Susan Burnett

Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes

Aim To compare the prevalence and causes of prescribing errors in newly written medication orders and how quickly they were rectified, in three NHS organisations. Methods Errors in newly written inpatient and discharge medication orders were recorded in Spring/Summer 2009 by ward pharmacists on medical admissions and surgical wards, as well as the number of erroneous doses administered (or omitted) before errors were corrected. Logistic regression analysis was used to explore the effects of ward (nested within organisation) and clinical specialty, and whether the pharmacist had checked the patients medication history during data collection. Causes were explored using semistructured interviews with key informants. Results Overall, 1025 prescribing errors were identified in 974 of 6605 medication orders (14.7%, 95% confidence interval (CI) 13.8% to 15.6%). A mean of 0.9 doses were administered (or omitted) before each error was corrected (range 0–11), with differences between specialties and organisations. The error rate on medical admissions wards (16.3%) was significantly higher than that on surgical wards (12.2%), but this was accounted for by the higher proportion of prescribing being on admission, where omission of patients usual medication was often identified. There were significant differences among wards (and organisations). Contributing factors included lack of feedback on errors, poor documentation and communication of prescribing decisions, and lack of information about patients medication histories from primary care. Conclusions There were variations among wards, organisations and specialties in error rates and how quickly they were rectified. Exploring reasons for differences between organisations may be useful in identifying best practice and potential solutions.

Studying large-scale programmes to improve patient safety in whole care systems: challenges for research.

Large-scale national and multi-institutional patient safety improvement programmes are being developed in the health care systems of several countries to address problems in the reliability of care delivered to patients. Drawing upon popular collaborative improvement models, these campaigns are ambitious in their aims to improve patient safety in macro-level systems such as whole health care organisations. This article considers the methodological issues involved in conducting research and evaluation of these programmes. Several specific research challenges are outlined, which result from the complexity of longitudinal, multi-level intervention programmes and the variable, highly sociotechnical care systems, with which they interact. Organisational-level improvement programmes are often underspecified due to local variations in context and organisational readiness for improvement work. The result is variable implementation patterns and local adaptations. Programme effects span levels and other boundaries within a system, vary dynamically or are cumulative over time and are problematic to understand in terms of cause and effect, where concurrent external influences exist and the impact upon study endpoints may be mediated by a range of organisational and social factors. We outline the methodological approach to research in the United Kingdom Safer Patients Initiative, to exemplify how some of the challenges for research in this area can be met through a multi-method, longitudinal research design. Specifically, effective research designs must be sensitive to complex variation, through employing multiple qualitative and quantitative measures, collect data over time to understand change and utilise descriptive techniques to capture specific interactions between programme and context for implementation. When considering the long-term, sustained impact of an improvement programme, researchers must consider how to define and measure the capability for continuous safe and reliable care as a property of the whole care system. This requires a sociotechnical approach, rather than focusing upon one microsystem, disciplinary perspective or single level of the system.

Perceptions of the impact of a large‐scale collaborative improvement programme: experience in the UK Safer Patients Initiative

RATIONALE AND AIMSnIn 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 Foundations 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 participants perceptions of the local impact of the programme and to form the basis of future research in this area.nnnMETHODSnData 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.nnnRESULTSnSpecific 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.nnnCONCLUSIONSnStudy 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.

Organisational readiness: exploring the preconditions for success in organisation-wide patient safety improvement programmes

Background Patient safety has been high on the agenda for more than a decade. Despite many national initiatives aimed at improving patient safety, the challenge remains to find coherent and sustainable organisation-wide safety-improvement programmes. In the UK, the Safer Patients Initiative (SPI) was established to address this challenge. Important in the success of such an endeavour is understanding ‘readiness’ at the organisational level, identifying the preconditions for success in this type of programme. This article reports on a case study of the four NHS organisations participating in the first phase of SPI, examining the perceptions of organisational readiness and the relationship of these factors with impact by those actively involved in the initiative. Materials and methods A mixed-methods design was used, involving a survey and semistructured interviews with senior executive leads, the principal SPI programme coordinator and the four operational leads in each of the SPI clinical work areas in all four organisations taking part in the first phase of SPI. Conclusions This preliminary work would suggest that prior to the start of organisation-wide quality- and safety-improvement programmes, organisations would benefit from an assessment of readiness with time spent in the preparation of the organisational infrastructure, processes and culture. Furthermore, a better understanding of the preconditions that mark an organisation as ready for improvement work would allow policymakers to set realistic expectations about the outcomes of safety campaigns.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol.

Backgroundalthough there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The Quality and Safety in Europe by Research (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them.The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients.Methods/designin-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features:• a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience• a conceptualisation of quality as a human, social, technical and organisational accomplishment• an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union.Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims).Discussionthe protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the organisational and cultural characteristics associated with better quality of care in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.

RATIONALE, AIMS AND OBJECTIVESnArguably, 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).nnnMETHODnA 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.nnnRESULTSnStatistically 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).nnnCONCLUSIONnThis 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.

Missing Clinical Information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care

BackgroundIn Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK.Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information.Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care.MethodsProspective descriptive study of missing information reported by surgeons, supplemented by interviews on the causes.Data were collected by surgeons in general, gastrointestinal, colorectal and vascular surgical clinics in three teaching hospitals across the UK for over a thousand outpatient appointments. Fifteen interviews were conducted with those involved in collating clinical information for these clinics.The study had ethics approval (Hammersmith and Queen Charlottes & Chelsea Research Ethics Committee), reference number (09/H0707/27). Participants involved in the interviews signed a consent form and were offered the opportunity to review and agree the transcript of their interview before analysis. No patients were involved in this research.ResultsIn 15% of outpatient consultations key items of clinical information were missing. Of these patients, 32% experienced a delay or disruption to their care and 20% had a risk of harm. In over half of cases the doctor relied on the patient for the information, making a clinical decision despite the information being missing in 20% of cases. Hospital mergers, temporary staff and non-integrated IT systems were contributing factors.ConclusionsIf these findings are replicated across the NHS then almost 10 million outpatients are seen each year without key clinical information, creating over a million unnecessary appointments, and putting nearly 2 million patients at risk of harm. There is a need for a systematic, regular audit of the prevalence of missing clinical information. Only then will we know the impact on clinical decision making and patient care of new technology, service reorganisations and, crucially given the present financial climate, temporary or reduced staffing levels. Further research is needed to assess the relationship between missing clinical information and diagnostic errors; to examine the issue in primary care; and to consider the patients perspective.

Medical engagement in organisation-wide safety and quality-improvement programmes: experience in the UK Safer Patients Initiative

Objectives To identify factors affecting doctors engagement with the Safer Patients Initiative (SPI). Design Qualitative interview study. Setting Four organisations participating in phase 1 of the SPI programme, from four different geographical locations in the UK. Participants 34 staff members, comprising senior executive/management leads involved in the SPI programme, the principal SPI programme coordinator and the operational leads in each of the SPI clinical work areas. Main outcome measures Staff perceptions of issues affecting medical engagement with SPI, identified in the interviews. Results Qualitative analysis identified seven factors that were reported to affect medical engagement with the SPI programme: (1) Organisation Track Record in QSI, (2) Resource Availability & Allocation, (3) Perceptions of the purpose of SPI, (4) Evidence of Efficacy of Programme, (5) External Expertise, (6) Local Programme Champions and (7) Managers Involvement. Specific barriers and general enabling strategies were identified and described for each factor, based upon participants experiences. Conclusions Medical engagement is a complex technical, socio-political and motivational issue that is underpinned by a series of inter-related factors associated with the organisational context, the design of improvement programmes and how they are implemented and promoted. Healthcare organisations planning to embark on safety and quality-improvement programmes may benefit from systematically addressing the core themes identified by this study, in order to promote optimal medical engagement.

Improving reliability of clinical care practices for ventilated patients in the context of a patient safety improvement initiative.

AIMSnTo 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).nnnMETHODSnQualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programmes 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.nnnRESULTSnThematic 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.nnnCONCLUSIONSnFuture 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.

Predictors of the perceived impact of a patient safety collaborative: an exploratory study.

OBJECTIVEnThe 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).nnnSTUDY DESIGNnA 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.nnnPARTICIPANTSnSenior 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).nnnINTERVENTIONnThe 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.nnnRESULTSnExploratory 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.nnnCONCLUSIONSnThe 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.