Checklists, safety, my culture and me.

abstract：OBJECTIVES:To provide national estimates of the number and clinical and economic burden of medication errors in the National Health Service (NHS) in England. METHODS:We used UK-based prevalence of medication errors (in prescribing, dispensing, administration and monitoring) in primary care, secondary care and care hom...

journal_title：BMJ quality & safety

authors： Elliott RA,Camacho E,Jankovic D,Sculpher MJ,Faria R

更新日期：2021-02-01 00:00:00

abstract：INTRODUCTION:Adverse events (AEs) affect 3-12% of hospitalised patients. These are estimates from a labour-intensive chart review process,which is not feasible outside research. Clinical deterioration on the wards triggers a rapid response teams (RRTs) consult and can be used to identify an AE prospectively. OBJECTIVE...

journal_title：BMJ quality & safety

authors： Amaral AC,McDonald A,Coburn NG,Xiong W,Shojania KG,Fowler RA,Chapman M,Adhikari NK

更新日期：2015-12-01 00:00:00

abstract：OBJECTIVES:To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. DESIGN:A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time res...

journal_title：BMJ quality & safety

authors： Boyce MB,Browne JP,Greenhalgh J

更新日期：2014-06-01 00:00:00

abstract：BACKGROUND:Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lo...

journal_title：BMJ quality & safety

authors： Guetterman TC,Kellenberg JE,Krein SL,Harrod M,Lehrich JL,Iwashyna TJ,Kronick SL,Girotra S,Chan PS,Nallamothu BK

更新日期：2019-11-01 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

authors： Bridges J,Griffiths P,Oliver E,Pickering RM

更新日期：2019-09-01 00:00:00

abstract：BACKGROUND:Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the inci...

journal_title：BMJ quality & safety

authors： Gunderson CG,Bilan VP,Holleck JL,Nickerson P,Cherry BM,Chui P,Bastian LA,Grimshaw AA,Rodwin BA

更新日期：2020-12-01 00:00:00

abstract：:This paper aims to draw attention to the social and micropolitical dimensions of attempting to implement improvements within healthcare organisations. It is argued that quality improvement initiatives, like other forms of organisational innovation, will fail unless they are conceived and implemented in such a way as t...

journal_title：BMJ quality & safety

authors： Langley A,Denis JL

更新日期：2011-04-01 00:00:00

abstract：INTRODUCTION:Intravenous medication errors persist despite the use of smart pumps. This suggests the need for a standardised methodology for measuring errors and highlights the importance of identifying issues around smart pump medication administration in order to improve patient safety. OBJECTIVES:We conducted a mul...

journal_title：BMJ quality & safety

authors： Schnock KO,Dykes PC,Albert J,Ariosto D,Call R,Cameron C,Carroll DL,Drucker AG,Fang L,Garcia-Palm CA,Husch MM,Maddox RR,McDonald N,McGuire J,Rafie S,Robertson E,Saine D,Sawyer MD,Smith LP,Stinger KD,Vanderveen TW,

更新日期：2017-02-01 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

authors： Pham HH,Bernabeo EC,Chesluk BJ,Holmboe ES

更新日期：2011-08-01 00:00:00

abstract：OBJECTIVE:Neonates are at high risk for significant morbidity and mortality from medication prescribing errors. Despite general awareness of these risks, mistakes continue to happen. Alerts in computerised physician order entry intended to help prescribers avoid errors have not been effective enough. This improvement p...

journal_title：BMJ quality & safety

authors： Sullivan KM,Suh S,Monk H,Chuo J

更新日期：2013-03-01 00:00:00

abstract：BACKGROUND:A safe delivery is part of a good start in life, and a continuous focus on preventing harm during delivery is crucial, even in settings with a good safety record. In January 2013, the labour unit at Copenhagen University Hospital, Hvidovre, undertook a quality improvement (QI) project to prevent asphyxia and...

journal_title：BMJ quality & safety

authors： Hollesen RVB,Johansen RLR,Rørbye C,Munk L,Barker P,Kjaerbye-Thygesen A

更新日期：2018-08-01 00:00:00

abstract：OBJECTIVES:In order to improve its quality-assurance programme based on ISO 9001, the Central Sterile Supply Department of a public university hospital has performed a prospective risk analysis using the Preliminary Risk Analysis method (PRA). The objectives were the achievement of a global risk mapping related to the ...

journal_title：BMJ quality & safety

authors： Niel-Lainé J,Martelli N,Bonan B,Talon D,Desroches A,Prognon P,Vincent F

更新日期：2011-08-01 00:00:00

abstract：BACKGROUND:Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identi...

journal_title：BMJ quality & safety

authors： Gathara D,Serem G,Murphy GAV,Obengo A,Tallam E,Jackson D,Brownie S,English M

更新日期：2020-01-01 00:00:00

abstract：BACKGROUND:Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these. METHODS:We used a mixed methods, controlled bef...

journal_title：BMJ quality & safety

authors： Ramsay AI,Turner S,Cavell G,Oborne CA,Thomas RE,Cookson G,Fulop NJ

更新日期：2014-02-01 00:00:00

abstract：OBJECTIVE:Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to...

journal_title：BMJ quality & safety

authors： Padula WV,Pronovost PJ,Makic MBF,Wald HL,Moran D,Mishra MK,Meltzer DO

更新日期：2019-02-01 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

authors： Patterson MD,Geis GL,Falcone RA,LeMaster T,Wears RL

更新日期：2013-06-01 00:00:00

abstract：BACKGROUND:Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic err...

journal_title：BMJ quality & safety

authors： Singh H,Graber ML,Kissam SM,Sorensen AV,Lenfestey NF,Tant EM,Henriksen K,LaBresh KA

更新日期：2012-02-01 00:00:00

abstract：OBJECTIVE:To describe the development of evidence-based electronic prescribing (e-prescribing) triggers and treatment algorithms for potentially inappropriate medications (PIMs) for older adults. DESIGN:Literature review, expert panel and focus group. SETTING:Primary care with access to e-prescribing systems. PARTIC...

journal_title：BMJ quality & safety

authors： Hume AL,Quilliam BJ,Goldman R,Eaton C,Lapane KL

更新日期：2011-10-01 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

authors： Chung JW,Ju MH,Kinnier CV,Haut ER,Baker DW,Bilimoria KY

更新日期：2014-11-01 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

authors： Meddings J,Rogers MA,Krein SL,Fakih MG,Olmsted RN,Saint S

更新日期：2014-04-01 00:00:00

abstract：BACKGROUND:Plan-do-study-act (PDSA) cycles provide a structure for iterative testing of changes to improve quality of systems. The method is widely accepted in healthcare improvement; however there is little overarching evaluation of how the method is applied. This paper proposes a theoretical framework for assessing t...

journal_title：BMJ quality & safety

authors： Taylor MJ,McNicholas C,Nicolay C,Darzi A,Bell D,Reed JE

更新日期：2014-04-01 00:00:00

abstract：BACKGROUND:Few studies have investigated whether clinicians can use checklists to verify their diagnostic decisions. Checklists may improve accuracy by prompting clinicians to reconsider or recollect information but might impair decision making by adding to clinicians' cognitive load. This study assessed whether checkl...

journal_title：BMJ quality & safety

authors： Sibbald M,de Bruin AB,Cavalcanti RB,van Merrienboer JJ

更新日期：2013-04-01 00:00:00

abstract：OBJECTIVES:To determine whether sharing of routinely collected health service performance data could have predicted a critical safety failure at an Australian maternity service. DESIGN:Observational quantitative descriptive study. SETTING:A public hospital maternity service in Victoria, Australia. DATA SOURCES:A pub...

journal_title：BMJ quality & safety

authors： Nowotny BM,Davies-Tuck M,Scott B,Stewart M,Cox E,Cusack K,Fletcher M,Saar E,Farrell T,Anil S,McKinlay L,Wallace EM

更新日期：2020-01-08 00:00:00

abstract：BACKGROUND:Non-drug technologies offer many benefits, but have been associated with adverse events, prompting calls for improved postmarket surveillance. There is little empirical research to guide the development of such a system. The purpose of this study was to identify optimal postmarket surveillance strategies for...

journal_title：BMJ quality & safety

authors： Gagliardi AR,Umoquit M,Lehoux P,Ross S,Ducey A,Urbach DR

更新日期：2013-03-01 00:00:00

abstract：OBJECTIVE:Paediatric cardiac surgery has a low error tolerance and demands high levels of cognitive and technical performance. Growing evidence suggests that further improvements in patient outcomes depend on system factors, in particular, effective team skills. The hypotheses that small intraoperative non-routine even...

journal_title：BMJ quality & safety

authors： Schraagen JM,Schouten T,Smit M,Haas F,van der Beek D,van de Ven J,Barach P

更新日期：2011-07-01 00:00:00

abstract：OBJECTIVE:To explore whether differences between collaboratives with respect to type of topic, type of targets, measures (systems) are also reflected in the degree of effectiveness. STUDY SETTING:182 teams from long-term healthcare organisation developed improvement initiatives in seven quality-improvement collaborati...

journal_title：BMJ quality & safety

authors： Strating MM,Nieboer AP,Zuiderent-Jerak T,Bal RA

更新日期：2011-04-01 00:00:00

abstract：BACKGROUND:The American College of Surgeons' Trauma Quality Improvement Program (TQIP) provides trauma centres with performance reports on their processes and outcomes of care relative to their peers. This study explored how performance reports are used by trauma centre leaders to engage in performance improvement and ...

journal_title：BMJ quality & safety

authors： Gotlib Conn L,Hoeft C,Neal M,Nathens A

更新日期：2019-09-01 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

authors： Manges KA,Ayele R,Leonard C,Lee M,Galenbeck E,Burke RE

更新日期：2020-09-21 00:00:00

abstract：OBJECTIVES:Systemic issues can adversely affect the diagnostic process. Many system-related barriers can be masked by 'resilient' actions of frontline providers (ie, actions supporting the safe delivery of care in the presence of pressures that the system cannot readily adapt to). We explored system barriers and resili...

journal_title：BMJ quality & safety

authors： Smith MW,Davis Giardina T,Murphy DR,Laxmisan A,Singh H

更新日期：2013-12-01 00:00:00

abstract：OBJECTIVE:This article is an exploration of views and experiences of Patient Safety Walkrounds, a widely recommended strategy for identifying patient safety problems and improving safety culture. DESIGN AND SETTING:Qualitative analysis of semistructured, in-depth interviews with 11 senior leaders and 33 front-line sta...

journal_title：BMJ quality & safety

authors： Rotteau L,Shojania KG,Webster F

更新日期：2014-10-01 00:00:00