Abstract:
BACKGROUND:Insulin is a high-risk medicine which may cause significant patient harm or death when given incorrectly. A 10-fold error in administered insulin dose commonly occurs when the abbreviation 'u' is used for 'units' and subsequently misinterpreted as a 'zero.' METHOD:A multidisciplinary working party was convened and mapped insulin prescribing, dispensing and administration. All inpatient orders above 25 units for short-acting insulin and 50 units for other insulin require validation by an additional source. Educational strategies to support adherence to the guideline and product-labelling alerts were developed. RESULTS:Implementation occurred in August 2008 across the three hospital sites. In 90 weeks after implementation, there were 150 patients identified in which 200 high doses of insulin were prescribed (>25 units for short-acting insulin and 50 units for other insulin). There were eight instances where high doses of insulin were prescribed in error but were detected and rectified through the new validation process. There were 12 dosing errors that occurred, including two 10-fold dosing errors. In contrast, seven major errors resulting in excessive insulin administration were identified over a 2-year period prior to the introduction of the insulin high-dose validation system. CONCLUSION:A structured validation process was successful in reducing incorrect prescription and administration of high-dose insulin and has reduced the risk of associated fatalities or significant patient harm. Consideration should be given to adopting this process in any setting where insulin is prescribed and administered.
journal_name
BMJ Qual Safjournal_title
BMJ quality & safetyauthors
Dooley MJ,Wiseman M,McRae A,Murray D,Van De Vreede M,Topliss D,Poole SG,Wyatt S,Newnham Hdoi
10.1136/bmjqs.2010.049668subject
Has Abstractpub_date
2011-07-01 00:00:00pages
637-44issue
7eissn
2044-5415issn
2044-5423pii
bmjqs.2010.049668journal_volume
20pub_type
杂志文章,多中心研究abstract:BACKGROUND:Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes. OBJECTIVES:(1) Test the psychometric properties of a brief four-item burnout ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-002831
更新日期:2014-10-01 00:00:00
abstract::People who are sick are often the most vulnerable in society. They frequently rely on caring and competent healthcare professionals and should and do have expectations of a safe and caring environment. In a recent unexpected adventure through the healthcare system, the organisation, professionalism, caring and compass...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000235
更新日期:2011-11-01 00:00:00
abstract:BACKGROUND:Recent research suggests that hospital rates of postoperative venous thromboembolism (VTE) are subject to surveillance bias: the more hospitals 'look for' VTE, the more VTE they find. However, little is known about what drives variation in hospital VTE imaging rates. We conducted an observational study to ex...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003150
更新日期:2014-11-01 00:00:00
abstract:BACKGROUND:In an international effort to reduce antibiotic resistance, in part suggested to be the effect of inappropriate antibiotic use, several quality indicators for outpatient antibiotic use have been proposed. In this study, geographical and educational differences in fluoroquinolone prescription in the treatment...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2008.028696
更新日期:2011-01-01 00:00:00
abstract:BACKGROUND:Advocates for quality and safety have called for healthcare that is patient-centred and decision-making that involves patients. OBJECTIVE:The aim of the paper is to explore the barriers and facilitators to patient-centred care in the hospital discharge process. METHODS:A qualitative study using purposive s...
journal_title:BMJ quality & safety
pub_type: 杂志文章,多中心研究
doi:10.1136/bmjqs-2012-001165
更新日期:2012-12-01 00:00:00
abstract:INTRODUCTION:Individual effort and practice systems contribute to quality performance, but the nature of their contributions remains unclear. METHODS:This study assessed the roles of individual attributes and behaviours versus practice attributes in quality performance by assessing general internists' perceptions of f...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2010.048991
更新日期:2011-08-01 00:00:00
abstract::BACKGROUND Previous research has shown a correlation between physician job satisfaction and patient satisfaction with quality of care, but the connection between job satisfaction of other primary care team members and patient satisfaction is yet unclear. OBJECTIVE To evaluate whether there is an association between pa...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2009.038166
更新日期:2011-06-01 00:00:00
abstract:PURPOSE:To evaluate the impact of implementation of a dedicated intensivist-led medical emergency team (IL-MET) on mortality in patients admitted to the intensive care unit (ICU). METHODS:All adult ward admissions to the ICU between July 2002 and December 2009 were reviewed (n=1920) after excluding readmissions and ad...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000393
更新日期:2012-02-01 00:00:00
abstract::This commentary explores the nature of creating safety in the here-and-now. Creating safety encompasses two dimensions: revisiting specific behaviours by focusing on substandard performance (reflection), and a more broad-ranging attention to everyday behaviours that are taken as given (reflexivity). The piece pays par...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs.2010.046714
更新日期:2011-04-01 00:00:00
abstract:BACKGROUND:National Hospital Quality Measures (NHQM) should accurately reflect quality of care, as they increasingly impact reimbursement and reputation. However, similar to risk adjustment of outcomes measures, NHQM process measures pose unique methodological concerns, including lack of representativeness of the final...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2015-004888
更新日期:2017-03-01 00:00:00
abstract:INTRODUCTION:Hip fractures are associated with high rates of morbidity and mortality and their incidence is set to increase. The National Hip Fracture Database and the Best Practice Tariff were introduced with the aim of improving patient care. This complete audit cycle charts the substantial clinical improvements that...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003700
更新日期:2015-08-01 00:00:00
abstract:BACKGROUND:Existing evidence indicates that reducing nurse staffing and/or skill mix adversely affects care quality. Nursing shortages may lead managers to dilute nursing team skill mix, substituting assistant personnel for registered nurses (RNs). However, no previous studies have described the relationship between nu...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2018-008948
更新日期:2019-09-01 00:00:00
abstract:OBJECTIVE:To assess the quality of guidelines, consensus statements and systematic reviews on flu and pneumococcal immunisations in HIV-infected children. METHOD:The authors screened PubMed and Embase databases until the year 2009 for guidelines, consensus statements and systematic reviews on flu and pneumococcal immu...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs.2010.047316
更新日期:2011-05-01 00:00:00
abstract::Cystic fibrosis (CF) is a chronic disease requiring patients to have frequent specialty healthcare visits to delay progression of lung disease, prevent and treat failure to thrive and initiate early interventions to prevent acute illness and complications. The CF Foundation recommends that patients have visits with th...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs-2013-002345
更新日期:2014-04-01 00:00:00
abstract:BACKGROUND:Experts in patient safety stress the importance of a shared culture of safety. Lack of consensus may be detrimental to patient safety. This study examines differences in patient safety culture perceptions among providers, management and staff in a large national survey of safety culture in ambulatory practic...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003914
更新日期:2016-08-01 00:00:00
abstract:BACKGROUND:Community pharmacists are well positioned to support patients' minor ailments. The objective was to evaluate the clinical and humanistic impact of a minor ailment service (MAS) in community pharmacy compared with usual pharmacist care (UC). METHODS:A cluster randomised controlled trial was conducted. Interv...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2019-010608
更新日期:2020-11-01 00:00:00
abstract:BACKGROUND:Errors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review was to identify interventions that might reduce the likelihood of these cognitive errors. DESIGN:We searched PubMed and other medical and non-medical databases and identified addition...
journal_title:BMJ quality & safety
pub_type: 杂志文章,评审
doi:10.1136/bmjqs-2011-000149
更新日期:2012-07-01 00:00:00
abstract:BACKGROUND:Despite the increased focus on improving patient's postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe processes used to prepare patients for postacute care in SNFs, and to explore differences between...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2020-011204
更新日期:2020-09-21 00:00:00
abstract:BACKGROUND:Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed. OBJECTIVES:Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that a...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2017-006529
更新日期:2017-11-01 00:00:00
abstract:BACKGROUND AND OBJECTIVES:Due to the multitude of questions in the Hospital-Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) survey, it may be difficult to decide where quality improvement efforts should be focused. Our organisation has supplemented the survey with a 'patient complaints' section. The s...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2015-004371
更新日期:2016-10-01 00:00:00
abstract:BACKGROUND:Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boa...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2018-008291
更新日期:2019-03-01 00:00:00
abstract:AIM:To evaluate the effectiveness of a 'Do not interrupt' bundled intervention to reduce non-medication-related interruptions to nurses during medication administration. METHODS:A parallel eight cluster randomised controlled study was conducted in a major teaching hospital in Adelaide, Australia. Four wards were rando...
journal_title:BMJ quality & safety
pub_type: 杂志文章,随机对照试验
doi:10.1136/bmjqs-2016-006123
更新日期:2017-09-01 00:00:00
abstract:BACKGROUND:Interest in the use of social network analysis (SNA) in healthcare research has increased, but there has been little methodological research on how to choose the name generators that are often used to collect primary data on the social connection between individuals for SNA. OBJECTIVE:We sought to determine...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2011-000521
更新日期:2012-12-01 00:00:00
abstract:BACKGROUND:Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use. METHODS:To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interven...
journal_title:BMJ quality & safety
pub_type: 杂志文章,meta分析,评审
doi:10.1136/bmjqs-2012-001774
更新日期:2014-04-01 00:00:00
abstract:OBJECTIVES:To sustainably reduce the rate of mislabelled laboratory specimens through implementation of a series of interventions as led and coordinated by a multidisciplinary performance improvement team. METHODS:The quality improvement project was performed at Cedars-Sinai Medical Center in Los Angeles, an academic ...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003005
更新日期:2014-08-01 00:00:00
abstract:BACKGROUND:Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse ou...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2014-003816
更新日期:2015-08-01 00:00:00
abstract:OBJECTIVE:Implement and demonstrate feasibility of in situ simulations to identify latent safety threats (LSTs) at a higher rate than lab-based training, and reinforce teamwork training in a paediatric emergency department (ED). METHODS:Multidisciplinary healthcare providers responded to critical simulated patients in...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2012-000942
更新日期:2013-06-01 00:00:00
abstract:OBJECTIVES:To determine whether the items on the Time Out and the Sign Out of the Surgical Safety Checklist are properly checked by operating room (OR) staff and to explore whether the number of checked items is influenced by the severity of the intervention and the use of the checklist as a memory tool during the Time...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2012-001634
更新日期:2013-08-01 00:00:00
abstract:BACKGROUND:Prevention of healthcare-associated urinary tract infection (UTI) has been the focus of a national effort, yet appropriate indications for insertion and removal of urinary catheters (UC) among surgical patients remain poorly defined. METHODS:We developed and implemented a standardised approach to perioperat...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2017-007458
更新日期:2019-01-01 00:00:00
abstract:INTRODUCTION:Although registered nurses (RNs) are central in patient care, we have not found prior research that specifically addresses how RNs assess the safety of patient care at their workplace and how factors in RNs' work environment are related to their assessments. This study aims to address these issues. METHOD...
journal_title:BMJ quality & safety
pub_type: 杂志文章
doi:10.1136/bmjqs-2012-001734
更新日期:2014-03-01 00:00:00