December 2010 Volume 19 Issue 6

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Quality & Safety in Health Care

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Contents Editorial 469 Navigating a revision D P Stevens

Commentaries 471 Creating a more efficient healthcare knowledge

market: using communities of practice to create checklists A Lashoher , P Pronovost

473 The state of science surrounding the clinical microsystem: a hedgehog or a fox? J K Johnson

Original research 475 Measuring quality in the therapeutic relationship—

Part 1: objective approaches T Greenhalgh , I Heath

479 Measuring quality in the therapeutic relationship—Part 2: subjective approaches T Greenhalgh , I Heath

484 The quality of cancer patient experience: perspectives of patients, family members, providers and experts E H Wagner , E J Aiello Bowles , S M Greene , L Tuzzio , C J Wiese , B Kirlin , S B Clauser

490 Improvement leaders: what do they and should they do? A summary of a review of research J Ovretveit

493 The published literature on handoffs in hospitals: deficiencies identified in an extensive review M D Cohen , P B Hilligoss

498 Development and evaluation of an implementation strategy for the German guideline on community-acquired pneumonia M Schnoor , T Meyer , N Suttorp , H Raspe , T Welte , T Schäfer , the CAPNETZ Study Group

503 Association between guideline adherence and clinical outcome for patients referred for diagnostic breast imaging L D B Vercauteren , A G H Kessels , T van der Weijden , J L Severens , J M A van Engelshoven , K Flobbe

509 How “should” we write guideline recommendations? Interpretation of deontic terminology in clinical practice guidelines: survey of the health services community E A Lomotan , G Michel , Z Lin , R N Shiffman

514 Evidence in action—guidelines directing workload R Sipilä , E Ketola , T Tala , M Klockars

519 Quality measures for primary mental healthcare: a multistakeholder, multijurisdictional Canadian consensus P Waraich , R S Saklikar , D Aubé , W Jones , D Haslam , K Hamill

526 Preventing ethics conflicts and improving healthcare quality through system redesign W A Nelson , P B Gardent , E Shulman , M E Splaine

Quality improvement report 531 Medication reconciliation in the emergency

department: opportunities for workflow redesign J Hummel , P C Evans , H Lee

536 Improving management of oesophageal varices in patients with cirrhosis R Wundke , R Altus , J Sandford , A Wigg

Education and training 542 The WHO patient safety curriculum guide for

medical schools M Walton , H Woodward , S Van Staalduinen , C Lemer , F Greaves , D Noble , B Ellis , L Donaldson , B Barraclough , for and on behalf of the Expert Group convened by the World Alliance of Patient Safety, as Expert Lead for the Sub-Programme

Error management 547 Assessing and improving safety culture

throughout an academic medical centre: a prospective cohort study L A Paine , B J Rosenstein , J B Sexton , P Kent , C G Holzmueller , P J Pronovost

555 The Rhode Island ICU collaborative: a model for reducing central line-associated bloodstream infection and ventilator-associated pneumonia statewide V A DePalo , L McNicoll , M Cornell , J M Rocha , L Adams , P J Pronovost

562 Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model R E White , P L Trbovich , A C Easty , P Savage , K Trip , S Hyland

568 Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit R Silas , J Tibballs

572 The Turkish version of the safety attitudes questionnaire: psychometric properties and baseline data S Kaya , S Barsbay , E Karabulut

578 The development and psychometric evaluation of a safety climate measure for primary care C de Wet , W Spence , R Mash , P Johnson , P Bowie

585 Patient safety culture: factors that influence clinician involvement in patient safety behaviours J G Wakefield , M-L McLaws , M Whitby , L Patton

592 Organisational culture: variation across hospitals and connection to patient safety climate T Speroff , S Nwosu , R Greevy , M B Weinger , T R Talbot , R J Wall , J K Deshpande , D J France , E W Ely , H Burgess , J Englebright , M V Williams , R S Dittus

December 2010 Volume 19 Issue 6

EDITOR’S CHOICE:Measuring quality in the doctor-patient relationship

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

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www.publicationethics.org.uk

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Contents Original research e1 ‘Quod scripsi, scripsi.’ The quality of the report of telephone consultations

at Dutch out-of-hours centres H Derkx , J-J Rethans , A Muijtjens , B Maiburg , R Winkens , H van Rooij , A Knottnerus

e2 Assessing quality of care from hospital case notes: comparison of reliability

of two methods A Hutchinson , J E Coster , K L Cooper , A McIntosh , S J Walters , P A Bath , M Pearson , K Rantell , M J Campbell , J Nicholl , P Irwin

e3 Experience: the most critical factor in choosing after-hours medical care

H Philips , D Mahr , R Remmen , M Weverbergh , D De Graeve , P Van Royen

e4 Are patients and healthcare providers satisfied with health sector reform

implemented in family health centres? M A Gadallah , M F Allam , A M A Ahmed , E M El-Shabrawy

e5 Quantifying variation of paediatric length of stay among intensive care units

in Australia and New Zealand L Straney , A Clements , J Alexander , A Slater , for the ANZICS Paediatric Study Group

e6 Relationship between patients’ and clinicians’ assessments of health status

before and after knee arthroplasty E Bream , S C Charman , B Clift , D Murray , N Black

e7 Healthcare workers’ self-reported effect of an interventional programme on

knowledge and behaviour related to infection control C Tvedt , G Bukholm

e8 Perceptions among Swedish hospital physicians on prescribing of antibiotics

and antibiotic resistance I Björkman , J Berg , M Röing , M Erntell , C S Lundborg

e9 The Patients Preferences Questionnaire for Angina treatment: results and

psychometrics from 383 patients in primary care in England A Bowling , B Reeves , G Rowe

e10 A comparative analysis of incident reporting lag times in academic medical

centres in Japan and the USA S E Regenbogen , M Hirose , Y Imanaka , E-H Oh , H Fukuda , A A Gawande , T Takemura , H Yoshihara

e11 Responding to patient safety incidents: the “seven pillars” T B McDonald , L A Helmchen , K M Smith , N Centomani , A Gunderson , D Mayer , W H Chamberlin

e12 Acute care practices relevant to quality end-of-life care: a survey of

Pennsylvania hospitals C Y Lin , R M Arnold , J R Lave , D C Angus , A E Barnato

e13 Efficacy and efficiency of a lean cataract pathway: a comparative study

E J van Vliet , W Sermeus , C M van Gaalen , J C A Sol , J M H Vissers

e14 Barriers to reporting medication errors: a measurement equivalence

perspective J M Etchegaray , T Throckmorton

e15 Overcoming barriers to guideline implementation: the case of cardiac

rehabilitation R S Fernandez , P Davidson , R Griffiths , Y Salamonson

e16 The importance of experienced adverse outcomes on patients’ future choice

of a hospital for surgery P J Marang-van de Mheen , J Dijs-Elsinga , W Otten , M Versluijs , H J Smeets , W J van der Made , R Vree , J Kievit

e17 Crude versus case-mix-adjusted control charts for safety monitoring in thyroid

surgery A Duclos , N Voirin , S Touzet , P Soardo , A-M Schott , C Colin , J-L Peix , J-C Lifante

e18 Evaluating the effectiveness of an educational and feedback intervention

aimed at improving consideration of sex differences in guideline development

D G Keuken , J A Haafkens , J Mohrs , N S Klazinga , P J E Bindels

e19 Taking a closer look: using statistical process control to identify patterns of

improvement in a quality-improvement collaborative T Timmerman , T Verrall , L Clatney , H Klomp , G Teare

e20 Surgical adverse outcome reporting as part of routine clinical care J Kievit , M Krukerink , P J Marang-van de Mheen

e21 Application of root cause analysis on malpractice claim files related to

diagnostic failures I van Noord , M P Eikens , A M Hamersma , M C de Bruijne

e22 Reducing dispensing errors in Swedish pharmacies: the impact of a barrier in

the computer system A Nordén-Hägg , K Andersson , S Kälvemark-Sporrong , L Ring , Å Kettis-Lindblad

e23 Application of the ICF to referral delay in total joint arthroplasty D Dixon , B Pollard , D Rowley , M Johnson

e24 Impact of sample size on variation of adverse events and preventable adverse

events: systematic review on epidemiology and contributing factors C Lessing , A Schmitz , B Albers , M Schrappe

e25 Teamwork training with nursing and medical students: does the method matter?

Results of an interinstitutional, interdisciplinary collaboration C Hobgood , G Sherwood , K Frush , D Hollar , L Maynard , B Foster , S Sawning , D Woodyard , C Durham , M Wright , J Taekman, on behalf of the Interprofessional Patient Safety Education Collaborative

e26 Comparison of methods for identifying patients at risk of medication-related

harm J E van Doormaal , M K Rommers , J G W Kosterink , I M Teepe-Twiss , F M Haaijer-Ruskamp , P G M Mol

e27 Outcomes of classroom-based team training interventions for

multiprofessional hospital staff. A systematic review L I Rabøl , D Østergaard , T Mogensen

e28 The nature and usefulness of patient experience information in producing

guidance about interventional procedures B Campbell , E Chambers , M Kelson , S Bennett , G Lyratzopoulos

e29 Assessing and improving teamwork in cardiac surgery J M Schraagen , T Schouten , M Smit , F Haas , D van der Beek , J van de Ven , P Barach

e30 Medication errors in paediatric outpatients R Kaushal , D A Goldmann , C A Keohane , E L Abramson , S Woolf , C Yoon , K Zigmont , D W Bates

e31 Optimal search filters for detecting quality improvement studies in Medline

N L Wilczynski , R B Haynes , for the QI Hedges Team

e32 Real-time operational feedback: daily discharge rate as a novel hospital

efficiency metric H J Wong , R C Wu , M Caesar , H Abrams , D Morra

e33 Speaking up about safety concerns: multi-setting qualitative study of

patients’ views and experiences V A Entwistle , D McCaughan , I S Watt , Y Birks , J Hall , M Peat , B Williams , J Wright, for the PIPS (Patient Involvement in Patient Safety) group

e34 How different are complications that affect the older adult inpatient? D Rowell , H S Nghiem , C Jorm , T J Jackson

e35 Development of a computerised alert system, ADEAS, to identify patients

at risk for an adverse drug event M K Rommers , M H Zegers , P A De Clercq , M L Bouvy , P H E M de Meijer , I M Teepe-Twiss , H-J Guchelaar

e36 The impact of shift patterns on junior doctors’ perceptions of fatigue, training,

work/life balance and the role of social support M Brown , P Tucker , F Rapport , H Hutchings , A Dahlgren , G Davies , P Ebden

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Contents e37 Understanding non-adherence in chronic heart failure: a mixed-method case

study M Oertle , R Bal

e38 A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit S Galhotra , M A DeVita , M A Dew , R L Simmons

e39 The impact of a tele-ICU on provider attitudes about teamwork and safety climate M Y L Chu-Weininger , L Wueste , J F Lucke , L Weavind , J Mazabob , E J Thomas

e40 A patient-centred instrument for assessment of quality of breast cancer care: results of a pilot questionnaire M de Kok , H J M Sixma , T van der Weijden , A G H Kessels , C D Dirksen , K F J Spijkers , C J H van de Velde , J A Roukema , F W C van der Ent , C Finaly-Marais , M F von Meyenfeldt

e41 STORC safety initiative: a multicentre survey on preparedness & confidence in obstetric emergencies J-M Guise , S Y Segel , K Larison , S M Jump , M Constable , H Li , P Osterweil , D Zimmer

e42 Intensive nursing work schedules and the risk of hypoglycaemia in critically ill patients who are receiving intravenous insulin K Louie , R Cheema , P Dodek , H Wong , A Wilmer , M Grubisic , J M FitzGerald , N T Ayas

e43 Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being R Sirriyeh , R Lawton , P Gardner , G Armitage

e44 Assessing the quality of patient handoffs at care transitions T Manser , S Foster , S Gisin , D Jaeckel , W Ummenhofer

e45 The relationship between external and local governance systems: the case of Health Care Associated Infections and medication errors in one NHS trust A Ramsay , C Magnusson , N Fulop

e46 Leadership in anaesthesia teams: the most effective leadership is shared B Künzle , E Zala-Mezö , J Wacker , M Kolbe , D R Spahn , G Grote

e47 Practice-based collection of quality indicator data for a comprehensive quality assessment programme in Canadian family practices D Price , M Howard , L Dolovich , S Laryea , L Hilts , A Barbara

e48 Facilitating organisational development using a group-based formative assessment and benchmarking method: design and implementation of the International Family Practice Maturity Matrix G Elwyn , M-J Bekkers , L Tapp , A Edwards , R Newcombe , T Eriksson , J Braspenning , C Kuch , Z O Adzic , O Ayankogbe , T Cvetko , K in ‘t Veld , A Karotsis , J Kersnik , L Lefebvre , I Mecini , G Petricek , L Pisco , J Thesen , J M Turón , E van Rossen , R Grol

e49 Assessing teamwork attitudes in healthcare: development of the TeamSTEPPS teamwork attitudes questionnaire D P Baker , A M Amodeo , K J Krokos , A Slonim , H Herrera

e50 Quality assessment of clinical practice guidelines in perioperative care: a systematic appraisal L Barajas-Nava , I Solà , M Delgado-Noguera , I Gich , C O Villagran , X Bonfill , P Alonso-Coello

e51 A 10-year cohort study of the burden and risk of in-hospital falls and fractures using routinely collected hospital data C A Brand , V Sundararajan

e52 Improving prenatal HIV screening with tailored educational interventions: an approach to guideline implementation B A Prairie , T Foster

e53 Use of an electronic information system to identify adverse events resulting in an emergency department visit S Ackroyd-Stolarz , N J MacKinnon , P J Zed , N Murphy

e54 Shared care arrangements for specialist drugs in the UK: the challenges facing GP adherence S Crowe , J A Cantrill , M P Tully

e55 Automated categorisation of clinical incident reports using statistical text classification M-S Ong , F Magrabi , E Coiera

e56 Tracing the foundations of a conceptual framework for a patient safety ontology W B Runciman , G R Baker , P Michel , S Dovey , R J Lilford , N Jensen , R Flin , W B Weeks , P Lewalle , I Larizgoitia , D Bates, on behalf of the Methods & Measures Working Group of the World Health Organization World Alliance for Patient Safety

e57 Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members S M Evans , A Murray , I Patrick , M Fitzgerald , S Smith , P Cameron

e58 The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies P Alonso-Coello , A Irfan , I Solà , I Gich , M Delgado-Noguera , D Rigau , S Tort , X Bonfill , J Burgers , H Schunemann

e59 Partners in our care: patient safety from a patient perspective R B Hovey , A Morck , S Nettleton , S Robin , D Bullis , A Findlay , H Massfeller

e60 Conceptualising barriers to incident reporting: a psychological framework Y Pfeiffer , T Manser , T Wehner

Quality improvement report e61 Pneumococcal vaccination process improvement in an acute care setting

A M Yancey , A B Jundt , K J Nelson

e62 Quality improvement of doctors’ shift-change handover in neuro-critical care M N Lyons , T D A Standley , A K Gupta

e63 System-wide learning from root cause analysis: a report from the New South Wales Root Cause Analysis Review Committee J Taitz , K Genn , V Brooks , D Ross , K Ryan , B Shumack , T Burrell , P Kennedy, on behalf of the NSW RCA Review

e64 Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process I Wubben , J G van Manen , B J v den Akker , S R Vaartjes , W H van Harten

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