Johanna I. Westbrook

CareTrack: Assessing the appropriateness of health care delivery in Australia

Objective: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence‐based or consensus‐based guidelines).

Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience

Background Intravenous medication administrations have a high incidence of error but there is limited evidence of associated factors or error severity. Objective To measure the frequency, type and severity of intravenous administration errors in hospitals and the associations between errors, procedural failures and nurse experience. Methods Prospective observational study of 107 nurses preparing and administering 568 intravenous medications on six wards across two teaching hospitals. Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity. Results Of 568 intravenous administrations, 69.7% (n=396; 95% CI 65.9 to 73.5) had at least one clinical error and 25.5% (95% CI 21.2 to 29.8) of these were serious. Four error types (wrong intravenous rate, mixture, volume, and drug incompatibility) accounted for 91.7% of errors. Wrong rate was the most frequent and accounted for 95 of 101 serious errors. Error rates and severity decreased with clinical experience. Each year of experience, up to 6 years, reduced the risk of error by 10.9% and serious error by 18.5%. Administration by bolus was associated with a 312% increased risk of error. Patient identification was only checked in 47.9% of administrations but was associated with a 56% reduction in intravenous error risk. Conclusions Intravenous administrations have a higher risk and severity of error than other medication administrations. A significant proportion of errors suggest skill and knowledge deficiencies, with errors and severity reducing as clinical experience increases. A proportion of errors are also associated with routine violations which are likely to be learnt workplace behaviours. Both areas suggest specific targets for intervention.

Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study

In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study

Background Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. Objective To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Design Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Settings Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Main measures Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). Conclusions Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

A comparison of self-reported and observational work sampling techniques for measuring time in nursing tasks

Objectives: To compare self-reported and observational work sampling techniques when applied to ward-based nurses. Methods: A self-reported work sampling study was undertaken with nine registered nurses in an Australian teaching hospital over 8.5 weeks, followed by an observational work sampling study conducted over 4.5 weeks. Both studies used a random reminder method and a multidimensional work task classification. Field notes were also recorded and analysed. Results: 3910 data points were collected, 667 during the self-report study and 3243 in the observational study. The two techniques yielded significant differences in work patterns of registered nurses. The observational study showed that compared with the self-reported study, patient care (40% versus 33%, P <0.000) and ward-related activities (7% versus 3%; P <0.001) were recorded significantly more frequently, and documentation less frequently (8% versus 19%; P <0.000). Both the techniques generated similar proportions of time spent in breaks (12%), medication tasks (13%) and clinical discussion (15%). The self-report technique was poorly accepted by nursing staff. The observational technique was well accepted and data collection was more effcient. Conclusions: The self-report work sampling technique is not a reliable method for obtaining an accurate reflection of the work tasks of ward-based nurses. The observational technique was preferred by nurses, and despite concern regarding a potential Hawthorne effect, this was not substantiated.

Narrative synthesis of health service accreditation literature

Aims To systematically identify and synthesise health service accreditation literature. Methods A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. Results The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, ‘organisational impacts’ and ‘relationship to quality measures’, were addressed 60 or more times in the literature. ‘Financial impacts’, ‘consumer or patient satisfaction’ and ‘survey and surveyor issues’ were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. Conclusions Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.

The safety implications of missed test results for hospitalised patients: a systematic review

Background Failure to follow-up test results is a critical safety issue. The objective was to systematically review evidence quantifying the extent of failure to follow-up test results and the impact on patient outcomes. Methods The authors searched Medline, CINAHL, Embase, Inspec and the Cochrane Database from 1990 to March 2010 for English-language articles which quantified the proportion of diagnostic tests not followed up for hospital patients. Four reviewers independently reviewed titles, abstracts and articles for inclusion. Results Twelve studies met the inclusion criteria and demonstrated a wide variation in the extent of the problem and the impact on patient outcomes. A lack of follow-up of test results for inpatients ranged from 20.04% to 61.6% and for patients treated in the emergency department ranged from 1.0% to 75% when calculated as a proportion of tests. Two areas where problems were particularly evident were: critical test results and results for patients moving across healthcare settings. Systems used to manage follow-up of test results were varied and included paper-based, electronic and hybrid paper-and-electronic systems. Evidence of the effectiveness of electronic test management systems was limited. Conclusions Failure to follow up test results for hospital patients is a substantial problem. Evidence of the negative impacts for patients when important results are not actioned, matched with advances in the functionality of clinical information systems, presents a convincing case for the need to explore solutions. These should include interventions such as on-line endorsement of results.

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]

BackgroundAccreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted.Methods/designTo understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation.DiscussionThe accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Are interventions to reduce interruptions and errors during medication administration effective?: a systematic review

Background Medication administration errors are frequent and lead to patient harm. Interruptions during medication administration have been implicated as a potential contributory factor. Objective To assess evidence of the effectiveness of interventions aimed at reducing interruptions during medication administration on interruption and medication administration error rates. Methods In September 2012 we searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Effective Practice and Organisation of Care Group reviews, Google and Google Scholar, and hand searched references of included articles. Intervention studies reporting quantitative data based on direct observations of at least one outcome (interruptions, or medication administration errors) were included. Results Ten studies, eight from North America and two from Europe, met the inclusion criteria. Five measured significant changes in interruption rates pre and post interventions. Four found a significant reduction and one an increase. Three studies measured changes in medication administration error rates and showed reductions, but all implemented multiple interventions beyond those targeted at reducing interruptions. No study used a controlled design pre and post. Definitions for key outcome indicators were reported in only four studies. Only one study reported κ scores for inter-rater reliability and none of the multi-ward studies accounted for clustering in their analyses. Conclusions There is weak evidence of the effectiveness of interventions to significantly reduce interruption rates and very limited evidence of their effectiveness to reduce medication administration errors. Policy makers should proceed with great caution in implementing such interventions until controlled trials confirm their value. Research is also required to better understand the complex relationship between interruptions and error to support intervention design.

Impact of Medication Reconciliation and Review on Clinical Outcomes

Objective: To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities. Data Source: This systematic review was undertaken in concordance with the PRISMA statement. Electronic databases, including MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for relevant articles published between January 2000 and March 2014. Study Selection and Data Extraction: Randomized and nonrandomized studies rating the severity of medication discrepancies and medication-related problems identified during medication reconciliation and/or review were considered for inclusion. Data were extracted independently by 2 authors using a data collection form. Data Synthesis: Of the 5292 articles identified, 83 articles met the inclusion criteria. Medication reconciliation identified unintentional medication discrepancies in 3.4% to 98.2% of patients. There is limited evidence of the potential of these discrepancies to cause harm. Medication reviews identified medication-related problems or possible adverse drug reactions in 17.2% to 94.0% of patients. The studies reported conflicting findings regarding the impact of medication review on length of stays, readmissions, and mortality. Conclusions: The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm, but the impact on clinical outcomes is less clear. Similarly, medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Overall, there is limited evidence that medication reconciliation and medication review processes, as currently performed, significantly improve clinical outcomes, such as reductions in hospital readmissions.