Objective To identify features of clinical decision support systems critical for improving clinical practice. Design Systematic review of randomised controlled trials. Data sources Literature searches via Medline, CINAHL, and the Cochrane Controlled Trials Register up to 2003; and searches of reference lists of included studies and relevant reviews. Study selection Studies had to evaluate the ability of decision support systems to improve clinical practice. Data extraction Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature. Results Seventy studies were included. Decision support systems significantly improved clinical practice in 68% of trials. Univariate analyses revealed that, for five of the system features, interventions possessing the feature were significantly more likely to improve clinical practice than interventions lacking the feature. Multiple logistic regression analysis identified four features as independent predictors of improved clinical practice: automatic provision of decision support as part of clinician workflow (P Conclusions Several features were closely correlated with decision support systems9 ability to improve patient care significantly. Clinicians and other stakeholders should implement clinical decision support systems that incorporate these features whenever feasible and appropriate.

https://www.bmj.com/content/bmj/330/7494/765.full.pdf

Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success

Background: Research into adverse events (AEs) has highlighted the need to improve patient safety. AEs are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management. We estimated the incidence of AEs among patients in Canadian acute care hospitals. Methods: We randomly selected 1 teaching, 1 large community and 2 small community hospitals in each of 5 provinces (British Columbia, Alberta, Ontario, Quebec and Nova Scotia) and reviewed a random sample of charts for nonpsychiatric, nonobstetric adult patients in each hospital for the fiscal year 2000. Trained reviewers screened all eligible charts, and physicians reviewed the positively screened charts to identify AEs and determine their preventability. Results: At least 1 screening criterion was identified in 1527 (40.8%) of 3745 charts. The physician reviewers identified AEs in 255 of the charts. After adjustment for the sampling strategy, the AE rate was 7.5 per 100 hospital admissions (95% confidence interval [CI] 5.7– 9.3). Among the patients with AEs, events judged to be preventable occurred in 36.9% (95% CI 32.0%–41.8%) and death in 20.8% (95% CI 7.8%–33.8%). Physician reviewers estimated that 1521 additional hospital days were associated with AEs. Although men and women experienced equal rates of AEs, patients who had AEs were significantly older than those who did not (mean age [and standard deviation] 64.9 [16.7] v. 62.0 [18.4] years; p = 0.016). Interpretation: The overall incidence rate of AEs of 7.5% in our study suggests that, of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185 000 are associated with an AE and close to 70 000 of these are potentially preventable.

/pdf/the-canadian-adverse-events-study-the-incidence-of-adverse-4ip66k5tbq.pdf

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

Introduction: Adverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. We performed a systematic review of the literature on inhospital adverse events. Methods: A formal search of Embase, Cochrane and Medline was performed. Studies were reviewed independently for methodology, inclusion and exclusion criteria and endpoints. Primary endpoints were incidence of in-hospital adverse events and percentage of preventability. Secondary endpoints were adverse event outcome and subdivision by provider of care, location and type of event. Results: Eight studies including a total of 74 485 patient records were selected. The median overall incidence of inhospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority. We present a summary of evidence-based interventions aimed at these categories of events. Conclusions: Adverse events during hospital admission affect nearly one out of 10 patients. A substantial part of these events are preventable. Since a large proportion of the in-hospital events are operation- or drug-related, interventions aimed at preventing these events have the potential to make a substantial difference.

https://qualitysafety.bmj.com/content/qhc/17/3/216.full.pdf

The incidence and nature of in-hospital adverse events: a systematic review

http://www.atulgawande.com/documents/Analysisoferrorsreportedbysurgeonsatthreeteachinghospitals.pdf

Analysis of errors reported by surgeons at three teaching hospitals

Objective To determine the prevalence of depression and burnout among residents in paediatrics and to establish if a relation exists between these disorders and medication errors

Design Prospective cohort study

Setting Three urban freestanding children’s hospitals in the United States

Participants 123 residents in three paediatric residency programmes

Main outcome measures Prevalence of depression using the Harvard national depression screening day scale, burnout using the Maslach burnout inventory, and rate of medication errors per resident month

Results 24 (20%) of the participating residents met the criteria for depression and 92 (74%) met the criteria for burnout Active surveillance yielded 45 errors made by participants Depressed residents made 62 times as many medication errors per resident month as residents who were not depressed: 155 (95% confidence interval 057 to 422) compared with 025 (014 to 046, P<0001) Burnt out residents and non-burnt out residents made similar rates of errors per resident month: 045 (020 to 098) compared with 053 (021 to 133, P=02)

Conclusions Depression and burnout are major problems among residents in paediatrics Depressed residents made significantly more medical errors than their non-depressed peers; however, burnout did not seem to correlate with an increased rate of medical errors

https://www.bmj.com/content/bmj/336/7642/488.full.pdf

Rates of medication errors among depressed and burnt out residents: prospective cohort study.

is one of the leading centres in the United Kingdom for research, teaching and consultancy in health policy and management Our academic staff are skilled and experienced in working at the interface between theory and practice, and helping NHS organisations to put ideas into action Our research reports are an important part of our academic work, and are designed to help disseminate the ideas and findings from our research and to spread good practice We are a self-financing, not-for-profit centre within the Manchester Business School, and are part of the University of Manchester The

/pdf/learning-from-litigation-an-analysis-of-claims-for-clinical-38a53r785v.pdf

Learning from litigation: an analysis of claims for clinical negligence

ObjectiveTo determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm.DesignQualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009.Participants52 preventable hospital deaths.SettingEngland.Main outcome measuresThe nature of problems in care and contributory factors underlying avoidable deaths in hospital.ResultsThe change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of ...

https://journals.sagepub.com/doi/pdf/10.1177/0141076814532394

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis:

with disaccharidase deficiencies. Alternatively it may be normal in the milder forms of sugar malabsorption. The excretion of more than 50 mg of lactic acid in a random sample of 100 g of frces can be taken as evidence of abnormal fermentation. Sugar-loading tests can be extremely useful as a diagnostic tool provided their interpretation is carefully considered. The recommended dose is 2 g/kg body weight or 50 g/m2 body surface area. The standard administration is a 10% solution of the sugar tested. An increase of blood glucose of over 30 mg/100 ml above the fasting level at any point of the tolerance curve can be regarded as normal. Values consistently below 20 mg/100 ml are indicative of malabsorption. In children it is important to carry out control tests with the component monosaccharides to exclude a monosaccharide malabsorption. Sugar excretion in the faeces may be a helpful guide towards further study; melituria is not a common feature except in lactose intolerance and in severe forms of gluten-induced enteropathy. Laws & Neale (1966) found radiological examination with a mixture of a disaccharide and barium helpful in demonstrating intestinal changes associated with sugar malabsorption. Enzyme assay in peroral intestinal biopsy sp_cimens is still being regarded as the most reliable way of determining disaccharidase deficiencies, but it has certain drawbacks in secondary forms of sugar malabsorption, particularly when the pathological process does not uniformly involve the whole area of intestinal absorptive mucosa. Diagnosis of monosaccharide malabsorption rests largely on the exclusion of disaccharidase deficiencies and evidence of malabsorption of actively transported sugars whilst fructose, which depends on a different mechanism of facilitated transfer, is normally utilized. More sophisticated in vitro methods were used to demonstrate the failure of mucosal uptake of labelled glucose or galactose as compared with control specimens.

Defects of sugar absorption. The diagnosis, incidence and significance of disaccharidase deficiency in adults.

Objective. To explore associations between the proportion of hospital deaths that are preventable and other measures of safety. Design. Retrospective case record review to provide estimates of preventable death proportions. Simple monotonic correlations using Spearman’s rank correlation coefficient to establish the relationship with eight other measures of patient safety. Setting. Ten English acute hospital trusts. Participants. One thousand patients who died during 2009. Results. The proportion of preventable deaths varied between hospitals (3–8%) but was not statistically significant (P = 0.94). Only one of the eight measures of safety (Methicillin-resistant Staphylococcus aureus bacteraemia rate) was clinically and statistically significantly associated with preventable death proportion (r = 0.73; P < 0.02). There were no significant associations with the other measures including hospital standardized mortality ratios (r= −0.01). There was a suggestion that preventable deaths may be more strongly associated with some other measures of outcome than with process or with structure measures. Conclusions. The exploratory nature of this study inevitably limited its power to provide definitive results. The observed relationships between safety measures suggest that a larger more powerful study is needed to establish the inter-relationship of different measures of safety (structure, process and outcome), in particular the widely used standardized mortality ratios.

/pdf/relationship-between-preventable-hospital-deaths-and-other-5emfx1cvgt.pdf

Relationship between preventable hospital deaths and other measures of safety: an exploratory study

Objective To identify patient safety factors in pre-hospital and hospital management of critically ill children dying in a paediatric intensive care unit (PICU).

Design Retrospective case notes review.

Setting Single tertiary regional PICU in London.

Participants 47 patients (7%) who died from a total of 679 children admitted during 2007 and 2008. Median age was 1.1 years and median predicted mortality from the Paediatric Index of Mortality 2 score was 39%.

Main outcome measures Adverse events contributing to death (AEds) and critical incidents (CIs). AEd was defined as an unintended injury or complication caused by health care management, contributing to death. CI was defined as an undesirable event in healthcare management, which could have led to harm or did lead to harm of the patient but did not contribute to the patient's death.

Results 22 AEds occurred in 17 of 47 (36%) cases. Two AEds occurred in primary care, 20 in pre-PICU hospital care, and none in PICU. AEds were mainly problems in diagnosis and management of critical illness. 37 CIs occurred in 28 of 47 (60%) cases. Two CIs occurred prior to hospital admission, 17 occurred in pre-PICU hospital care, 1 during inter-hospital transport and 17 in PICU. CIs were predominantly medical management and procedure related. Individual, team and organisational factors caused the majority of AEds and CIs.

Conclusion Adverse events in pre-PICU hospital care were common in children who subsequently died in PICU. CIs occurred throughout the patient journey. Interventional studies of healthcare organisation and delivery are necessary to identify appropriate strategies to improve patient safety.

https://qualitysafety.bmj.com/content/qhc/20/10/863.full.pdf

Graham Neale

Papers

Learning from litigation: an analysis of claims for clinical negligence

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis:

Defects of sugar absorption. The diagnosis, incidence and significance of disaccharidase deficiency in adults.

Relationship between preventable hospital deaths and other measures of safety: an exploratory study

Patient safety factors in children dying in a paediatric intensive care unit (PICU): a case notes review study