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 Officer’s 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 Agency’s 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 NHS’s 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 Department’s 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 Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s 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

The on-going challenges of changing transfusion practice and harnessing the potential of data-driven strategies

No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on ‘A data-enabled programme of research to improve transfusion practices’. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice

Management of acute intracerebral haemorrhage – an update

Managing acute intracerebral haemorrhage is a challenging task for physicians. Evidence shows that outcome can be improved with admission to an acute stroke unit and active care, including urgent reversal of anticoagulant effects and, potentially, intensive blood pressure reduction. Nevertheless, many management issues remain controversial, including the use of haemostatic therapy, selection of patients for neurosurgery and neurocritical care, the extent of investigations for underlying causes and the benefit versus risk of restarting antithrombotic therapy after an episode of intracerebral haemorrhage

The organisational and communication implications of electronic ordering systems for hospital pathology services

Computerised Provider Order Entry (CPOE) systems provide clinicians with the ability to electronically enter hospital orders for laboratory tests and services. CPOE is able to integrate with hospital information systems and provide point of care decision support to users thereby making a potentially significant contribution to the efficiency and effectiveness of care delivery. The evidence of the impact of CPOE systems on pathology services is not extensive and insufficient attention has been paid to their effect on organisational and communication processes. This thesis aimed to investigate the implications of CPOE systems for pathology laboratories, their work processes and relationships with other hospital departments, using comparative examinations to identify the tasks they are involved in and the particular needs the laboratories expect to be filled by the new system. This longitudinal study of a CPOE system was carried out over three years using multiple cases from a hospital pathology service based at a large Sydney teaching hospital. Multi-methods using quantitative and qualitative data were employed to achieve triangulation of data, theory and methods. The findings provide evidence of a significant 14.3% reduction of laboratory turnaround times from 42 to 36 minutes when laboratory data for two months were compared before and after CPOE implementation. The findings also reveal changes in the pattern and organisation of information communication, highlighting transformations in the way that work is planned, negotiated and synchronised. These findings are drawn together in a comprehensive organisational communication framework that is highly relevant for developing a contingent and situational understanding of the impact of CPOE on pathology services

Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

<p>Abstract</p> <p>Background</p> <p>Acute medical care often demands timely, accurate decisions in complex situations. Computerized clinical decision support systems (CCDSSs) have many features that could help. However, as for any medical intervention, claims that CCDSSs improve care processes and patient outcomes need to be rigorously assessed. The objective of this review was to systematically review the effects of CCDSSs on process of care and patient outcomes for acute medical care.</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. MEDLINE, EMBASE, Evidence-Based Medicine Reviews databases (Cochrane Database of Systematic Reviews, DARE, ACP Journal Club, and others), and the Inspec bibliographic database were searched to January 2010, in all languages, for randomized controlled trials (RCTs) of CCDSSs in all clinical areas. We included RCTs that evaluated the effect on process of care or patient outcomes of a CCDSS used for acute medical care compared with care provided without a CCDSS. A study was considered to have a positive effect (<it>i.e.</it>, CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.</p> <p>Results</p> <p>Thirty-six studies met our inclusion criteria for acute medical care. The CCDSS improved process of care in 63% (22/35) of studies, including 64% (9/14) of medication dosing assistants, 82% (9/11) of management assistants using alerts/reminders, 38% (3/8) of management assistants using guidelines/algorithms, and 67% (2/3) of diagnostic assistants. Twenty studies evaluated patient outcomes, of which three (15%) reported improvements, all of which were medication dosing assistants.</p> <p>Conclusion</p> <p>The majority of CCDSSs demonstrated improvements in process of care, but patient outcomes were less likely to be evaluated and far less likely to show positive results.</p

Implementing Real-Time Computerized Clinical Decision Support During Trauma Resuscitations: Lessons Learned From Simulation.

Through the combination of clinical expertise, research, and patient values evidence-based practice (EBP) is becoming the new standard of patient care. Despite the main benefits of EBP medical providers are hesitant to implement based on a multitude of barriers. In order to increase adoption of EBP we need to develop deliver systems that bring best evidence in an easy to use format to the bedside. We tested the implementation of a computerized clinical decision support documentation platform during trauma team resuscitations. The simulation sessions were geared to help identify opportunities for improvement in our implementation methodology. During the simulation sessions an improvement in care was not identified in comparison to previous in situ simulation sessions. We did identify several opportunities to improve patient care through the use of disruptive alerts, additional training, and a time period for familiarization with the product

Institute of Hematology and Transfusion Medicine — a novel approach of combining comprehensiveness, coordination, innovation and pro-quality measures for improving diagnosis, treatment, patient care, and the advancement of medical science

  W Polsce, podobnie jak w innych krajach europejskich, obserwuje się ciągły wzrost zapotrzebowa­nia na świadczenia zdrowotne w zakresie chorób krwi. Na to zjawisko składa się nie tylko obser­wowana od kilkudziesięciu lat zwiększona zapadalność na nowotwory układów krwiotwórczego i chłonnego, ale również dynamiczny rozwój metod diagnostycznych i leczniczych, jaki się dokonał w ostatnim czasie. Instytut Hematologii i Transfuzjologii jest referencyjną jednostką naukowo­-kliniczną prowadzącą badania naukowe i translacyjne w dziedzinie hematologii, transfuzjologii i dyscyplin pokrewnych oraz udziela świadczeń medycznych w tym zakresie. Instytut to nowoczesny ośrodek krajowy, w którym stawia się na skoordynowane leczenie i nowe technologie medyczne. W działalności medycznej personel kieruje się zasadą wielospecjalistycznego podejścia, co oznacza udział wszystkich niezbędnych specjalistów na etapie rozpoznawania i określania zaawansowania choroby, a także leczenia i prowadzenia rehabilitacji oraz obserwacji po leczeniu. Kompleksowe postępowanie zapewnia możliwość uzyskania najlepszych wyników terapii. Skoordynowana opieka medyczna, jaką swoim Pacjentom oferuje Instytut, przekłada się przede wszystkim na szybszy i lep­szy efekt medyczny. Dla osiągnięcia tego celu ważne są interoperacyjność i autentyczna współpraca między poszczególnymi jednostkami diagnostycznymi i medycznymi, a także innymi ośrodkami prowadzącymi leczenie specjalistyczne. Oprócz standardowych metod diagnostyki i leczenia Insty­tut oferuje możliwość wysokospecjalistycznego i nowatorskiego leczenia celowanego molekularnie, a także uczestnictwo w międzynarodowych badaniach klinicznych z zastosowaniem nowatorskich i eksperymentalnych sposobów leczenia chorych na nowotwory układów krwiotwórczego i chłonnego. Prowadzone przez Instytut badania naukowe zaowocowały możliwością stosowania nowoczesnych technik immunologicznych i genetycznych we wszystkich wymagających takich technologii proce­sach diagnostyczno-leczniczych. Procesy te są zadaniem złożonym i interdyscyplinarnym; dotyczą nie tylko prawidłowego rozpoznania choroby, ale również oceny markerów prognostyczno-predykcyj­nych, wczesnej diagnostyki i prewencji powikłań, doboru dawców i biorców przeszczepów komórek krwiotwórczych, a także oceny głębokości remisji. We współpracy z innymi podmiotami w kraju i za granicą Instytut uczestniczy w programie kompleksowego i skoordynowanego zachowania rozrodczości u kobiet chorych na nowotwory poddawanych chemio- i radioterapii. Przez ostatnie lata Instytut prowadził działania inwestycyjne, które pozwoliły wyposażyć poszczególne pracownie w innowacyjną aparaturę i specjalistyczne urządzenia. Dzięki specjalistycznym zasobom kadrowym, doświadczeniu hematopatologów oraz wspierającemu ich zespołowi biologów i biotechnologów Instytut dysponuje niezbędnym know-how do skutecznego wdrażania i komercjalizacji wyników badań naukowych. Dynamiczny rozwój tej dziedziny działalności prowadzi do powstawania inno­wacyjnych produktów tworzonych w ramach Krajowych Inteligentnych Specjalizacji. Taka sytuacja buduje przewagę konkurencyjną Instytutu w zakresie innowacyjnych technologii medycznych — nie tylko na poziomie krajowym, ale też na arenie międzynarodowej.    Like in all European countries, Poland has witnessed a continuing rise in healthcare services needed for treating hematological disease. Not only have morbidity rates increased in myeloid and lymphoid malignancies but, in parallel, a dynamic development of diagnostic methods and therapeutic treatments has occurred in recent times. The Institute of Hematology and Transfusion Medicine constitutes a reference centre in Poland committed to delivering scientific-clinical excel­lence where it undertakes scientific studies and translational research in hematology, transfusion medicine and related disciplines along with providing healthcare services in such fields. This is a modern medical centre focused on coordinating and integrating treatment using new medical technologies. A multidisciplinary strategy to medicine ensures that all necessary specialists are engaged in disease diagnoses and also for defining disease progression stages together with actual treatment, subsequent rehabilitation and follow-up monitoring. By adopting this comprehensive approach, optimal therapeutic solutions are thereby achieved; patients receive coordinated medi­cal healthcare, which above all else, results in faster and more effective treatments. In order to achieve such aims, it is vital that all diagnostic and medical units collaborate, including with those from other medical centres whenever added specialist treatment is required. In addition to standard diagnostics and treatment, the Institute provides highly specialised and innovative treat­ments that are molecularly targeted, as well as the opportunity of participating in international clinical trials, where innovative and experimental therapies are used on patients with myeloid and lymphoid malignancies. Such trials have enabled the Institute to apply modern immunological and genetic technologies to diagnoses-treatment. Performing such procedures requires a complex and multidisciplinary approach, not just for ensuring correct diagnoses, but for also assessing prognostic-predictive disease markers, making the diagnoses early, preventing complications, selecting appropriate donor-recipients for hematopoietic cell transplants and evaluating the extent of remission. In collaboration with other national centres and those abroad, the Institute is also engaged in complex and coordinated programmes devoted to preserving women’s fertility for those suffering from cancer and who are treated with chemo/radio-therapy. Over recent years, the Insti­tute has invested in furnishing individual laboratories with the latest equipment and specialised instrumentation. Because of its highly specialist staff, the wide experience of hematopathologists and the supporting teams of biologists and biotechnologists, the Institute has at its disposition the vital ‘know-how’ thereby allowing developments from scientific studies to become successfully im­plemented and commercialised. The dynamic rise in this area has driven the creation of innovative products under the National Smart Specialisation initiative; this giving the Institute a competitive advantage in developing new medical technologies, at both country and international levels

Implementing a New Electronic Health Record System in a University Hospital : The Effect on Reported Medication Errors

Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.Peer reviewe

Implementing a New Electronic Health Record System in a University Hospital : The Effect on Reported Medication Errors

Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.Peer reviewe