Quality and Safety in Health Care Journal

What can we learn from patients perspectives on the quality and safety of hospital care?

In 2001, the Institute of Medicine defined high-quality healthcare as care that is safe, effective, patient-centred, timely, efficient and equitable.1 Subsequently, efforts to improve quality have tended to treat the six dimensions as separate rather than interrelated, with improvement in the various dimensions being pursued independently, led by different professions and occupational groups. Investment in research and improvement knowledge across the dimensions has been comparatively uneven, with little shared learning between researchers and professionals working to improve quality in one dimension about the value and efficacy of improvement approaches and methods used in others. Despite policy efforts to define quality in the round as safe, effective and patient-centred,2 3 and despite intermittent calls for patients to be involved in patient safety,4 the dimensions of quality do not have equal status within the improvement community, and patients and families do not play...

What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study


Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital.


Feedback about the experience of safety within hospital was gathered from 2471 inpatients as part of a multicentre, waitlist cluster randomised controlled trial of an intervention, undertaken within 33 wards across three English NHS Trusts, between May 2013 and September 2014. Patient volunteers, supported by researchers, developed a classification framework of patient-reported safety concerns from a random sample of 231 reports. All reports were then classified using the patient-developed categories. Following this, all patient-reported safety concerns underwent a two-stage clinical review process for identification of patient safety incidents.


Of the 2471 inpatients recruited, 579 provided 1155 patient-reported incident reports. 14 categories were developed for classification of reports, with communication the most frequently occurring (22%), followed by staffing issues (13%) and problems with the care environment (12%). 406 of the total 1155 patient incident reports (35%) were classified by clinicians as a patient safety incident according to the standard definition. 1 in 10 patients (264 patients) identified a patient safety incident, with medication errors the most frequently reported incident.


Our findings suggest that patients can provide insight about safety that complements existing patient safety measurement, with a frequency of reported patient safety incidents that is similar to those obtained via case note review. However, patients provide a unique perspective about hospital safety which differs from and adds to current definitions of patient safety incidents.

Trial registration number

ISRCTN07689702; pre-results.

The association between patient experience factors and likelihood of 30-day readmission: a prospective cohort study


Hospital care comprises nearly a third of US healthcare expenditures. Fifteen to 20 per cent of this spending is considered to be potentially preventable. Risk prediction models have suboptimal accuracy and typically exclude patient experience data. No studies have explored patient perceptions of the likelihood of readmission during index admission. Our objective was to examine associations between patient perceptions of care during index hospital admission and 30-day readmission.


Prospective cohort study.


Two inpatient adult medicine units at Massachusetts General Hospital, Boston, Massachusetts.


Eight hundred and forty-six patients admitted to study units between January 2012 and January 2016 who met eligibility criteria and consented to enrolment.

Main outcome

Odds of 30-day readmission.


Of 1754 eligible participants, 846 (48%) were enrolled and 201 (23.8%) were readmitted within 30 days. Readmitted participants were less likely to have a high school diploma/GED (44.3% not readmitted vs 53.5% readmitted, P=0.02). In multivariable models adjusting for baseline differences, respondents who reported being ‘very satisfied’ with the care received during the index hospitalisation were less likely to be readmitted (adjusted OR 0.61, 95% CI 0.43 to 0.88, P=0.007). Participants reporting doctors ‘always listened to them carefully’ were less likely to be readmitted (adjusted OR 0.68, 95% CI 0.48 to 0.97, P=0.03). Participants reporting they were ‘very likely’ to be readmitted were not more likely to be readmitted (adjusted OR 1.35, 95% CI 0.83 to 2.19, P=0.22).


Participants reporting high satisfaction and good provider communication were less likely to be readmitted. Rates of readmission were increased among participants stating they were very likely to be readmitted though this association was not statistically significant. Incorporating patient-reported measures during index hospitalisations may improve readmission prediction.

Next-generation audit and feedback for inpatient quality improvement using electronic health record data: a cluster randomised controlled trial


Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting.


We conducted a cluster randomised control trial comparing intensive audit and feedback with usual audit and feedback from February 2016 to June 2016. The study subjects were internal medicine teams on the teaching service at an urban tertiary care hospital. Teams in the intensive feedback arm received access to a daily-updated team-based data dashboard as well as weekly inperson review of performance data (‘STAT rounds’). The usual feedback arm received ongoing twice-monthly emails with graphical depictions of team performance on selected quality metrics. The primary outcome was performance on a composite discharge metric (Discharge Mix Index, ‘DMI’). A washout period occurred at the end of the trial (from May through June 2016) during which STAT rounds were removed from the intensive feedback arm.


A total of 40 medicine teams participated in the trial. During the intervention period, the primary outcome of completion of the DMI was achieved on 79.3% (426/537) of patients in the intervention group compared with 63.2% (326/516) in the control group (P<0.0001). During the washout period, there was no significant difference in performance between the intensive and usual feedback groups.


Intensive audit and feedback using timely data and STAT rounds significantly increased performance on a composite discharge metric compared with usual feedback. With the cessation of STAT rounds, performance between the intensive and usual feedback groups did not differ significantly, highlighting the importance of feedback delivery on effecting change.

Clinical Trial

The trial was registered with ClinicalTrials.gov (NCT02593253).

Interprofessional Teamwork Innovation Model (ITIM) to promote communication and patient-centred, coordinated care


Despite recommendations and the need to accelerate redesign of delivery models to be team-based and patient-centred, professional silos and cultural and structural barriers that inhibit working together and communicating effectively still predominate in the hospital setting. Aiming to improve team-based rounding, we developed, implemented and evaluated the Interprofessional Teamwork Innovation Model (ITIM).


This quality improvement (QI) study was conducted at an academic medical centre. We followed the system’s QI framework, FOCUS-PDSA, with Lean as guiding principles. Primary outcomes included 30-day all-cause same-hospital readmissions and 30-day emergency department (ED) visits. The intervention group consisted of patients receiving care on two hospitalist ITIM teams, and patients receiving care from other hospitalist teams were matched with a control group. Outcomes were assessed using difference-in-difference analysis.


Team members reported enhanced communication and overall time savings. In multivariate modelling, patients discharged from hospitalist teams using the ITIM approach were associated with reduced 30-day same-hospital readmissions with an estimated point OR of 0.56 (95% CI 0.34 to 0.92), but there was no impact on 30-day same-hospital ED visits. Difference-in-difference analysis showed that ITIM was not associated with changes in average total direct costs nor average cost per patient day, after adjusting for all other covariates in the models, despite the addition of staff resources in the ITIM model.


The ITIM approach facilitates a collaborative environment in which patients and their family caregivers, physicians, nurses, pharmacists, case managers and others work and share in the process of care.

Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns


Healthcare organisations often fail to harvest and make use of the ‘soft intelligence’ about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns.


Qualitative study involving personnel from three academic hospitals in two countries. Interviews were conducted with 165 participants from a wide range of occupational and professional backgrounds, including senior leaders and those from the sharp end of care. Data analysis was based on the constant comparative method.


Leaders reported that they valued employee voice; they identified formal organisational channels as a key route for the expression of concerns by employees. Formal channels and processes were designed to ensure fairness, account for all available evidence and achieve appropriate resolution. When processed through these formal systems, concerns were destined to become evidenced, formal and tractable to organisational intervention. But the way these systems operated meant that some concerns were never voiced. Participants were anxious about having to process their suspicions and concerns into hard evidentiary facts, and they feared being drawn into official procedures designed to allocate consequence. Anxiety about evidence and process was particularly relevant when the intelligence was especially ‘soft’—feelings or intuitions that were difficult to resolve into a coherent, compelling reconstruction of an incident or concern. Efforts to make soft intelligence hard thus risked creating ‘forbidden knowledge’: dangerous to know or share.


The legal and bureaucratic considerations that govern formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. Leaders responsible for quality and safety should consider complementing formal mechanisms with alternative, informal opportunities for listening to concerns.

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit


Clinical decision support (CDS) displayed in electronic health records has been found to reduce the incidence of medication errors and adverse drug events (ADE). Recent data suggested that medication-related CDS alerts were frequently over-ridden, often inappropriately. Patients in the intensive care unit (ICU) are at an increased risk of ADEs; however, limited data exist on the benefits of CDS in the ICU. This study aims to evaluate potential harm associated with medication-related CDS over-rides in the ICU.


This was a prospective observational study of adults admitted to any of six ICUs between July 2016 and April 2017 at our institution. Patients with provider-overridden CDS for dose (orders for scheduled frequency and not pro re nata), drug allergy, drug–drug interaction, geriatric and renal alerts (contraindicated medications for renal function or renal dosing) were included. The primary outcome was the appropriateness of over-rides, which were evaluated by two independent reviewers. Secondary outcomes included incidence of ADEs following alert over-ride and risk of ADEs based on over-ride appropriateness.


A total of 2448 over-ridden alerts from 712 unique patient encounters met inclusion criteria. The overall appropriateness rate for over-rides was 81.6% and varied by alert type. More ADEs (potential and definite) were identified following inappropriate over-rides compared with appropriate over-rides (16.5 vs 2.74 per 100 over-ridden alerts, Fisher’s exact test P<0.001). An adjusted logistic regression model showed that inappropriate over-rides were associated with an increased risk of ADEs (OR 6.14, 95% CI 4.63 to 7.71, P<0.001).


Approximately four of five identified CDS over-rides were appropriately over-ridden, with the rate varying by alert type. However, inappropriate over-rides were six times as likely to be associated with potential and definite ADEs, compared with appropriate over-rides. Further efforts should be targeted at improving the positive predictive value of CDS such as by suppressing alerts that are appropriately over-ridden.

Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre-post study


In this UK study, we investigated the impact of computerised physician order entry (CPOE) and clinical decision support (CDS) implementation on the rate of 78 high-risk prescribing errors amenable to CDS.


We conducted a preintervention/postintervention study in three acute hospitals in England. A predefined list of prescribing errors was incorporated into an audit tool. At each site, approximately 4000 prescriptions were reviewed both pre-CPOE and 6 months post-CPOE implementation. The number of opportunities for error and the number of errors that occurred were collated. Error rates were then calculated and compared between periods, as well as by the level of CDS.


The prescriptions of 1244 patients were audited pre-CPOE and 1178 post-CPOE implementation. A total of 28 526 prescriptions were reviewed, with 21 138 opportunities for error identified based on 78 defined errors. Across the three sites, for those prescriptions where opportunities for error were identified, the error rate was found to reduce significantly post-CPOE implementation, from 5.0% to 4.0% (P<0.001). CDS implementation by error type was found to differ significantly between sites, ranging from 0% to 88% across clinical contraindication, dose/frequency, drug interactions and other error types (P<0.001). Overall, 43/78 (55%) of the errors had some degree of CDS implemented in at least one of the hospitals.


Implementation of CPOE with CDS was associated with clinically important reductions in the rate of high-risk prescribing errors. Given the pre-post design, these findings however need to be interpreted with caution. The occurrence of errors was found to be highly dependent on the level of restriction of CDS presented to the prescriber, with the effect that different configurations of the same CPOE system can produce very different results.

Using Q-methodology to guide the implementation of new healthcare policies

There are many challenges in the development, implementation and evaluation of healthcare policy. One challenge is understanding how different stakeholders view a particular policy and what impact these views may have during implementation. Q-methodology is one approach that can be used to help policy makers and researchers actively engage with those who are important in policy implementation, and anticipate their responses. Q-methodology combines qualitative and quantitative research methods to systematically explore and describe the range of viewpoints about a topic. Participants are required to rank a set of predefined statements relating to the topic, according to their own viewpoint. Factor analytic techniques then identify people who are like-minded in the way they view the topic and enable areas of consensus and divergence in viewpoint to be clearly defined. This mapping of viewpoints allows those working in policy implementation to anticipate likely barriers and levers in implementing new policies.

Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why


Intentional rounding (IR) is a structured process whereby nurses conduct one to two hourly checks with every patient using a standardised protocol.


A realist synthesis of the evidence on IR was undertaken to develop IR programme theories of what works, for whom, in what circumstances and why.


A three-stage literature search and a stakeholder consultation event was completed. A variety of sources were searched, including AMED, CINAHL, MEDLINE, PsycINFO, HMIC, Google and Google Scholar, for published and unpublished literature. In line with realist synthesis methodology, each study’s ‘fitness for purpose’ was assessed by considering its relevance and rigour.


A total of 44 papers met the inclusion criteria. To make the programme theories underpinning IR explicit, we identified eight a priori propositions: (1) when implemented in a comprehensive and consistent way, IR improves healthcare quality and satisfaction, and reduces potential harms; (2) embedding IR into daily routine practice gives nurses ‘allocated time to care’; (3) documenting IR checks increases accountability and raises fundamental standards of care; (4) when workload and staffing levels permit, more frequent nurse–patient contact improves relationships and increases awareness of patient comfort and safety needs; (5) increasing time when nurses are in the direct vicinity of patients promotes vigilance, provides reassurance and reduces potential harms; (6) more frequent nurse–patient contact enables nurses to anticipate patient needs and take pre-emptive action; (7) IR documentation facilitates teamwork and communication; and (8) IR empowers patients to ask for what they need to maintain their comfort and well-being. Given the limited evidence base, further research is needed to test and further refine these propositions.


Despite widespread use of IR, this paper highlights the paradox that there is ambiguity surrounding its purpose and limited evidence of how it works in practice.

The problem with using patient complaints for improvement

‘The Problem with...’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.

Identifying vendors in studies of electronic health records: the editor replies

I thank Dr O’Donnell for his letter asking if we did not name the vendors in a study of the electronic health record (EHR)-generated discharge summaries1 as a matter of policy or simply due to an oversight. The vulnerabilities and unintended consequences of health information technologies have appeared as recurring themes in both research papers2–7 and editorials8–10 at BMJ Quality & Safety. We agree that such studies should generally mention the vendors involved, just as one would expect to occur in studies of medical devices, such as infusion pumps or surgical implants.

In this case, the omission of the vendors did indeed result from an oversight. We had asked the authors to identify the vendors in our comments as part of the editorial comments added to those from external...

Problems with discharge summaries produced by electronic health records: why are the vendors not named?

The study by Sarzynski and colleagues1 uses rigorous analysis to obtain important insights about the real-time information that patients receive at discharge. It is puzzling that the electronic health records (EHRs) used were not named. One can infer from a look through the Michigan State University website that they have both Cerner and Epic, but why is such detective work necessary? The heart of quality/safety work is one of transparency balanced by humility. We should not expect health information technology systems to be any more perfect than we are. But, these systems would not improve if we do not have more openness about their shortcomings.

The lack of scientific foundations and published postmarketing surveillance for our EHRs, especially the ascendant ones, was initially surprising. However, as they achieve complete market dominance, with less overt scientific review and public guidance and commentary,2 the silence is deafening....

Questions regarding the authors conclusions about the lack of change in Hospital Survey on Patient Safety Culture (HSOPS) scores related to reduction of hospital-acquired infections

We were very interested to read the article by Meddings et al which evaluated the association between patient safety culture and catheter-associated infections among hospitals in two infection-reducing collaboratives.1 The authors found that while infection rates declined, there was no association between 13 dimensions of patient safety culture, as measured by the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS), and unadjusted infection rates (catheter-associated urinary tract infections (CAUTI) and central-line-associated bloodstream infection (CLABSI) rates per 1000 catheter days).

We comment on several of the article’s conclusions and pose some questions about the data collection and analysis methods used to examine the relationship between HSOPS and infection rates.

First, the study reported HSOPS response rates averaging 24% for the CLABSI collaborative and 43% for the CAUTI collaborative, which were described as ’a low response rate' and ’important finding' which they attribute to...

On being human: reflections on a daily error

The importance of the respiratory rate (RR) as a vital sign is hardly new, but the recent article by Badawy et al1 uses an elegant and scientific approach to shine new light on an old issue, that of the reliability of recorded vital signs. The article relates to an important function of healthcare: early detection and prevention of patient deterioration. From where I write, in Australia, recognising and responding to deterioration is one of ten National Health Standards.2 I believe RR is a microcosm of the challenges we face in healthcare and Badawy’s article has implications for patient safety and quality as a whole.

RR is an extremely valuable indicator; it is an integral part of early warning systems (EWS) and a diagnostic criterion for systemic inflammatory response syndrome.3 Its prognostic value can even rival complex prognostic tools such as the Pneumonia Severity...

Roadmap for improving the accuracy of respiratory rate measurements

We thank Dr Wong for his detailed description of the importance of respiratory rate (RR) and his astute reflections on the interactions between predictable human errors and the systems in which humans work. We agree that RR is prone to error because of the human element. However, what is unique to healthcare compared with aviation is not that human error exists, but that tolerance for these errors has become an accepted part of everyday practice.1 We hypothesise that RRs can be measured both accurately and efficiently, but this requires institutional culture change starting with improvements in staff education, expectations and accountability, which can be accomplished through a quality improvement (QI) initiative. We have initiated this process at our own institution.

To guide our local ongoing QI initiative, we mapped the workflows for routine RR measurements by patient care assistants (PCA) through direct observation in a single inpatient...

Correction: Advancing Implementation Science for Quality and Safety in Primary Health Care: The Integrated Care for Older Adults with Complex Health Needs Study (iCOACH)

Shaw J, McKillop A, Sheridan N, et al. BMJ Qual Saf 2017; doi:10.1136/bmjqs-2017-006696.2.

The corrected affiliations for this paper should read as follows:

James Shaw,1, 4 Ann McKillop,2 Nicolette Sheridan,2 Carolyn Steele Gray,3, 4 Peter Carswell,2 Walter P Wodchis,4, 7, 8 Mylaine Breton,5 Jean-Louis Denis,6 G. Ross Baker,4 Timothy Kenealy2

  • Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada

  • Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

  • Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada

  • Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

  • Département des sciences de la santé communautaire, Universite de Sherborooke, Longueuil, Quebec, Canada

  • Département d’administration de la santé, Universite de Montreal, Montreal, Quebec, Canada

  • Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada

  • Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada

  • doi:10.1136/bmjqs-2017-006696corr1

    Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care

    In his book on the psychology of persuasion, Robert Cialdini noted: "as the stimuli saturating our lives continue to grow more intricate and variable, we will have to depend increasingly on our shortcuts to handle them all".1 Such cognitive shortcuts, or heuristics, are responsible for much of human success in complex environments. Heuristics allow us to skip steps and save mental energy. Similarly, emotions provide a shorthand for remembering and reacting to complex situations and sociability allows us to function well in groups.

    Medicine is the art of managing complexity. Physicians’ success similarly depends on effective use of these heuristics, emotion and sociability. When admitting a patient to the hospital, a physician must diagnose the presenting symptoms, reconcile and start medications, order diagnostic testing, communicate with consultants and participate in shared-decision making. In ambulatory visits, the time pressure and tasks are slightly different, but comparably complex. In both...

    Impact of order set design on urine culturing practices at an academic medical centre emergency department


    Urinalysis and urine culture are commonly ordered tests in the emergency department (ED). We evaluated the impact of removal of order sets from the ‘frequently ordered test’ in the computerised physician order entry system (CPOE) on urine testing practices.


    We conducted a before (1 September to 20 October 2015) and after (21 October to 30 November 2015) study of ED patients. The intervention consisted of retaining ‘urinalysis with reflex to microscopy’ as the only urine test in a highly accessible list of frequently ordered tests in the CPOE system. All other urine tests required use of additional order screens via additional mouse clicks. The frequency of urine testing before and after the intervention was compared, adjusting for temporal trends.


    During the study period, 6499 (28.2%) of 22 948 ED patients had ≥1 urine test ordered. Urine testing rates for all ED patients decreased in the post intervention period for urinalysis (291.5 pre intervention vs 278.4 per 1000 ED visits post intervention, P=0.03), urine microscopy (196.5vs179.5, P=0.001) and urine culture (54.3vs29.7, P<0.001). When adjusted for temporal trends, the daily culture rate per 1000 ED visits decreased by 46.6% (–46.6%, 95% CI –66.2% to –15.6%), but urinalysis (0.4%, 95% CI –30.1 to 44.4%), microscopy (–6.5%, 95% CI –36.0% to 36.6%) and catheterised urine culture rates (17.9%, 95% CI –16.9 to 67.4) were unchanged.


    A simple intervention of retaining only ‘urinalysis with reflex to microscopy’ and removing all other urine tests from the ‘frequently ordered’ window of the ED electronic order set decreased urine cultures ordered by 46.6% after accounting for temporal trends. Given the injudicious use of antimicrobial therapy for asymptomatic bacteriuria, findings from our study suggest that proper design of electronic order sets plays a vital role in reducing excessive ordering of urine cultures.

    Implementation of a colour-coded universal protocol safety initiative in Guatemala


    Universal protocol implementation can be challenging in low-income or middle-income countries, particularly when providers work together across language barriers. The aim of this quality improvement initiative was to test the implementation of a colour-coded universal protocol in a Guatemalan hospital staffed by US and Guatemalan providers.


    From 2013 to 2016, a US and Guatemalan team implemented a universal protocol at a Guatemalan surgical centre for children undergoing general surgical or urologic procedures. The protocol was a two-step patient identification and documentation checklist, with the first step of all chart element verification in the preoperative area, after which a blue hat was placed on the patient as a visual cue that this was completed. The second step included checklist confirmation in the operating room prior to the procedure. We tested protocol implementation over three phases, identifying implementation barriers and modifying clinical workflow after each phase. We measured the error rate in documentation or other universal protocol steps at each phase and made modifications based on iterative analysis.


    Over the course of programme implementation, we substantially decreased the rate of errors in documentation or other universal protocol elements. After the first phase, 30/51 patients (58.8%) had at least one error. By the third phase, only 2/43 patients (4.6%) had any errors. All errors were corrected prior to surgery with no adverse outcomes.


    Care teams of providers from different countries pose potential challenges with patient safety. Implementation of a colour-coded universal protocol in this setting can prevent and reduce errors that could potentially lead to patient harm.