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

Development of an intervention to support the implementation of evidence-based strategies for optimising antibiotic prescribing in general practice.

BACKGROUND: Trials show that antimicrobial stewardship (AMS) strategies, including communication skills training, point-of-care C-reactive protein testing (POC-CRPT) and delayed prescriptions, help optimise antibiotic prescribing and use in primary care. However, the use of these strategies in general practice is limited and inconsistent. We aimed to develop an intervention to enhance uptake and implementation of these strategies in primary care. METHODS: We drew on the Person-Based Approach to develop an implementation intervention in two stages. (1) Planning and design: We defined the problem in behavioural terms drawing on existing literature and conducting primary qualitative research (nine focus groups) in high-prescribing general practices. We identified 'guiding principles' with intervention objectives and key features and developed logic models representing intended mechanisms of action. (2) Developing the intervention: We created prototype intervention materials and discussed and refined these with input from 13 health professionals and 14 citizens in two sets of design workshops. We further refined the intervention materials following think-aloud interviews with 22 health professionals. RESULTS: Focus groups highlighted uncertainties about how strategies could be used. Health professionals in the workshops suggested having practice champions, brief summaries of each AMS strategy and evidence supporting the AMS strategies, and they and citizens gave examples of helpful communication strategies/phrases. Think-aloud interviews helped clarify and shorten the text and user journey of the intervention materials. The intervention comprised components to support practice-level implementation: antibiotic champions, practice meetings with slides provided, and an 'implementation support' website section, and components to support individual-level uptake: website sections on each AMS strategy (with evidence, instructions, links to electronic resources) and material resources (patient leaflets, POC-CRPT equipment, clinician handouts). CONCLUSIONS: We used a systematic, user-focussed process of developing a behavioural intervention, illustrating how it can be used in an implementation context. This resulted in a multicomponent intervention to facilitate practice-wide implementation of evidence-based strategies which now requires implementing and evaluating. Focusing on supporting the uptake and implementation of evidence-based strategies to optimise antibiotic use in general practice is critical to further support appropriate antibiotic use and mitigate antimicrobial resistance

Feeding wet distillers grains plus solubles with and without a direct-fed microbial to determine performance, carcass characteristics, and fecal shedding of Escherichia coli O157:H7 in feedlot heifers

Citation: Wilson, B. K., Holland, B. P., Step, D. L., Jacob, M. E., VanOverbeke, D. L., Richards, C. J., . . . Krehbiel, C. R. (2016). Feeding wet distillers grains plus solubles with and without a direct-fed microbial to determine performance, carcass characteristics, and fecal shedding of Escherichia coli O157:H7 in feedlot heifers. Journal of Animal Science, 94(1), 297-305. doi:10.2527/jas2015-9601The inclusion of wet distillers grains plus solubles (WDGS) in feedlot diets has become a common practice in many regions of the United States due to the expanded production of byproducts and fluctuating corn prices related to ethanol production and other factors. In addition, societal concerns over the continued use of antimicrobials in agriculture production combined with an enhanced interest in disease and pathogen prevention in the food supply have led to an increased interest in use of direct-fed microbials (DFM) in growing and finishing cattle. Direct-fed microbials have been shown to improve ADG and feed efficiency, alter ruminal fermentation, and decrease fecal shedding of potential harmful pathogens in feedlot cattle in some experiments. The objective of this experiment was to evaluate the effects of WDGS inclusion with or without a DFM containing Lactobacillus acidophilus (1 x 10(6) cfu . heifer(-1) . d(-1)) combined with Propionibacterium freudenreichii (1 x 10(9) cfu , heifer(-1) . d(-1)) on the performance, carcass characteristics, and Escherichia coli O157:H7 shedding in feedlot heifers. In early August, 288 crossbred heifers (initial BW = 295 +/- 28 kg) were assigned to 1 of 4 treatments (12 pens per treatment; 6 heifers per pen) in a randomized complete block design with a 2 x 2 factorial arrangement of treatments. Body weights and fecal grab samples were obtained at approximately 28-d intervals throughout the experiment. Across the feeding period, heifers fed 30% WDGS tended (P = 0.09) to have greater ADG and had greater carcass-adjusted ADG (P = 0.05) compared with heifers fed dry-rolled corn (DRC). Dry matter intake was not affected (P = 0.65) by diet, although carcass-adjusted G:F tended (P = 0.10) to be improved for heifers fed WDGS. Heifers fed 30% WDGS tended (P 0.10) on performance or carcass merit in the present experiment. The incidence of E. coli O157:H7 throughout the experiment was low, with only 18 positive samples across all sampling periods. Neither WDGS inclusion nor the inclusion of L. acidophilus combined with P. freudenreichii in the diet had any effect (P > 0.10) on E. coli O157:H7 shedding in this experiment. Feeding 30% WDGS to feedlot heifers improved animal performance compared to the DRC-based control diet

Confronting Ceftolozane-Tazobactam Susceptibility in Multidrug-Resistant Enterobacterales Isolates and Whole-Genome Sequencing Results (STEP Study)

Ceftolozane-tazobactam (C/T) is frequently used for infections caused by multidrug-resistant (MDR)-Enterobacterales isolates. Whole-genome sequencing (WGS, Illumina-Hiseq 4000/NovaSeq 6000, OGC, UK) was used to study the population structure, the resistome and the virulome of C/T-susceptible and -resistant MDR Escherichia spp. (n=30) and Klebsiella spp. (n=78) isolates, recovered from lower respiratory, intra-abdominal and urinary tract infections of ICU patients from 11 Portuguese Hospitals (STEP study, 2017-2018). Minimum inhibitory concentrations (MICs) were determined (ISO-broth microdilution, breakpoints EUCAST-2020). In Escherichia spp., a weak concordance between the phenotypic and the WGS method (P=0.051) was observed in the carbapenemase detection (3/30) [blaVIM-2 (2/3), blaKPC-3 (1/3)]; VIM-2-Escherichia coli isolates were C/T-susceptible and only the KPC-3-Escherichia marmotae producer showed C/T-resistance. Overall, CTX-M-15-E. coli-ST131-O25:H4-H30-Rx (11/30) was the most frequent subclone, followed by CTX-M-27-E. coli-ST131-O25:H4-H30 (4/4). Moreover, a wide resistome and virulome were detected in all E. coli isolates. Among Klebsiella spp. isolates [K. pneumoniae (67/78), K. aerogenes (7/78), K. oxytoca (2/78), K. variicola (2/78)], concordance (P<0.001) was observed between the phenotypic and the genomic carbapenemase detection (21/78) [blaKPC-3 (14/21), blaOXA-48 (3/21), blaOXA-181 (3/21)]. A high correlation between C/T-resistance and carbapenemase detection was established (P<0.05). Overall, a high clonal diversity was observed, mainly in KPC-3-producing K. pneumoniae isolates. An extensive resistome was detected in Klebsiella spp. isolates, whereas virulence determinants were mostly identified in carbapenemase producers (P<0.001). WGS is a powerful tool for typing characterization and microbiological study of MDR-Enterobacterales pathogens. Furthermore, carbapenemase genes are associated with C/T-resistance in Klebsiella spp., but other mechanisms might also be involved.info:eu-repo/semantics/publishedVersio

A mixed treatment comparison meta-analysis of metaphylaxis treatments for bovine respiratory disease in beef cattle

Citation: Abell, K. M., Theurer, M. E., Larson, R. L., White, B. J., & Apley, M. (2017). A mixed treatment comparison meta-analysis of metaphylaxis treatments for bovine respiratory disease in beef cattle. Journal of Animal Science, 95(2), 626-635. doi:10.2527/jas2016.1062The objective of this project was to evaluate the effects of antimicrobials approved for parenteral metaphylactic use in feeder and stocker calves on morbidity and mortality for bovine respiratory disease with the use of a mixed treatment comparison meta-analysis. An initial literature review was conducted in April 2016 through Pubmed, Agricola, and CAB (Commonwealth Agricultural Bureau) for randomized controlled trials for metaphylaxis antimicrobial administered parentally to incoming feedlot or stocker calves within 48 h of arrival. The final list of publications included 29 studies, with a total of 37 trials. There were 8 different metaphylactic antimicrobials. Final event outcomes were categorized into bovine respiratory disease (BRD) morbidity cumulative incidence d 1 to <= 60 of the feeding period, BRD morbidity cumulative incidence d 1 to closeout of the feeding period, BRD mortality cumulative incidence d 1 to closeout of the feeding period, and BRD retreatment cumulative incidence morbidity d 1 to closeout of the feeding period. Network meta-analysis combined direct and indirect evidence for all the event outcomes to determine mean odds ratio (OR) with 95% credibility intervals (CrIs) for all metaphylactic antimicrobial comparisons. The "upper tier" treatment arms for morbidity d 1 to <= 60 included tulathromycin, gamithromycin, and tilmicosin. For BRD mortality cumulative incidence d 1 to closeout and BRD retreatment morbidity d 1 to closeout, classifying the treatment arms into tiers was not possible due to overlapping 95% CrIs. The results of this project accurately identified differences between metaphylactic antimicrobials, and metaphylactic antimicrobial options appear to offer different outcomes on BRD morbidity and mortality odds in feedlot cattle

Reconciling research and implementation in micro health insurance experiments in India: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Microinsurance or Community-Based Health Insurance is a promising healthcare financing mechanism, which is increasingly applied to aid rural poor persons in low-income countries. Robust empirical evidence on the causal relations between Community-Based Health Insurance and healthcare utilisation, financial protection and other areas is scarce and necessary. This paper contains a discussion of the research design of three Cluster Randomised Controlled Trials in India to measure the impact of Community-Based Health Insurance on several outcomes.</p> <p>Methods/Design</p> <p>Each trial sets up a Community-Based Health Insurance scheme among a group of micro-finance affiliate families. Villages are grouped into clusters which are congruous with pre-existing social groupings. These clusters are randomly assigned to one of three waves of implementation, ensuring the entire population is offered Community-Based Health Insurance by the end of the experiment. Each wave of treatment is preceded by a round of mixed methods evaluation, with quantitative, qualitative and spatial evidence on impact collected. Improving upon practices in published Cluster Randomised Controlled Trial literature, we detail how research design decisions have ensured that both the households offered insurance and the implementers of the Community-Based Health Insurance scheme operate in an environment replicating a non-experimental implementation.</p> <p>Discussion</p> <p>When a Cluster Randomised Controlled Trial involves randomizing within a community, generating adequate and valid conclusions requires that the research design must be made congruous with social structures within the target population, to ensure that such trials are conducted in an implementing environment which is a suitable analogue to that of a non-experimental implementing environment.</p

Waste Electrical and Electronic Equipment (WEEE): Flows, Quantities, and Management—A Global Scenario

International audienc

The business of death: a qualitative study of financial concerns of widowed older women

BACKGROUND: The feminisation of ageing and increasing number of widowed women in contemporary society has significant implications. Older women are at risk of poor health, social, and economic outcomes upon widowhood. The aim of the study was to describe women’s experiences in the period soon after their husbands’ death, including their financial issues and concerns, and the ways in which these experiences impacted on the transition to widowhood late in life. METHODS: This was a longitudinal study using serial in-depth semi-structured interviews with 21 community-dwelling women over the age of 65 in Australia. Verbatim transcripts underwent Interpretive Phenomenological Analysis. RESULTS: Thematic analysis revealed: 1) administrative burden increases vulnerability; 2) gender roles impact on transitions; and 3) financial adjustments render housing insecurity and health risk. High administrative burden within the context of significant grief and mourning was a defining feature of the early bereavement period. Complicated protracted administrative processes, insensitive interactions, and reminders of loss contributed to distress, anxiety and feelings of demoralisation. Several women identified assumption of household financial management as the most difficult aspect of coping with their husband’s death. CONCLUSIONS: Older women may have unmet needs for assistance with administrative, financial, and legal issues immediately following spousal death and potentially for years afterward. Lack of familiarity and absence of instrumental support with financial and legal issues signal the need for policy reform, resources to improve financial literacy in women throughout the life course, increased advocacy, and consideration of different support and service models