October 2010 Volume 19 Issue 5

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e 19 Issue 5 Pages 367--468 Q

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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

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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

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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

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