'e-Nudge trial' : a randomised controlled trial of electronic feedback to reduce the cardiovascular risk of individuals in general practice [ISRCTN64828380]
Background: Cardiovascular disease (including coronary heart disease and stroke) is a major
cause of death and disability in the United Kingdom, and is to a large extent preventable, by lifestyle
modification and drug therapy. The recent standardisation of electronic codes for cardiovascular
risk variables through the United Kingdom's new General Practice contract provides an
opportunity for the application of risk algorithms to identify high risk individuals. This randomised
controlled trial will test the benefits of an automated system of alert messages and practice
searches to identify those at highest risk of cardiovascular disease in primary care databases.
Design: Patients over 50 years old in practice databases will be randomised to the intervention
group that will receive the alert messages and searches, and a control group who will continue to
receive usual care. In addition to those at high estimated risk, potentially high risk patients will be
identified who have insufficient data to allow a risk estimate to be made. Further groups identified
will be those with possible undiagnosed diabetes, based either on elevated past recorded blood
glucose measurements, or an absence of recent blood glucose measurement in those with
established cardiovascular disease.
Outcome measures: The intervention will be applied for two years, and outcome data will be
collected for a further year. The primary outcome measure will be the annual rate of cardiovascular
events in the intervention and control arms of the study. Secondary measures include the
proportion of patients at high estimated cardiovascular risk, the proportion of patients with missing
data for a risk estimate, and the proportion with undefined diabetes status at the end of the trial
A safer place for patients: learning to improve patient safety
1 Every day over one million people are treated
successfully by National Health Service (NHS) acute,
ambulance and mental health trusts. However, healthcare
relies on a range of complex interactions of people,
skills, technologies and drugs, and sometimes things do
go wrong. For most countries, patient safety is now the
key issue in healthcare quality and risk management.
The Department of Health (the Department) estimates
that one in ten patients admitted to NHS hospitals will be
unintentionally harmed, a rate similar to other developed
countries. Around 50 per cent of these patient safety
incidentsa could have been avoided, if only lessons from
previous incidents had been learned.
2
There are numerous stakeholders with a role in
keeping patients safe in the NHS, many of whom require
trusts to report details of patient safety incidents and near
misses to them (Figure 2). However, a number of previous
National Audit Office reports have highlighted concerns
that the NHS has limited information on the extent and
impact of clinical and non-clinical incidents and trusts need
to learn from these incidents and share good practice across
the NHS more effectively (Appendix 1).
3 In 2000, the Chief Medical Officerās report An
organisation with a memory
1
, identified that the key
barriers to reducing the number of patient safety incidents
were an organisational culture that inhibited reporting and
the lack of a cohesive national system for identifying and
sharing lessons learnt.
4 In response, the Department published Building a
safer NHS for patients3 detailing plans and a timetable
for promoting patient safety. The goal was to encourage
improvements in reporting and learning through the
development of a new mandatory national reporting
scheme for patient safety incidents and near misses. Central
to the plan was establishing the National Patient Safety
Agency to improve patient safety by reducing the risk of
harm through error. The National Patient Safety Agency was
expected to: collect and analyse information; assimilate
other safety-related information from a variety of existing
reporting systems; learn lessons and produce solutions.
5 We therefore examined whether the NHS has
been successful in improving the patient safety culture,
encouraging reporting and learning from patient safety
incidents. Key parts of our approach were a census of
267 NHS acute, ambulance and mental health trusts in
Autumn 2004, followed by a re-survey in August 2005
and an omnibus survey of patients (Appendix 2). We also
reviewed practices in other industries (Appendix 3) and
international healthcare systems (Appendix 4), and the
National Patient Safety Agencyās progress in developing its
National Reporting and Learning System (Appendix 5) and
other related activities (Appendix 6).
6 An organisation with a memory1
was an important
milestone in the NHSās patient safety agenda and marked
the drive to improve reporting and learning. At the
local level the vast majority of trusts have developed a
predominantly open and fair reporting culture but with
pockets of blame and scope to improve their strategies for
sharing good practice. Indeed in our re-survey we found
that local performance had continued to improve with more
trusts reporting having an open and fair reporting culture,
more trusts with open reporting systems and improvements
in perceptions of the levels of under-reporting. At the
national level, progress on developing the national reporting
system for learning has been slower than set out in the
Departmentās strategy of 2001
3
and there is a need to
improve evaluation and sharing of lessons and solutions by
all organisations with a stake in patient safety. There is also
no clear system for monitoring that lessons are learned at the
local level. Specifically:
a The safety culture within trusts is improving, driven
largely by the Departmentās clinical governance
initiative
4
and the development of more effective risk
management systems in response to incentives under
initiatives such as the NHS Litigation Authorityās
Clinical Negligence Scheme for Trusts (Appendix 7).
However, trusts are still predominantly reactive in
their response to patient safety issues and parts of
some organisations still operate a blame culture.
b All trusts have established effective reporting systems
at the local level, although under-reporting remains
a problem within some groups of staff, types of
incidents and near misses. The National Patient Safety
Agency did not develop and roll out the National
Reporting and Learning System by December 2002
as originally envisaged. All trusts were linked to the
system by 31 December 2004. By August 2005, at
least 35 trusts still had not submitted any data to the
National Reporting and Learning System.
c Most trusts pointed to specific improvements
derived from lessons learnt from their local incident
reporting systems, but these are still not widely
promulgated, either within or between trusts.
The National Patient Safety Agency has provided
only limited feedback to trusts of evidence-based
solutions or actions derived from the national
reporting system. It published its first feedback report
from the Patient Safety Observatory in July 2005
A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations
Parenteral nutrition (PN) serves as an important therapeutic modality that is used in adults, children, and infants for a variety of indications. The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Complications can occur as a result of the therapy and as the result of the PN process. These consensus recommendations are based on practices that are generally accepted to minimize errors with PN therapy, categorized in the areas of PN prescribing, order review and verification, compounding, and administration. These recommendations should be used in conjunction with other A.S.P.E.N. publications, and researchers should consider studying the questions brought forth in this document
Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO) : primary research
Background and objectives:
Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover.
Methods:
Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways.
Results:
Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows.
Conclusions:
The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued
Predictive Modeling in Action: How 'Virtual Wards' Help High-Risk Patients Receive Hospital Care at Home
Describes a program to reduce hospitalizations by providing multidisciplinary case management and coordinated preventive care at home to chronic disease patients found to be at risk of emergency hospitalization by predictive modeling. Outlines challenges
Barnes Hospital Bulletin
https://digitalcommons.wustl.edu/bjc_barnes_bulletin/1148/thumbnail.jp
How Labor-Management Partnerships Improve Patient Care, Cost Control, and Labor Relations: Case Studies of Fletcher Allen Health Care, Kaiser Permanente, and Montefiore Medical Centerās Care Management Corporation
[Excerpt] This paper explores the ways in which healthcare unions and their members are strategically engaging with management through partnership to control costs and improve the patient experience, clinical outcomes, workplace environment, and labor relations. These initiatives depend on making use of the knowledge of front-line healthcare workers, improving communication between all staff members, and increasing transparency. In turn, these initiatives can also lead to more robust and dynamic local unions. Through participating in joint work activities, many union members note feeling more respected in their workplace and more connected to their union. Unions can benefit from these activities by offering their members the ability to inform decisions about how work gets done
Controls in the NICU
Medication dosage errors cause too many adverse clinical events in both inpatient and outpatient settings. In this disguised and partially fictionalized teaching case a hospital administrator considers whether the skills she recently acquired in an MBA Accounting Information System class could be adapted for use in a quality improvement program related to medication errors. The case illustrates how the preparation of a system flowchart mapped to a control matrix ā a technique that auditors commonly use to support analysis of the adequacy of controls over financial processes ā can be adapted to support analysis of clinical process controls and controls over related information. The case offers an opportunity for students to discuss some of the benefits and limitations of this technique, and possible extensions of it to non-financial processes in health care and elsewhere
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