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1.
Int J Qual Health Care ; 33(Supplement_1): 25-30, 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33432982

RESUMO

WHY IS THE AREA IMPORTANT?: A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable. WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?: We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE: Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.


Assuntos
Erros Médicos , Gestão da Segurança , Atenção à Saúde , Humanos , Erros Médicos/prevenção & controle , Segurança do Paciente , Gestão de Riscos
2.
BMC Med ; 16(1): 174, 2018 10 11.
Artigo em Inglês | MEDLINE | ID: mdl-30305088

RESUMO

BACKGROUND: Ensuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management. METHODS: In a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis. RESULTS: Fourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed. CONCLUSIONS: Traditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.


Assuntos
Atenção à Saúde/normas , Sepse/terapia , Humanos , Atenção Primária à Saúde , Sepse/patologia
3.
Educ Prim Care ; 27(4): 258-66, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27491656

RESUMO

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a 'systems approach' could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a 'Just Culture' where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame 'human error'. System complexity makes reduction into component parts difficult; thus attempting to 'find-and-fix' malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a 'systems approach' that can increase learning and reduce the damaging effects on morale when 'human error' is blamed. This may result in 'human error' becoming the starting point of an investigation and not the endpoint.


Assuntos
Educação Médica Continuada/normas , Erros Médicos/ética , Segurança do Paciente/normas , Médicos de Atenção Primária/educação , Médicos de Atenção Primária/ética , Atenção Primária à Saúde/ética , Pessoal de Saúde/educação , Pessoal de Saúde/ética , Humanos , Internato e Residência/ética , Internato e Residência/normas , Atenção Primária à Saúde/normas
4.
Educ Prim Care ; 27(3): 162-71, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27177434

RESUMO

In the third article in the series, we describe the outputs from a series of roundtable discussions by Human Factors experts and General Practice (GP) Educational Supervisors tasked with examining the GP (family medicine) training and work environments through the lens of the systems and designed-centred discipline of Human Factors and Ergonomics (HFE). A prominent issue agreed upon proposes that the GP setting should be viewed as a complex sociotechnical system from a care service and specialty training perspective. Additionally, while the existing GP specialty training curriculum in the United Kingdom (UK) touches on some important HFE concepts, we argue that there are also significant educational gaps that could be addressed (e.g. physical workplace design, work organisation, the design of procedures, decision-making and human reliability) to increase knowledge and skills that are key to understanding workplace complexity and interactions, and supporting everyday efforts to improve the performance and wellbeing of people and organisations. Altogether we propose and illustrate how future HFE content could be enhanced, contexualised and integrated within existing training arrangements, which also serves as a tentative guide in this area for continuing professional development for the wider GP and primary care teams.


Assuntos
Currículo , Ergonomia , Medicina Geral/educação , Especialização , Currículo/normas , Tomada de Decisões , Humanos , Segurança do Paciente , Melhoria de Qualidade , Reino Unido
5.
Educ Prim Care ; 27(6): 443-450, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27800711

RESUMO

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.


Assuntos
Clínicos Gerais/educação , Segurança do Paciente , Currículo , Atenção à Saúde/organização & administração , Atenção à Saúde/normas , Medicina Geral/educação , Humanos , Erros Médicos , Reino Unido
6.
Scott Med J ; 60(4): 208-13, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26416768

RESUMO

BACKGROUND AND OBJECTIVES: Small-scale quality improvement projects are expected to make a significant contribution towards improving the quality of healthcare. Enabling doctors-in-training to design and lead quality improvement projects is important preparation for independent practice. Participation is mandatory in speciality training curricula. However, provision of training and ongoing support in quality improvement methods and practice is variable. We aimed to design and deliver a quality improvement training package to core medical and general practice specialty trainees and evaluate impact in terms of project participation, completion and publication in a healthcare journal. METHOD: A quality improvement training package was developed and delivered to core medical trainees and general practice specialty trainees in the west of Scotland encompassing a 1-day workshop and mentoring during completion of a quality improvement project over 3 months. A mixed methods evaluation was undertaken and data collected via questionnaire surveys, knowledge assessment, and formative assessment of project proposals, completed quality improvement projects and publication success. RESULTS: Twenty-three participants attended the training day with 20 submitting a project proposal (87%). Ten completed quality improvement projects (43%), eight were judged as satisfactory (35%), and four were submitted and accepted for journal publication (17%). Knowledge and confidence in aspects of quality improvement improved during the pilot, while early feedback on project proposals was valued (85.7%). CONCLUSION: This small study reports modest success in training core medical trainees and general practice specialty trainees in quality improvement. Many gained knowledge of, confidence in and experience of quality improvement, while journal publication was shown to be possible. The development of educational resources to aid quality improvement project completion and mentoring support is necessary if expectations for quality improvement are to be realised.


Assuntos
Políticas Editoriais , Educação de Pós-Graduação em Medicina/métodos , Medicina Geral/educação , Publicações Periódicas como Assunto , Editoração/normas , Melhoria de Qualidade , Educação de Pós-Graduação em Medicina/normas , Humanos , Mentores , Projetos Piloto , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Garantia da Qualidade dos Cuidados de Saúde , Pesquisadores , Escócia
7.
Scott Med J ; 60(4): 196-201, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26209611

RESUMO

INTRODUCTION: Warfarin is an effective drug for patients at risk of thromboembolic events, but sub-optimal pharmacological management may cause significant harm. As part of the Scottish patient safety programme in primary care, one health board region aimed to determine if the international normalised ratio control for patients taking warfarin in general practice improved over the first 12 months of participation. METHODS: A before and after study of a multi-intervention improvement strategy was employed that combined financial incentivisation, a regional learning collaborative, clinical care bundle implementation, audit and feedback and clinical 'safety champions'. The main patient outcome measures were: mean time in therapeutic range; proportion with good control (time in therapeutic range >60%) and excellent control (time in therapeutic range > 75%); and the proportion of very abnormal results (international normalised ratio < 1.5 or >5). Chi-square tests were used to determine statistical differences. RESULTS: In total, 49 of 55 general practices participated (89%) with 33/55 providing usable data (60%) on 1480 patients (before) and 1946 patients (after), respectively. Improvements were observed in mean time in therapeutic range (P < 0.05) as well as in the proportion of patients with good control (time in therapeutic range > 60%, P < 0.01) and excellent control (time in therapeutic range > 75%, P = 0.06). A reduction in the proportion of very abnormal results (international normalised ratio < 1.5 or >5) was also observed (P < 0.01), while the mean number of patient attendances reduced (P < 0.05). CONCLUSIONS: The introduction of a complex safety improvement intervention via a national patient safety programme has resulted in modest improvements in the control of warfarin monitoring in a single region. These improvements may potentially reduce the incidence of serious adverse events. The study method, interventions and findings should be of interest to primary care settings with similar warfarin management arrangements internationally.


Assuntos
Anticoagulantes/administração & dosagem , Medicina Geral/normas , Monitorização Fisiológica , Segurança do Paciente , Atenção Primária à Saúde/normas , Varfarina/administração & dosagem , Anticoagulantes/efeitos adversos , Atitude do Pessoal de Saúde , Humanos , Coeficiente Internacional Normatizado , Informática Médica , Avaliação de Resultados em Cuidados de Saúde , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde , Escócia/epidemiologia , Varfarina/efeitos adversos
8.
BMC Health Serv Res ; 14: 206, 2014 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-24885953

RESUMO

BACKGROUND: In general practice internationally, many care teams handle large numbers of laboratory test results relating to patients in their care. Related research about safety issues is limited with most of the focus on this workload from secondary care and in North American settings. Little has been published in relation to primary health care in the UK and wider Europe. This study aimed to explore experiences and perceptions of patients with regards to the handling of test results by general practices. METHODS: A qualitative research approach was used with patients. The setting was west of Scotland general practices from one National Health Service territorial board area. Patients were purposively sampled from practice held lists of patients who received a number of laboratory tests because of chronic medical problems or surveillance of high risk medicines. Focus groups were held and were audio-recorded. Tapes were transcribed and subjected to qualitative analysis. Transcripts were coded and codes merged into themes by two of the researchers. RESULTS: 19 participants from four medical practices took part in four focus groups. The main themes identified were: 1. Patients lacked awareness of the results handling process in their practice. 2. Patients usually did not contact their practice for test results, unless they considered themselves to be ill. 3. Patients were concerned about the appropriateness of administrators being involved in results handling. 4. Patients were concerned about breaches of confidentiality when administrators were involved in results handling. 5. Patients valued the use of dedicated results handling staff. 6. Patients welcomed the use of technology to alert them to results being available, and valued the ability to choose how this happened. CONCLUSIONS: The study confirms the quality and safety of care problems associated with results handling systems and adds to our knowledge of the issues that impact in these areas. Practices need to be aware that patients may not contact them about results, and they need to publicise their results handling processes to patients and take steps to reassure patients about confidentiality with regards to administrators.


Assuntos
Testes Diagnósticos de Rotina , Medicina Geral , Segurança do Paciente , Satisfação do Paciente , Qualidade da Assistência à Saúde , Idoso , Idoso de 80 Anos ou mais , Feminino , Grupos Focais , Humanos , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa
9.
BMJ Qual Saf ; 33(4): 232-245, 2024 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-37802647

RESUMO

BACKGROUND: Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care. These reports conflict with policy goals to improve coordination of care and dissolve boundaries between specialist services and the community. AIM: To explore how care is coordinated for patients with HFpEF, with a focus on the interface between primary care and specialist services in England. METHODS: We applied systems thinking methodology to examine the relationship between work-as-imagined and work-as-done for coordination of care for patients with HFpEF. We analysed clinical guidelines in conjunction with a secondary applied thematic analysis of semistructured interviews with healthcare professionals caring for patients with HFpEF including general practitioners, specialist nurses and cardiologists and patients with HFpEF themselves (n=41). Systems Thinking for Everyday Work principles provided a sensitising theoretical framework to facilitate a deeper understanding of how these data illustrate a complex health system and where opportunities for improvement interventions may lie. RESULTS: Three themes (working with complexity, information transfer and working relationships) were identified to explain variability between work-as-imagined and work-as-done. Participants raised educational needs, challenging work conditions, issues with information transfer systems and organisational structures poorly aligned with patient needs. CONCLUSIONS: There are multiple challenges that affect coordination of care for patients with HFpEF. Findings from this study illuminate the complexity in coordination of care practices and have implications for future interventional work.


Assuntos
Clínicos Gerais , Insuficiência Cardíaca , Humanos , Insuficiência Cardíaca/terapia , Volume Sistólico , Inglaterra , Atenção Secundária à Saúde
10.
Arterioscler Thromb Vasc Biol ; 31(9): 2157-64, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21680897

RESUMO

OBJECTIVE: Leukocyte telomere length (LTL), a marker of cellular senescence, is inversely associated with cardiovascular events. However, whether LTL reflects plaque extent or unstable plaques, and the mechanisms underlying any association are unknown. METHODS AND RESULTS: One hundred seventy patients with stable angina or acute coronary syndrome referred for percutaneous coronary intervention underwent 3-vessel virtual histology intravascular ultrasound; 30 372 mm of intravascular ultrasound pullback and 1096 plaques were analyzed. LTL was not associated with plaque volume but was associated with calcified thin-capped fibroatheroma (OR, 1.24; CI, 1.01-1.53; P=0.039) and total fibroatheroma numbers (OR, 1.19; CI, 1.02-1.39; P=0.027). Monocytes from coronary artery disease patients showed increased secretion of proinflammatory cytokines. To mimic leukocyte senescence, we disrupted telomeres and binding and expression of the telomeric protein protection of telomeres protein-1, inducing DNA damage. Telomere disruption increased monocyte secretion of monocyte chemoattractant protein-1, IL-6, and IL-1ß and oxidative burst, similar to that seen in coronary artery disease patients, and lymphocyte secretion of IL-2 and reduced lymphocyte IL-10. CONCLUSIONS: Shorter LTL is associated with high-risk plaque morphology on virtual histology intravascular ultrasound but not total 3-vessel plaque burden. Monocytes with disrupted telomeres show increased proinflammatory activity, which is also seen in coronary artery disease patients, suggesting that telomere shortening promotes high-risk plaque subtypes by increasing proinflammatory activity.


Assuntos
Doença da Artéria Coronariana/etiologia , Inflamação/etiologia , Leucócitos/metabolismo , Placa Aterosclerótica/etiologia , Telômero , Ultrassonografia de Intervenção , Senescência Celular , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/imunologia , Citocinas/metabolismo , Humanos , Linfócitos/imunologia , Placa Aterosclerótica/diagnóstico por imagem , Placa Aterosclerótica/imunologia , Risco , Fatores de Risco
11.
BMJ Open Qual ; 9(1)2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32209593

RESUMO

INTRODUCTION: 'Systems thinking' is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a 'Safety-II systems approach' to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting. METHODS: The original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders. RESULTS: Six interrelated principles for healthcare were agreed. The foundation concept acknowledges that 'most healthcare problems and solutions belong to the system'. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions-demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design. CONCLUSIONS: Application of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.


Assuntos
Melhoria de Qualidade/tendências , Análise de Sistemas , Adulto , Educação/métodos , Educação/tendências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade/normas
12.
BMJ Open Qual ; 9(4)2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33184042

RESUMO

BACKGROUND: Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context. METHODS: A multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and 'experts' to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented. RESULTS: A redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%-98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%). CONCLUSIONS: The checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.


Assuntos
Lista de Checagem , Medicina Geral , Medicina de Família e Comunidade , Humanos , Qualidade da Assistência à Saúde , Reprodutibilidade dos Testes
13.
BMJ Open Qual ; 8(1): e000507, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31259272

RESUMO

Background: 'Always Events' (AE) is a validated quality improvement (QI) method where patients, and/or carers, are asked what is so important that it should 'always' happen when they interact with healthcare services. Answers that meet defined criteria can be used to direct patient-centred QI activities. This method has never, to our knowledge, been applied in the care of a UK homeless population. We aimed to test the aspects of the acceptability and feasibility of the AE method to inform on its potential application to improve care for this vulnerable group of patients. Methods: All patients attending three consecutive drop-in clinics at a specialist homeless general practitioner service in Glasgow, who agreed to participate, were interviewed. Anonymised responses were transcribed and coded and a thematic analysis performed. Themes were summarised to generate candidate AE using the patient's own words. The authors then determined if they met the AE criteria. Results: Twenty out of 22 eligible patients were interviewed. Oral transcribing was found to be an acceptable way to gather data in this group. Nine candidate AEs were generated, of which five fitted the criteria to be used as metrics for future QI projects. This project generated AEs and QI targets, and highlighted issues of importance to patients that could be easily addressed. Conclusion: In the homeless context, obtaining high engagement and useful patient feedback, in a convenient way, is difficult. The AE method is an acceptable and feasible tool for generating QI targets that can lead to improvements in care for this vulnerable group.


Assuntos
Pessoas Mal Alojadas/psicologia , Assistência Centrada no Paciente/normas , Atenção Primária à Saúde , Melhoria de Qualidade , Especialização , Retroalimentação , Feminino , Pessoal de Saúde/psicologia , Humanos , Masculino , Reino Unido
14.
BMJ Qual Saf ; 27(4): 308-320, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29248878

RESUMO

BACKGROUND: Pharmacists' completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload. METHODS: This is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively. RESULTS: Fourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre-post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload. CONCLUSIONS: Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.


Assuntos
Reconciliação de Medicamentos/normas , Alta do Paciente , Farmacêuticos , Papel Profissional
15.
Can J Cardiol ; 33(12): 1708-1715, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29173609

RESUMO

BACKGROUND: Previous studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS. METHODS: Twenty-six patients with newly diagnosed OSAS and a moderate-large PFO (prevalence, 18% of 143 patients screened) were referred for PFO closure. The oxygen desaturation index (ODI), apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), 6-minute walk test (6MWT), and Sleep Apnea Quality of Life Index (SAQLI) results were compared in these patients at baseline (before continuous positive pressure ventilation [CPAP]) and at 6-month follow-up (after interrupting CPAP for 1 week). RESULTS: All PFOs were safely sealed at 6 months, as confirmed by repeated transthoracic echocardiography. The ODI (44.8 [interquartile range (IQR), 31.2-63.5) vs 42.3 [IQR, 34.0-60.8]; P = 0.89) and AHI (47.9 [IQR, 31.5-65.2] vs 42.3 [IQR, 32.1-63]; P = 0.99) did not change after PFO closure nor did the 6MWT, although the ESS (13.0 [IQR, 12.0-16.8] vs 6.0 [IQR, 4.0-8.8]; P < 0.001) and the SAQLI (3.4 [IQR, 2.8-4.3] vs 4.4 [IQR, 3.9-5.3]; P < 0.001) did improve. CONCLUSIONS: The prevalence of PFO in OSAS appears to be no higher than that in the general population. Although PFO closure is safe and effective, it did not improve respiratory polygraphy measures of OSAS severity. The improvement in the ESS and SAQLI likely reflect residual benefits from CPAP.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Forame Oval Patente/cirurgia , Apneia Obstrutiva do Sono/complicações , Cirurgia Assistida por Computador/métodos , Idoso , Pressão Positiva Contínua nas Vias Aéreas , Ecocardiografia Transesofagiana , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Polissonografia , Prognóstico , Qualidade de Vida , Apneia Obstrutiva do Sono/fisiopatologia , Inquéritos e Questionários
16.
Educ Prim Care ; 27(1): 3-9, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26862792

RESUMO

In the first series of related articles, we describe how assurance of patient safety in primary care was traditionally viewed by the medical profession hierarchy as being wholly dependent at the individual level upon a combination of education and training, knowledge, skill, experience and commitment to professional development. As well as summarising the evidence underpinning what we know about patient safety in primary care, we outline how contemporary thinking has evolved to recognise that the safety issue is complex, problematic and systemic, and that it is now beginning to attract the attention of national policymakers, educators and research funders in some countries. We also describe a range of recently developed educational safety concepts and methods that have been implemented as part of current national programme initiatives in the United Kingdom and internationally. Finally, we reflect on international progress on patient safety in primary care thus far; propose a future direction for related education, development and research; and briefly introduce the Human Factors based topics to be addressed in the forthcoming series of interrelated articles in this journal.


Assuntos
Medicina Geral/educação , Segurança do Paciente , Atenção Primária à Saúde/organização & administração , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Competência Clínica , Educação Médica Continuada , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Equipe de Assistência ao Paciente , Atenção Primária à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Reino Unido
17.
Atherosclerosis ; 183(2): 268-74, 2005 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-15894320

RESUMO

The chemokines are a family of signalling proteins that participate in regulation of the immune system and have been implicated in the pathogenesis of vascular diseases. Deleting the gene encoding the chemokine MCP-1 in mouse models of atherosclerosis reduces lipid lesion formation and circulating chemokines are upregulated in man immediately following myocardial infarction (MI) or coronary angioplasty. We have therefore investigated whether circulating levels of two chemokines (MCP-1 and eotaxin) differ between subjects with and without atherosclerosis. We have used three different methods of measuring the presence and extent of atherosclerosis in human subjects: duplex ultrasonography of the carotid arteries and clinical diagnosis of coronary heart disease on individuals from the general population and coronary angiography on patients with suspected heart disease. There was no difference in the levels of circulating MCP-1 or eotaxin, measured by ELISA, between subjects with and without atherosclerosis. Furthermore, any increase in circulating MCP-1 following acute MI must be short-lived, since chemokine levels were not different in subjects who had had an MI previously compared to those who had not. We conclude that although there may be a transient increase in circulating chemokine levels following coronary angioplasty, there is no difference in the levels of circulating MCP-1 or eotaxin in subjects with and without atherosclerosis.


Assuntos
Quimiocina CCL2/sangue , Quimiocinas CC/sangue , Fatores Quimiotáticos de Eosinófilos/sangue , Doença da Artéria Coronariana/sangue , Infarto do Miocárdio/sangue , Idoso , Aterosclerose/sangue , Aterosclerose/diagnóstico por imagem , Aterosclerose/fisiopatologia , Biomarcadores/sangue , Velocidade do Fluxo Sanguíneo , Doenças das Artérias Carótidas/sangue , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/fisiopatologia , Quimiocina CCL11 , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Infarto do Miocárdio/diagnóstico por imagem , Prognóstico , Índice de Gravidade de Doença , Ultrassonografia Doppler em Cores
18.
Am J Cardiol ; 96(2): 187-92, 2005 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-16018839

RESUMO

Impaired coronary flow reserve is widely reported in diabetes mellitus (DM) but its effect on myocardial contrast echocardiography (MCE) is unclear. We sought to identify whether DM influences the accuracy of qualitative and quantitative assessment of coronary artery disease (CAD) using MCE in 83 patients who underwent coronary angiography (60 men, 27 with DM; 56 +/- 11 years;). Destruction replenishment imaging was performed at rest and after combined dipyridamole-exercise stress testing. Ischemia was identified by the development of new wall motion abnormalities, qualitative MCE (new perfusion defects apparent 1 second after flash during hyperemia), and quantitative MCE (myocardial blood flow reserve <2.0 in the anterior circulation). Qualitative and quantitative assessment of perfusion was feasible in 100% and 92% of patients, respectively. Significant left anterior descending coronary stenosis (>50% by quantitative angiography) was present in 28 patients (including 8 with DM); 55 patients had no CAD (including 19 with DM). The myocardial blood flow reserve was reduced in patients with coronary stenosis compared with those with no CAD (1.6 +/- 1.1 vs 3.8 +/- 2.5, p <0.001). Among patients with no CAD, those with DM had an impaired flow reserve compared with control patients without DM (2.4 +/- 1.0 vs 4.5 +/- 2.8, p = 0.003). In conclusion, DM significantly influenced the quantitative, but not the qualitative, assessment of MCE, with a marked reduction in specificity in patients with DM.


Assuntos
Estenose Coronária/diagnóstico por imagem , Diabetes Mellitus/diagnóstico , Ecocardiografia/métodos , Idoso , Análise de Variância , Estudos de Casos e Controles , Meios de Contraste/farmacologia , Angiografia Coronária/métodos , Circulação Coronária/fisiologia , Estenose Coronária/epidemiologia , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Probabilidade , Estudos Prospectivos , Valores de Referência , Medição de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença
19.
Artigo em Inglês | MEDLINE | ID: mdl-26734324

RESUMO

The Scottish Patient Safety Programme in Primary Care (SPSP-PC) aims to improve the medicines reconciliation process in primary care to help reduce the number of adverse events causing avoidable harm. [1] The aim of this project is to improve the process for handling Immediate Discharge Documents (IDDs) in a single practice and develop a protocol using the care bundle approach. The care bundle consisted of: 1. Medicines reconciled and repeat prescription updated 2. Follow up documented 3. Diagnosis coded 4. Were all actions completed? A baseline audit was performed followed by three PDSA cycles. Interventions included: education at each cycle, decision that all Doctors would use the Medicines Reconciliation Polypharmacy LES template and constructing an electronic checklist for the care bundle. Compliance with the care bundle rose from 20% in the baseline measurement to 100% in PDSA cycles two and three. In conclusion, a protocol was developed for the processing of IDDs utilizing the care bundle approach with an electronic checklist, resulting in an improvement in the practice management of IDDs.

20.
Artigo em Inglês | MEDLINE | ID: mdl-26734335

RESUMO

It is known that the management of chronic gout in relation to serum uric acid (SUA) monitoring, allopurinol dosing, and lifestyle advice is often sub-optimal in primary care.[1] A quality improvement project in the form of a criterion based audit was carried out in an urban general practice to improve the care of patients being treated for gout. Baseline searching of EMIS confirmed that management of patients with gout who were taking allopurinol was not in line with current guidance. 51(40%) had a SUA checked in the past 12 months, 88(25%) had a SUA below target level, and gout lifestyle advice was not being recorded. An audit was performed to measure and improve the following criteria: Monitoring of SUA levels in the past 12 monthsTitration of urate lowering therapy to bring the SUA below target levelLifestyle advice in the past 12 months An audit standard of 60% achievement at 2 months and 80% achievement at 4 months was set. The intervention consisted of a custom electronic template within EMIS which allowed guidance of gout management to be displayed and for data to be entered. All members of the team including GPs and administrative staff were educated regarding the intervention. This resulted in a sustained improvement over a 6 month period in all 3 components of the audit with 112(84%) having a SUA level checked, 79(51%) having a SUA below target level and 76(57%) receiving lifestyle advice. Although the improvement did not reach the audit standard in 2 of the criteria it would be expected that outcomes would continue given the systems changes which have been made.

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