Quality and Safety in Health Care Journal

The personal and the organisational perspective on iatrogenic harm: bridging the gap through reconciliation processes

A pervasive theme of healthcare reform globally is greater candour about the imperfections of care quality, particularly for patients and family members when things go wrong. Numerous healthcare systems now have published policies around disclosure. However, as Moore and Mello document in their paper in this issue of BMJ Quality and Safety,1 details about how, what and when to disclose are scant, and based on minimal evidence about what works for patients, families, clinicians and organisations. Moore and Mello provide important insights from New Zealand, where a mandatory system for compensation following treatment injuries has been in place for over 40 years, on how to achieve reconciliation that satisfies the concerns of aggrieved patients and carers while being acceptable to clinicians and organisations.

Moore and Mello relate their findings in particular to the North American context. The traditional medical malpractice liability system in the USA has long...

Preventing hospital readmissions: the importance of considering 'impactibility, not just predicted risk

Reducing 28-day or 30-day readmissions has become an important aim for healthcare services, spurred in part by the introduction of financial incentives for hospitals with high readmission rates in the USA, England, Denmark, Germany and elsewhere.1 Unfortunately, many of the most effective interventions are costly, since they are multimodal and involve several components and multiple healthcare practitioners.2 Therefore, some healthcare teams are turning to predictive models in order to identify patients at high risk for readmission and focus resource intensive readmission prevention strategies on such ‘at risk’ patients. Recent years have seen an explosion in these predictive models, which use patterns observed within large data sets to generate readmission risks for individual patients. In 2011, a systematic review found 26 models for readmissions,3 but an updated review that examined papers published up to 2015 found 68 more.4

While doubts remain about...

Keep calm... and prepare

On 22 July 2011, a terrible attack by a lone shooter on the Norwegian island of Utøya cost 77 young lives, injured 78 and changed the lives of hundreds forever within 73 min. In the current international context of increased threat, sharing experience about disaster response is crucial. With some exceptions,1–3 many of these studies adopt a deficit-based analysis approach and focus on dysfunctions rather than positive lessons.

In contrast, Brandrud et al4 adopted an original approach. The group used the conclusions of two official and independent commissions as starting point, namely that the medical response to the incident was particularly well managed. This enabled a ‘positive deviance’5 6 analysis to draw important lessons from this incident.

The authors attempted to gather crucial insights with the help of detailed group interviews and expert review: How did a rural...

Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand


Despite the investment in exploring patient-centred alternatives to medical malpractice in New Zealand (NZ), the UK and the USA, patients' experiences with these processes are not well understood. We sought to explore factors that facilitate and impede reconciliation following patient safety incidents and identify recommendations for strengthening institution-led alternatives to malpractice litigation.


We conducted semistructured interviews with 62 patients injured by healthcare in NZ, administrators of 12 public hospitals, 5 lawyers specialising in Accident Compensation Corporation (ACC) claims and 3 ACC staff. NZ was chosen as the research site because it has replaced medical malpractice litigation with a no-fault scheme. Thematic analysis was used to identify key themes from interview transcripts.


Interview responses converged on five elements of the reconciliation process that were important: (1) ask, rather than assume, what patients and families need from the process and recognise that, for many patients, being heard is important and should occur early in the reconciliation process; (2) support timely, sincere, culturally appropriate and meaningful apologies, avoiding forced or tokenistic quasi-apologies; (3) choose words that promote reconciliation; (4) include the people who patients want involved in the reconciliation discussion, including practitioners involved in the harm event; and (5) engage the support of lawyers and patient relations staff as appropriate.


Policymakers and healthcare institutions are keenly interested in non-litigation approaches to resolving malpractice incidents. Interviewing participants involved in patient safety incident reconciliation processes suggests that healthcare institutions should not view apology as a substitute for other remedial actions; use flexible guidelines that distil best-practice principles, ensuring that steps are not missed, while not prescribing a ‘one size fits all’ communication approach.

Simplification of the HOSPITAL score for predicting 30-day readmissions


The HOSPITAL score has been widely validated and accurately identifies high-risk patients who may mostly benefit from transition care interventions. Although this score is easy to use, it has the potential to be simplified without impacting its performance. We aimed to validate a simplified version of the HOSPITAL score for predicting patients likely to be readmitted.

Design and setting

Retrospective study in 9 large hospitals across 4 countries, from January through December 2011.


We included all consecutively discharged medical patients. We excluded patients who died before discharge or were transferred to another acute care facility.


The primary outcome was any 30-day potentially avoidable readmission. We simplified the score as follows: (1) ‘discharge from an oncology division’ was replaced by ‘cancer diagnosis or discharge from an oncology division’; (2) ‘any procedure’ was left out; (3) patients were categorised into two risk groups (unlikely and likely to be readmitted). The performance of the simplified HOSPITAL score was evaluated according to its overall accuracy, its discriminatory power and its calibration.


Thirty-day potentially avoidable readmission rate was 9.7% (n=11 307/117 065 patients discharged). Median of the simplified HOSPITAL score was 3 points (IQR 2–5). Overall accuracy was very good with a Brier score of 0.08 and discriminatory power remained good with a C-statistic of 0.69 (95% CI 0.68 to 0.69). The calibration was excellent when comparing the expected with the observed risk in the two risk categories.


The simplified HOSPITAL score has good performance for predicting 30-day readmission. Prognostic accuracy was similar to the original version, while its use is even easier. This simplified score may provide a good alternative to the original score depending on the setting.

Local emergency medical response after a terrorist attack in Norway: a qualitative study


On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.


We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS’ success. Two independent teams of professional experts classified and validated the identified determinants.


Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.


The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting


Medication errors are frequent and may cause harm to patients and increase healthcare expenses.


To explore whether a new labelling influences time and errors when preparing medications in accordance with medication charts in an experimental setting.


We carried out an uncontrolled before and after study with 3 months inbetween experiments. Phase I used original labelling and phase II used new generic labelling. We set up an experimental medicine room, simulating a real-life setting. Twenty-five nurses and ten pharmacy technicians participated in the study. We asked them to prepare medications in accordance with medication charts, place packages on a desk and document the package prepared. We timed the operation. Participants were asked to prepare medications in accordance with as many charts as possible within 30 min.


Nurses prepared significantly more medication charts with the generic labelling compared with the original 3.3 versus 2.6 (p=0.009). Mean time per medication chart was significantly lower with the generic labelling 6.9 min/chart versus 8.5 min/chart (p<0.001). Pharmacy technicians were significantly faster than the nurses in both phase I (6.8 min/chart vs 9.5 min/chart; p<0.001) and phase II (6.1 min/chart vs 7.2 min/chart; p=0.013). The number of errors was low and not significantly different between the two labellings, with errors affecting 9.1% of charts in phase I versus 6.5% in phase II (p=0.5).


A new labelling of medication packages with prominent placement of the active substance(s) and strength(s) in the front of the medication package may reduce time for nurses when preparing medications, without increasing medication errors.

Thematic analysis of US stakeholder views on the influence of labour nurses care on birth outcomes


Childbirth is a leading reason for hospital admission in the USA, and most labour care is provided by registered nurses under physician or midwife supervision in a nurse-managed care model. Yet, there are no validated nurse-sensitive quality measures for maternity care. We aimed to engage primary stakeholders of maternity care in identifying the aspects of nursing care during labour and birth they believe influence birth outcomes, and how these aspects of care might be measured.


This qualitative study used 15 focus groups to explore perceptions of 73 nurses, 23 new mothers and 9 physicians regarding important aspects of care. Transcripts were analysed thematically. Participants in the final six focus groups were also asked whether or not they thought each of five existing perinatal quality measures were nurse-sensitive.


Nurses, new mothers and physicians identified nurses' support of and advocacy for women as important to birth outcomes. Support and advocacy actions included keeping women and their family members informed, being present with women, setting the emotional tone, knowing and advocating for women's wishes and avoiding caesarean birth. Mothers and nurses took technical aspects of care for granted, whereas physicians discussed this more explicitly, noting that nurses were their ‘eyes and ears’ during labour. Participants endorsed caesarean rates and breastfeeding rates as likely to be nurse-sensitive.


Stakeholder values support inclusion of maternity nursing care quality measures related to emotional support and providing information in addition to physical support and clinical aspects of care. Care models that ensure labour nurses have sufficient time and resources to engage in the supportive relationships that women value might contribute to better health outcomes and improved patient experience.

Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults


Respiratory rate (RR) is an independent predictor of adverse outcomes and an integral component of many risk prediction scores for hospitalised adults. Yet, it is unclear if RR is recorded accurately. We sought to assess the potential accuracy of RR by analysing the distribution and variation as a proxy, since RR should be normally distributed if recorded accurately.


We conducted a descriptive observational study of electronic health record data from consecutive hospitalisations from 2009 to 2010 from six diverse hospitals. We assessed the distribution of the maximum RR on admission, using heart rate (HR) as a comparison since this is objectively measured. We assessed RR patterns among selected subgroups expected to have greater physiological variation using the coefficient of variation (CV=SD/mean).


Among 36 966 hospitalisations, recorded RR was not normally distributed (p<0.001), but right skewed (skewness=3.99) with values clustered at 18 and 20 (kurtosis=23.9). In contrast, HR was relatively normally distributed. Patients with a cardiopulmonary diagnosis or hypoxia only had modestly greater variation (CV increase of 2%–6%). Among 1318 patients transferred from the ward to the intensive care unit (n=1318), RR variation the day preceding transfer was similar to that observed on admission (CV 0.24 vs 0.26), even for those transferred with respiratory failure (CV 0.25).


The observed patterns suggest that RR is inaccurately recorded, even among those with cardiopulmonary compromise, and represents a ‘spot’ estimate with values of 18 and 20 breaths per minute representing ‘normal.’ While spot estimates may potentially be adequate to indicate clinical stability, inaccurate RR may alternatively lead to misclassification of disease severity, potentially jeopardising patient safety. Thus, we recommend greater training for hospital personnel to accurately record RR.

Mobilising or standing still?A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016


The WHO Surgical Safety Checklist (SSC) was developed in 2008 as part of the Safe Surgery Saves Lives campaign.1 Broadly mandated and put into practice in hospitals around the world, the SSC has been the focus of 8 years of extensive research. Initial studies reported positive outcomes on morbidity and mortality.2 3 Other studies have reported more limited impacts, for example,4 still others have reported no impact at all5 6 or questioned the effectiveness of SSC.7 Such results have prompted calls for the reconsideration of policies mandating the SSC as an organisational safety practice.8

Much is at stake here. The role of team communication in care quality is incontrovertible9 10; therefore, decisions to pursue or abandon the SSC are consequential and should be made by drawing from a robust...

The role of social media around patient experience and engagement

Social media usage has become a cultural norm in the USA. Overall, 76% of online adults in the USA use social media.1 And it is not just a phenomenon embraced by the young—31% of all seniors are on Facebook.2 With growing engagement across demographics, social media networks offer new platforms of digital interaction at a scale that is hard to comprehend—313 million active Twitter users sending half a billion tweets and 1.9 billion Facebook accounts uploading 350 million photos every day. SnapChat has created some of the country's youngest billionaires. All these activities, driven by the public's desire to curate and share life experiences, provide new opportunities to observe and understand lived reality in greater detail and closer to real time than ever before.

Concurrently, the concept of patient centredness, whether through better understanding of the patient experience, or better engagement with the patient in...

Measurement with a wink

The Smartest Person is a popular Dutch television quiz show in which three contestants receive a few seconds to answer trivia questions. In one of the rounds, to answer the question, contestants must hit certain key words, for example, ‘Apartheid’, ‘Prison’, ‘Nobel Peace Prize’ and ‘South Africa’ for the question ‘What do you know about Nelson Mandela?’ Contestants who mention one of these key words, regardless of context, hear a rewarding ‘ting!’ and receive 20 extra seconds. The most efficient strategy to win is to mention the four key words without a linking sentence; answering with a complete and cogent sentence costs precious seconds. In fact, contestants can win even when they get the context wrong, for example: ‘Nelson Mandela is an Italian actor starring in a film about the Apartheid (ting!). He recently spent a night in Prison (ting!) after he egged the house of a Nobel Peace Prize...

Drug shortage leading to serendipitous adoption of high-value care practice


Value in healthcare is the clinical outcome and patient experience relative to the costs of care. Traditionally, healthcare providers have primarily focused on improving the quality of care in order to increase value. In fact, change introduced with the primary intention of saving costs is viewed with suspicion, lest it negatively impact the quality of care. Modifying existing practices to primarily decrease costs can thus be quite challenging, even when these changes are evidence-based and have no adverse impact on the quality of care. Attempting to limit the use of intravenous proton pump inhibitors (PPIs) to appropriate indications falls under this category of changes. PPIs are one of the most overused medications, and the intravenous route is often used when oral administration would suffice, significantly increasing medication and administration costs.1–3 Studies have shown that oral PPIs have similar efficacy compared with...

Quantifying low-value care: a patient-centric versus service-centric lens

Low-value healthcare has been defined as care that is inappropriate for a specific clinical indication, inappropriate for a clinical indication in a specific population or an excessive frequency of services relative to expected benefit.1 Quantifying the prevalence of low-value healthcare informs clinicians and health policy makers on the use and associations of unwarranted care.2 In this Viewpoint, we clarify the approaches used in the literature for measuring and reporting the level of low-value care in a given population. Categorising low-value service measures depends on the denominator used. Future analyses should consider using all types of measures when possible, or explain why it is not practical or desirable to do so, and at the very least describe for the reader which measure has been used, as this can dramatically impact interpretation of the results.

Low-value care: listed and (variably) measured

Defining, quantifying and reducing low-value...

Thank you to our reviewers 2016

The Editor would like to publicly acknowledge the people listed below who served as reviewers on the journal during 2016. Without their efforts, the quality of the journal could not be sustained.

Abel Gary

Aggarwal Rajesh

Agyeman-Duah Josephine

Ahmed Zamzam

Al-Tawfiq Jaffar

Alldred Dave

Altomare Antonia

Amalberti Rene

Angell Emma

Appelbaum Nicholas

Ash Joan

Aveling Emma-Louise

Aylin Paul

Baker Ross

Baker Richard

Banerjee Jaydip

Barrow Emily

Bartunek Jean

Beck MJ

Beckett Daniel

Bell Helen

Benishek Lauren

Berry William

Bezemer Jeff

Bhatia Sacha

Bhattacharya Debi

Bilimoria Karl

Birks Yvonne

Bishop Simon

Bjertnaes Oyvind

Blais Regis

Blaschke Gregory

Bloodworth Kerry

Blot Koen

Borzecki Ann

Boutis Kathy

Bouwman Renée

Boyd Matthew

Branch-Elliman Westyn

Bray Benjamin

Brennan Sue

Brewster Liz

Brouwers Corline

Browne John

Byrne Kerry

Callanan Ian

Campbell John

Cane Paul

Card Alan

Carroll Katherine

Carson-Stevens Andrew

Carson-Stevens Andy

Carter Pam

Casserly Brian

Chang David

Charani Esmita

Cheraghi-Sohi Sudeh

Chew Sarah


From polyformacy to formacology

In this issue, Redley and Raggatt1 report on the use of risk assessment tools in the care of older people in Victoria, Australia. Concern with healthcare quality and safety has precipitated widespread use of a range of such seemingly simple interventions. Checklists, pathways, algorithms are a tempting way for organisations and healthcare professionals to signal to the outside world that they are making a good faith effort to ensure service quality. Yet the popularity of these everyday tools has not been matched by their systematic and critical analysis, leading to concern about the potential impact of a growing epidemic of ‘polyformacy’ on healthcare systems. Redley and Raggatt draw into view specific insights about risk management in older people, but their research highlights issues of wider relevance about the use of everyday technologies for healthcare quality and safety that merit further reflection.

A key finding from the study...

A single-centre hospital-wide handoff standardisation report: what is so special about that?

Healthcare leaders and scholars have articulated gaps in handoff quality across nearly all healthcare settings. A variety of drivers, including hospital accreditation, internal and external safety event analyses and medical education objectives, have given rise to a proliferation of imperatives to improve this situation. Healthcare leaders have developed a greater appreciation that handoff is a key component of a larger set of culture and teamwork strategies that are necessary to reduce harm. Researchers and medical educators have created handoff programmes, provided empirical evidence for their positive impact on safety and worked tirelessly to disseminate them.1 2 Quality improvers from a variety of disciplines have begun to adapt and apply standardised handoff in an increasingly diverse array of settings.

In light of this, one might think it less than noteworthy to discover a report of a single institution's hospital-wide handoff standardisation programme.3 To the...

Interruptions in medication administration: are we asking the right questions?

The nature of today’s healthcare practice makes interruptions, distractions and multitasking commonplace, even during complex and high-risk tasks.1–3 Interruptions are often cited as a problem in medication safety, particularly in relation to nurses administering medication.1 4 Previous studies5 6 suggest an association between interruptions and medication administration errors. While a direct causal relationship remains to be proven, reducing interruptions during medication administration to decrease multitasking and cognitive load represents a generally accepted goal.1 4

In this issue of BMJ Quality and Safety, Westbrook7 and colleagues report a cluster randomised controlled trial of a bundled intervention to reduce interruptions during medication administration in a hospital using paper-based prescribing. This well-designed feasibility study tested a bundled intervention based on ‘Do Not Disturb’ vests and the education of healthcare professionals, patients and...

Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: a mixed methods study


Standard risk screening and assessment forms are frequently used in strategies to prevent harm to older people in hospitals. Little is known about good practices for their use.


Scope the preventable harms addressed by standard forms used to screen and assess older people and how standard forms are operationalised in hospitals across Victoria, Australia.


Mixed methods study: (1) cross-sectional audit of the standard risk screening and assessment forms used to assess older people at 11 health services in 2015; (2) nine focus groups with a purposive sample of 69 participants at 9 health services. Descriptive analysis examined the number of items on forms, preventable harms assessed and sources of duplication. Qualitative thematic analysis of focus group data identified themes explaining issues commonly affecting how health services used the forms.


152 standard assessment forms from 11 Victorian health services included over 3700 items with 17% duplicated across multiple forms. Assessments of skin integrity and mobility loss (including falls) were consistently included in forms; however, nutrition, cognitive state, pain and medication risks were inconsistent; and continence, venous thromboembolism risk and hospital acquired infection from invasive devices were infrequent. Qualitative analyses revealed five themes explaining issues associated with current use of assessment forms: (1) comprehensive assessment of preventable harms; (2) burden on staff and the older person, (3) interprofessional collaboration, (4) flexibility to individualise care and (5) information management. Examples of good practice were identified.


Current use of standard risk screening and assessment forms is associated with a high burden and gaps in assessment of several common preventable harms that can increase risk to older people in hospital. Improvement should focus on streamlining forms, increased guidance on interventions to prevent harm and facilitating front-line staff to manage complex decisions.

A qualitative study of emergency physicians perspectives on PROMS in the emergency department


There is a growing emphasis on including patients' perspectives on outcomes as a measure of quality care. To date, this has been challenging in the emergency department (ED) setting. To better understand the root of this challenge, we looked to ED physicians' perspectives on their role, relationships and responsibilities to inform future development and implementation of patient-reported outcome measures (PROMs).


ED physicians from hospitals across Canada were invited to participate in interviews using a snowballing sampling technique. Semistructured interviews were conducted by phone with questions focused on the role and practice of ED physicians, their relationship with their patients and their thoughts on patient-reported feedback as a mechanism for quality improvement. Transcripts were analysed using a modified constant comparative method and interpretive descriptive framework.


Interviews were completed with 30 individual physicians. Respondents were diverse in location, training and years in practice. Physicians reported being interested in ‘objective’ postdischarge information including adverse events, readmissions, other physicians’ notes, etc in a select group of complex patients, but saw ‘patient-reported’ feedback as less valuable due to perceived biases. They were unsure about the impact of such feedback mainly because of the episodic nature of their work. Concerns about timing, as well as about their legal and ethical responsibilities to follow-up if poor patient outcomes are reported, were raised.


Data collection and feedback are key elements of a learning health system. While patient-reported outcomes may have a role in feedback, ED physicians are conflicted about the actionability of such data and ethical implications, given the inherently episodic nature of their work. These findings have important implications for PROM design and implementation in this unique clinical setting.