quality & safety in health care · quality & safety in health care qshc.bmj.com contents...
TRANSCRIPT
October 2010 Volume 19 Issue 5
19
5
Volum
e 19 Issue 5 Pages 367--468 Q
uality & Safety in H
ealth Care
October 2010
Quality & Safety in Health Care
qshc.bmj.com
Contents Editorial 367 The leader’s work in the improvement of
healthcare P Batalden
Commentary 369 Admitting medication errors: five critical
concepts E Etchells
Original research 371 Pharmacist- versus physician-acquired
medication history: a prospective study at the emergency department S De Winter , I Spriet , C Indevuyst , P Vanbrabant , D Desruelles , M Sabbe , J B Gillet , A Wilmer , L Willems
376 Lean thinking in healthcare: a realist review of the literature P Mazzocato , C Savage , M Brommels , H Aronsson , J Thor
383 Are evaluated respiratory service developments implemented into clinical practice? N J Roberts , M Glasser , M R Partridge
387 Performance on rheumatoid arthritis quality indicators in an Alaska Native healthcare system E D Ferucci , K J Donnithorne , K R Koller , A Swango-Wilson , J Pflaum , A P Lanier
392 Rationalising the treatment of anaemia in cardiac surgery: short and mid-term results from a local quality improvement initiative D S Likosky , S D Surgenor , L J Dacey , G R DeFoe , E L Maislen , J A Clark , J P Aubuchon , J H Higgins , P A Beaulieu , G T O’Connor , C S Ross
399 Transforming administrative data into real-time information in the Department of Surgery P A Beaulieu , J H Higgins , L J Dacey , W C Nugent , G R DeFoe , D S Likosky
405 Departures from the protocol during conduct of a clinical trial: a pattern from the data record consistent with a learning curve J M Taekman , M Stafford-Smith , E J Velazquez , M C Wright , B G Phillips-Bute , M A Pfeffer , M A Sellers , K S Pieper , M F Newman , F Van de Werf , R Diaz , J Leimberger , R M Califf
411 Cardiometabolic treatment decisions in patients with type 2 diabetes: the role of repeated measurements and medication burden J Voorham , F M Haaijer-Ruskamp , B H R Wolffenbuttel , R P Stolk , P Denig , Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) Group
416 Finding the best examples of healthcare quality improvement in Sub-Saharan Africa C Liu , J Babigumira , A Chiunda , A Katamba , I Litvak , L Miller , I Namagembe , J Sekandi , A Seicean , S Seicean , D Neuhauser
420 Reasons for discharges against medical advice: a qualitative study E Onukwugha , E Saunders , C D Mullins , F G Pradel , M Zuckerman , M R Weir
425 Development of trigger tools for surveillance of adverse events in ambulatory surgery H M A Kaafarani , A K Rosen , J R Nebeker , S Shimada , H J Mull , P E Rivard , L Savitz , A Helwig , M H Shin , K M F Itani
Education and training 430 The impact of traditional and smart pump
infusion technology on nurse medication administration performance in a simulated inpatient unit P L Trbovich , S Pinkney , J A Cafazzo , A C Easty
Error management 435 Identifying causes of adverse events detected
by an automated trigger tool through in-depth analysis S E Muething , P H Conway , E Kloppenborg , A Lesko , P J Schoettker , M Seid , U Kotagal
440 The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems J C Pham , E Colantuoni , F Dominici , A Shore , C Macrae , S Scobie , M Fletcher , K Cleary , C A Goeschel , P J Pronovost
446 Establishing a global learning community for incident-reporting systems J C Pham , S Gianci , J Battles , P Beard , J R Clarke , H Coates , L Donaldson , N Eldridge , M Fletcher , C A Goeschel , E Heitmiller , J Hensen , E Kelley , J Loeb , W Runciman , S Sheridan , A W Wu , P J Pronovost
452 Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL A A Tanon , F Champagne , A-P Contandriopoulos , M-P Pomey , A Vadeboncoeur , H Nguyen
462 Patient safety begins with proper planning: a quantitative method to improve hospital design D J Birnbach , I Nevo , S R Scheinman , M Fitzpatrick , I Shekhter , J L Lombard
Heroes and martyrs 466 Henry K Beecher: pain, belief and truth at the
bedside. The powerful placebo, ethical research and anaesthesia safety M Best , D Neuhauser
October 2010 Volume 19 Issue 5
EDITOR’S CHOICE:Transforming administrative data into real-time information in the Department of Surgery
This article has been chosen by the Editor to
be of special interest or importance and is
freely available online.
Articles carrying the Unlocked Logo are freely
available online under the BMJ Journals
unlocked scheme.
See http://qshc.bmj.com/info/unlocked.dtl
This journal is a member of and subscribes to
the principles of the Committee on Publication
Ethics
www.publicationethics.org.uk
Contents continued
See overleaf for more articles
available online only. To view these
papers visit the journal website
at qshc.bmj.com
on May 21, 2020 by guest. P
rotected by copyright.http://qualitysafety.bm
j.com/
Qual S
af Health C
are: first published as on 1 October 2010. D
ownloaded from
Quality & Safety in Health Care
qshc.bmj.com
Contents Original research - Electronic pages e1 Evaluation of a clinical communication programme for perioperative
and surgical care practitioners D Nestel , R Kneebone , A Barnet , T Tierney , A Darzi
e2 Psychometric properties of the Hospital Survey on Patient Safety Culture: findings from the UK P Waterson , P Griffiths , C Stride , J Murphy , S Hignett
e3 Pressure ulcers and incontinence-associated dermatitis: effectiveness of the Pressure Ulcer Classification education tool on classification by nurses D Beeckman , L Schoonhoven , J Fletcher , K Furtado , H Heyman , L Paquay , D De Bacquer , T Defloor
e4 Factors influencing paediatric nurses’ responses to medication administration L Davis , R S Ware , D McCann , S Keogh , K Watson
e5 Exploring the causes of adverse events in hospitals and potential prevention strategies M Smits , M Zegers , P P Groenewegen , D R M Timmermans , L Zwaan , G van der Wal , C Wagner
e6 Economic evaluation of healthcare safety: which attributes of safety do healthcare professionals consider most important in resource allocation decisions? L Steuten , M Buxton
e7 Incidence of medication errors and adverse drug events in the ICU: a systematic review A Wilmer , K Louie , P Dodek , H Wong , N Ayas
e8 Skilful anticipation: maternity nurses’ perspectives on maintaining safety A Lyndon
e9 Am I (un)safe here? Chemotherapy patients’ perspectives towards engaging in their safety D L B Schwappach , M Wernli
e10 Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review J Hall , M Peat , Y Birks , S Golder , on behalf of the PIPS Group , V Entwistle , S Gilbody , P Mansell , D McCaughan , T Sheldon , I Watt , B Williams , J Wright
e11 Automated detection of harm in healthcare with information technology: a systematic review M Govindan , A D Van Citters , E C Nelson , J Kelly-Cummings , G Suresh
e12 Readiness for organisational change among general practice staff B Christl , M F Harris , U W Jayasinghe , J Proudfoot , J Taggart , J Tan, on behalf of the Teamwork study group
e13 How RNs rescue patients: a qualitative study of RNs’ perceived involvement in rapid response teams L S Leach , A Mayo , M O’Rourke
e14 The evolution of the pathway and its role in improving patient care G Mould , J Bowers , M Ghattas
e15 Patient-specific electronic decision support reduces prescription of excessive doses H M Seidling , S P W Schmitt , T Bruckner , J Kaltschmidt , M G Pruszydlo , C Senger , T Bertsche , I Walter-Sack , W E Haefeli
e16 Electronic health records and adverse drug events after patient transfer K S Boockvar , E E Livote , N Goldstein , J R Nebeker , A Siu , T Fried
e17 Assessment of patient safety culture in Saudi Arabian hospitals H A Alahmadi
e18 Quality systems to improve care in older patients with urinary incontinence receiving home care: do they work? M F M T Du Moulin , M N Chenault , F E S Tan , J P H Hamers , R H G Halfens
e19 Clinical simulation in maternity (CSiM): interprofessional learning through simulation team training L Gum , J Greenhill , K Dix
e20 Multilayered approach to patient safety culture T Reiman , E Pietikäinen , P Oedewald
e21 Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network A M Wessell , C Litvin , R G Jenkins , P J Nietert , L S Nemeth , S M Ornstein
e22 Patient and public involvement in clinical guidelines: international experiences and future perspectives A Boivin , K Currie , B Fervers , J Gracia , M James , C Marshall , C Sakala , S Sanger , J Strid , V Thomas , T van der Weijden , R Grol , J Burgers , on behalf of G-I-N PUBLIC
e23 Using quality-improvement methods to reduce variation in surfactant administration L Bookman , R Troy , M McCaffrey , G Randolph
e24 A core questionnaire for the assessment of patient satisfaction in academic hospitals in The Netherlands: development and first results in a nationwide study S M Kleefstra , R B Kool , C M A Veldkamp , A C M Winters-van der Meer , M A P Mens , G H Blijham , J C J M de Haes
e25 Validation of Hospital Administrative Dataset for adverse event screening S Verelst , J Jacques , K Van den Heede , P Gillet , P Kolh , A Vleugels , W Sermeus
e26 Prospective pilot intervention study to prevent medication errors in drugs administered to children by mouth or gastric tube: a programme for nurses, physicians and parents T Bertsche, A Bertsche, E-M Krieg, N Kunz, K Bergmann, G Hanke, T Hoppe-Tichy, F Ebinger, WE Haefeli
e27 Reducing referral delays in colorectal cancer diagnosis: is it about how you ask? H Singh , L A Petersen , K Daci , C Collins , M Khan , H B El-Serag
October 2010 Volume 19 Issue 5
Contents continued
on May 21, 2020 by guest. P
rotected by copyright.http://qualitysafety.bm
j.com/
Qual S
af Health C
are: first published as on 1 October 2010. D
ownloaded from
Quality & Safety in Health Care
qshc.bmj.com
Contents e28 Study of patient complaints reported over 30 months at a large
heart centre in Tehran J Manouchehri Moghadam , H Ibrahimipour , A Sari Akbari , M Farahbakhsh , Z Khoshgoftar
e29 Errors associated with the preparation of aseptic products in UK hospital pharmacies: lessons from the national aseptic error reporting scheme R Bateman , P Donyai
e30 Prospective assessment of hospital-acquired bloosdstream infections: how many may be preventable? C Bonnal , B Mourvillier , R Bronchard , D de Paula , L Armand-Lefevre , F L’heriteau , J-L Quenon , J-C Lucet
e31 Consistency of performance indicators for cardiovascular risk management across procedures and panels J van Lieshout , E Nouwens , M Bouma , C Spreeuwenberg , M Wensing
e32 Safety through redundancy: a case study of in-hospital patient transfers M-S Ong , E Coiera
e33 Patient report on information given, consultation time and safety in primary care J J Mira , C Nebot , S Lorenzo , V Pérez-Jover
e34 Patients providing the answers: narrowing the gap in data quality for emergency care S C Porter , P Forbes , S Manzi , L A Kalish
e35 Improving follow-up in hospitalised children G L McPhail , M D Ednick , M C Fenchel , R VanDyke , A Chima , R S Amin , M Seid
e36 Organisational efforts to improve quality while reducing healthcare disparities: the case of breast cancer screening among Arab women in Israel R Wilf-Miron , N Galai , A Gabali , I Lewinhoff , O S Tov , O Lernau , J Shemer
e37 Documenting organisational development in general practice using a group-based assessment method: the Maturity Matrix T Eriksson , V D Siersma , L Løgstrup , M S Buch , G Elwyn , A Edwards
e38 Usefulness of a national parent experience survey in quality improvement: views of paediatric department employees H H Iversen , Ø A Bjertnæs , G Groven , G Bukholm
e39 Metrics for monitoring local inequalities in access to maternity care: developing a basket of markers from routinely available data S F Murray , A M Buller , S Bewley , J Sandall
e40 Tailoring adverse drug event surveillance to the paediatric inpatient A L Long , M M Horvath , H Cozart , J Eckstrand , J Whitehurst , J Ferranti
e41 Patient-held medical records for patients with chronic disease: a systematic review H Ko , T Turner , C Jones , C Hill
e42 Multidose drug dispensing and discrepancies between medication records L J Wekre , O Spigset , O Sletvold , J K Sund , A Grimsmo
e43 Lean implementation in primary care health visiting services in National Health Service UK A L Grove , J O Meredith , M Macintyre , J Angelis , K Neailey
e44 Medical engagement in organisation-wide safety and quality-improvement programmes: experience in the UK Safer Patients Initiative A Parand , S Burnett , J Benn , S Iskander , A Pinto , C Vincent
Quality improvement reports - Electronic pages e45 A structured women’s preventive health clinic for residents:
a quality improvement project designed to meet training needs and improve cervical cancer screening rates M K Singh , D Einstadter , R Lawrence
e46 Introduction of a comprehensive management protocol for severe sepsis is associated with sustained improvements in timeliness of care and survival R MacRedmond , K Hollohan , R Stenstrom , R Nebre , D Jaswal , P Dodek
e47 A multi-faceted approach to the physiologically unstable patient G Robb , M Seddon
e48 Introduction of the chronic care model into an academic rheumatology clinic S Ranatunga , S Myers , S Redding , S L Scaife , M D Francis , M L Francis
e49 The value of ‘gentle reminder’ on safe medical behaviour I Erev , D Rodensky , M-A Levi , M Englard-Hershler , H Admi , Y Donchin
e50 Lessons learnt from attempting to assess the evidence base for a complex intervention introduced into New Zealand general practice M Horsburgh , F Goodyear-Smith , J Bycroft , F Mahony , D Roy , D Miller , E Donnell
e51 Email triage is an effective, efficient and safe way of managing new referrals to a neurologist V Patterson , J Humphreys , M Henderson , G Crealey
e52 The impact of a set of interventions to reduce interruptions and distractions to nurses during medication administration E Relihan , V O’Brien , S O’Hara , B Silke
e53 Adverse event categorisation across NHS Scotland A Ross , M Plunkett , K Walsh
e54 Electronic consultation as an alternative to hospital referral for patients with chronic kidney disease: a novel application for networked electronic health records to improve the accessibility and efficiency of healthcare J Stoves , J Connolly , C K Cheung , A Grange , P Rhodes , D O’Donoghue , J Wright
October 2010 Volume 19 Issue 5
on May 21, 2020 by guest. P
rotected by copyright.http://qualitysafety.bm
j.com/
Qual S
af Health C
are: first published as on 1 October 2010. D
ownloaded from