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.

Twenty years ago I was called to the casualty department to see an unconscious 38 year old man with a rigid abdomen He was scarcely breathing His blood pressure was unrecordable After several hours' resuscitation the duty surgeon opened the abdomen and repaired a perforation The patient survived but was left with irreversible neurological damage During the 24 hours before admission he had been seen on two occasions by different doctors working for the emergency service One diagnosed dyspepsia; the other constipation Both doctors administered opiates and the patient was left in the care of his wife who finally dialled 999 The man was self employed and his wife and five children were left in straitened circumstances A year later his wife asked if I would provide a statement for her solicitors as she wished to make a claim After a further three years the case went to the High Court I expected to be asked to describe quite simply my findings and to be questioned on the dangers of giving opiates to a patient with an …

We should look at complaints again

Editor—Black calls for nurses to transform our hospitals.1 This will not happen without a major change in the clinical culture that pervades hospital practice.

Observational studies show inadequate communication between doctors and other clinical staff.2 Attempts to foster collaboration are undermined by differential power and status, lack of interprofessional socialisation, and inadequate attention …

/pdf/rise-and-demise-of-the-hospital-managing-hospital-inpatient-3bvphx2f68.pdf

Rise and demise of the hospital: managing hospital inpatient care.

Rise and demise of the hospital

It was a Thursday morning ward teaching session some years ago. My final year students were not happy. They were due to take a written examination within the next week or so and thought that they should be free of ward work to study pathology. But they also had to be signed up in clinical medicine, and I was not disposed to let them off the hook. I tried to be placatory. They could choose the patients we would see. I was faced with a truculent silence. So, why not a new admission? Two students had seen patients the previous night but still no offers. It was time to …

https://www.bmj.com/content/bmj/322/7291/901.full.pdf

A memorable patient: Just another chronic chest

EDITOR—Godlee's comment about the fragmented care described by Gannon in his personal view prompts us to provide additional evidence from our study at a district general hospital.1 2 As part of a research project we persuaded clinical teams to examine the quality of care in their own units.

We found evidence of adverse events or critical incidents in 60/154 …

/pdf/will-the-lead-clinician-please-stand-up-we-should-be-2bwr7qlmel.pdf

Graham Neale

Papers

We should look at complaints again

Rise and demise of the hospital: managing hospital inpatient care.

Rise and demise of the hospital

A memorable patient: Just another chronic chest

Will the lead clinician please stand up? We should be promoting total quality care.