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

https://www.healio.com/psychiatry/journals/psycann/1976-12-6-12/{806b8887-c02e-40c8-a228-57f1cdb2bdba}/the-stress-of-life.pdf

The stress of life

Riedel DJ, Gonzalez-Cuyar LF, Zhao XF, Redfi eld RR, Gilliam BL. Plasmablastic lymphoma of the oral cavity: a rapidly progressive lymphoma associated with HIV infection. Lancet Infect Dis 2008; 8: 261–67. In this Grand Round, the references for the sentence “Occasionally, CD138-negative plasmablastic lymphoma cases (such as this case) have been reported” (page 265) should be 32, 34, and 38. Book Systematic reviews: CRD’s guidance for undertaking reviews in health care

/pdf/systematic-reviews-crd-s-guidance-for-undertaking-reviews-in-4hcrkbrbv4.pdf

Systematic reviews: CRD's guidance for undertaking reviews in health care

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

Objectives: To examine the feasibility of detecting adverse events through record review in British hospitals and to make preliminary estimates of the incidence and costs of adverse events. Design: Retrospective review of 1014 medical and nursing records. Setting: Two acute hospitals in Greater London area. Main outcome measure: Number of adverse events. Results: 110 (10.8%) patients experienced an adverse event, with an overall rate of adverse events of 11.7% when multiple adverse events were included. About half of these events were judged preventable with ordinary standards of care. A third of adverse events led to moderate or greater disability or death. Conclusions: These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources. Some are major events; others are frequent, minor events that go unnoticed in routine clinical care but together have massive economic consequences

https://www.bmj.com/content/bmj/322/7285/517.full.pdf

Adverse events in british hospitals: preliminary retrospective record review

The impact of stress on surgical performance: a systematic review of the literature.

Background
Although the general literature on stress and performance is extensive, little is known about specific effects of stress in surgical practice. This qualitative study explored key surgical stressors, their impact on performance, and coping strategies used by surgeons.
Methods
Individual in-depth semistructured interviews with surgeons were analyzed by 2 researchers independently. Key themes were discussed within the research team.
Results
Sixteen interviews were performed, including interviews with consultants (n = 9) and surgeons in training (n = 7). A wide range of intraoperative stressors was identified. Although stress had both positive and negative effects, undue levels of stress impaired judgment, decision making, and communication. Although junior surgeons showed uncertainty about their ability to cope, senior surgeons had developed sophisticated strategies for controlling each situation.
Conclusions
Although stress poses significant risks, coping strategies are not taught explicitly during surgical training. This article presents a framework for categorizing surgical stress and suggests key elements for effective coping strategies.

The effects of stress on surgical performance

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

https://qualitysafety.bmj.com/content/qhc/18/5/341.full.pdf

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

In a previous paper we reported that 10.8% of patients admitted to two large hospitals in Greater London experienced one or more adverse events, of which half were deemed preventable. Here we examine the underlying causes of errors in clinical practice. Rather than identifying specific errors made by individuals, we have looked at possible faults in the organization of care. Adverse events were grouped according to stages in the care process: diagnosis, preoperative assessment and care, operative or invasive procedure (including anaesthesia), ward management, use of drugs and intravenous fluids and discharge from hospital.

Less than 20% of preventable adverse events were directly related to surgical operations or invasive procedures and less than 10% to misdiagnoses. 53% of preventable adverse events occurred in general ward care (including initial assessment and the use of drugs and intravenous fluids) and 18% in care at the time of discharge. Probable contributory factors in these errors included dependence on diagnoses made by inexperienced clinicians, poor records, poor communication between professional carers, inadequate input by consultants into day-to-day care, and lack of detailed assessment of patients before discharge.

https://journals.sagepub.com/doi/pdf/10.1177/014107680109400702

Maria Woloshynowych

Papers

Adverse events in british hospitals: preliminary retrospective record review

The impact of stress on surgical performance: a systematic review of the literature.

The effects of stress on surgical performance

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Exploring the causes of adverse events in NHS hospital practice.