Prevalence of Effective Audit-and-Feedback Practices in Primary Care Settings: A Qualitative Examination Within Veterans Health Administration.

OBJECTIVE: The purpose of this study is to uncover and catalog the various practices for delivering and disseminating clinical performance in various Veterans Affairs (VA) locations and to evaluate their quality against evidence-based models of effective feedback as reported in the literature. BACKGROUND: Feedback can enhance clinical performance in subsequent performance episodes. However, evidence is clear that the way in which feedback is delivered determines whether performance is harmed or improved. METHOD: We purposively sampled 16 geographically dispersed VA hospitals based on high, low, consistently moderate, and moderately average highly variable performance on a set of 17 outpatient clinical performance measures. We excluded four sites due to insufficient interview data. We interviewed four key personnel from each location (n = 48) to uncover effective and ineffective audit and feedback strategies. Interviews were transcribed and analyzed qualitatively using a framework-based content analysis approach to identify emergent themes. RESULTS: We identified 102 unique strategies used to deliver feedback. Of these strategies, 64 (62.74%) have been found to be ineffective according to the audit-and-feedback research literature. Comparing features common to effective (e.g., individually tailored, computerized feedback reports) versus ineffective (e.g., large staff meetings) strategies, most ineffective strategies delivered feedback in meetings, whereas strategies receiving the highest effectiveness scores delivered feedback via visually understood reports that did not occur in a group setting. CONCLUSIONS: Findings show that current practices are leveraging largely ineffective feedback strategies. Future research should seek to identify the longitudinal impact of current feedback and audit practices on clinical performance. APPLICATION: Feedback in primary care has little standardization and does not follow available evidence for effective feedback design. Future research in this area is warranted.

Small-scale release of non-gene drive mosquitoes in Burkina Faso: from engagement implementation to assessment, a learning journey.

BACKGROUND: Innovative tools are needed to complement the existing approach for malaria elimination. Gene drive mosquitoes are one potential new technology in the control of malaria vectors. Target Malaria is one of the research projects developing this technology, and in July 2019, the project proceeded to an important step for this evaluation pathway: the small-scale release of non-gene drive sterile male mosquitoes in a village in Burkina Faso. In addition to the entomological and laboratory work to prepare for this important milestone, significant community and stakeholder engagement work was done. The existing guidelines on gene drive mosquito provide an overall framework for such engagement work. However, they do not provide a road map on how to proceed or what benchmarks should be used to assess this work. METHODS: This study provides a review of engagement activities relevant to field trials on non-gene drive genetically-modified mosquitoes as well as an assessment framework-using both qualitative and quantitative studies as well as an audit procedure. The latter was implemented to evaluate whether the release activities could proceed with the appropriate level of agreement from the community. RESULTS: This paper shows the importance of this first phase of work to innovate and learn about engagement processes for responsible research in the field of genetic approaches for malaria vector control. The function of these assessments is crucial for the learning agenda. The assessments demonstrated ways to increase understanding and ensure effective progress with field studies and, therefore, the pathway for responsible research. CONCLUSION: Gene drive technology is increasingly considered as a promising approach to control vector borne diseases, in particular malaria. Stakeholders' involvement in this research process is one of the recurring requirements in international guidance documents. With this paper Target Malaria offers an opportunity to explore the practical achievements and challenges of stakeholder engagement during early phases of a technology evaluation, and in particular how it implemented an assessment framework to learn from its experience.

Long-Term Assessment of the Cecal Intubation Rates in High-Performing Colonoscopists: Time for Review.

OBJECTIVES: The cecal intubation rate (CIR) is one of the 3 priority indicators for quality in colonoscopy. Whether continuous measurement of CIR is useful in high performers is uncertain. METHODS: At an academic center, we identified 16 physicians who performed at least 50 procedures over 6 consecutive years. We analyzed all colonoscopy procedures excluding those with poor/inadequate preparation or severe colitis for CIR trend over the years. We calculated the numbers needed to establish CIR over minimum threshold levels with 95% confidence. RESULTS: The overall CIR was 99.4%. None of the 16 physicians had a CIR <96.6% in any year. Sensitivity analyses including patients without intent to reach the cecum and inadequate bowel preparation had little impact on the results. Overall cecal photo documentation rate was 98.4%. No significant correlation was observed between procedure volume at our center and CIR (σ = -0.196, P = 0.483). Physicians with CIR ≥99% need to have only 24 examinations reviewed to establish CIR is >95%. DISCUSSION: Continuous measurement of CIR, at least in high performers, appears to be of limited value. Very high performers need to evaluate small number of cases to demonstrate that CIR is above the recommended thresholds.

Accuracy of medical billing data against the electronic health record in the measurement of colorectal cancer screening rates.

OBJECTIVE: Medical billing data are an attractive source of secondary analysis because of their ease of use and potential to answer population-health questions with statistical power. Although these datasets have known susceptibilities to biases, the degree to which they can distort the assessment of quality measures such as colorectal cancer screening rates are not widely appreciated, nor are their causes and possible solutions. METHODS: Using a billing code database derived from our institution's electronic health records, we estimated the colorectal cancer screening rate of average-risk patients aged 50-74 years seen in primary care or gastroenterology clinic in 2016-2017. 200 records (150 unscreened, 50 screened) were sampled to quantify the accuracy against manual review. RESULTS: Out of 4611 patients, an analysis of billing data suggested a 61% screening rate, an estimate that matches the estimate by the Centers for Disease Control. Manual review revealed a positive predictive value of 96% (86%-100%), negative predictive value of 21% (15%-29%) and a corrected screening rate of 85% (81%-90%). Most false negatives occurred due to examinations performed outside the scope of the database-both within and outside of our institution-but 21% of false negatives fell within the database's scope. False positives occurred due to incomplete examinations and inadequate bowel preparation. Reasons for screening failure include ordered but incomplete examinations (48%), lack of or incorrect documentation by primary care (29%) including incorrect screening intervals (13%) and patients declining screening (13%). CONCLUSIONS: Billing databases are prone to substantial bias that may go undetected even in the presence of confirmatory external estimates. Caution is recommended when performing population-level inference from these data. We propose several solutions to improve the use of these data for the assessment of healthcare quality.

Artificial intelligence outperforms human students in conducting neurosurgical audits.

OBJECTIVES: Neurosurgical audits are an important part of improving the safety, efficiency and quality of care but require considerable resources, time, and funding. To that end, the advent of the Artificial Intelligence-based algorithms offered a novel, more economically viable solution. The aim of the study was to evaluate whether the algorithm can indeed outperform humans in that task. PATIENTS & METHODS: Forty-six human students were invited to inspect the clinical notes of 45 medical outliers on a neurosurgical ward. The aim of the task was to produce a report containing a quantitative analysis of the scale of the problem (e.g. time to discharge) and a qualitative list of suggestions on how to improve the patient flow, quality of care, and healthcare costs. The Artificial Intelligence-based Frideswide algorithm (FwA) was used to analyse the same dataset. RESULTS: The FwA produced 44 recommendations whilst human students reported an average of 3.89. The mean time to deliver the final report was 5.80 s for the FwA and 10.21 days for humans. The mean relative error for factual inaccuracy for humans was 14.75 % for total waiting times and 81.06 % for times between investigations. The report produced by the FwA was entirely factually correct. 13 out of 46 students submitted an unfinished audit, 3 out of 46 made an overdue submission. Thematic analysis revealed numerous internal contradictions of the recommendations given by human students. CONCLUSION: The AI-based algorithm can produce significantly more recommendations in shorter time. The audits conducted by the AI are more factually accurate (0 % error rate) and logically consistent (no thematic contradictions). This study shows that the algorithm can produce reliable neurosurgical audits for a fraction of the resources required to conduct it by human means.

Patient experience in a surgical assessment unit following a closed-loop audit using a Kaizen Lean system.

BACKGROUND: The Acute Surgical Assessment Unit (ASAU) in University Hospital Limerick (UHL) has provided a solution to overcrowding and long waiting times since centralization of emergency services to UHL. Recognising the importance of its evolving role, the ASAU in UHL has recently undergone a major revamp to ease the pressure in the overcrowded emergency department (ED). This included a new purpose state-of-the-art-built unit and equipment, improved staffing levels and use of a Kaizen Lean system to identify key area of delays and inefficiency with subsequent implementation of suggestions derived after Kaizen Lean. Patient satisfaction reporting was analysed in the older building and subsequently in the new site post Kaizen Lean to complete a closed-loop audit. The aim of the study was to examine patient satisfaction response rates with the ASAU prior to and following Kaizen Lean implementation and transfer to a new purpose-built unit. METHODS: The survey comprised of two phases. In phase 1, 100 questionnaires were distributed to patients in ASAU (older building, pre-Kaizen Lean). In phase 2, the survey was repeated (100 patients) after Kaizen Lean implementation and transfer to the new state-of-the-art unit. Questionnaire design was based on WHO strategy on responsiveness measurement guidelines and was tailored to a population of surgical patients. Results were analysed using IBM SPSS, version 21 and Excel 2013. RESULTS: Two hundred questionnaires were analysed. Implementation of suggestions derived post Kaizen Lean translated into improved resource usage with reduced waiting time to be seen by nurses and doctors. Patients had better awareness about their treatment plan and planned next steps in the management. Satisfaction across different domains, perceptions of privacy and overall treatment were also improved. CONCLUSIONS: A Kaizen Lean approach improved the transition of an ASAU to a new purpose-built unit and further improved overall patient satisfaction with services of the ASAU.

Effectiveness of audit and feedback in addressing over prescribing of antibiotics and injectable medicines in a middle-income country: an RCT.

Overprescribing of antibiotics and injectable medicines is common in ambulatory care in many low- and middleincome countries. We evaluated the effects of three different interventions in improving physician prescribing. We conducted a four-armed randomized controlled trial with one-month and three- months follow-up. General physicians, pediatricians, and infectious disease specialists were included in this study if they had an outpatient office in Tehran, Iran. The study involved two behaviorally guided interventions: "new-design audit and feedback (NA&F)"; "printed educational material (PEM)" and an existing intervention of "routinely conducted audit and feedback (RA&F)". The theoretical framework underpinning the intervention was the theory of planned behavior. Main outcome measures were the percentage change in the proportion of prescriptions containing injectable dexamethasone; oral amoxicillin and cefixime. NA&F reduced the proportion of prescriptions particularly those containing dexamethasone injectable and cefixime (1.64, 0.99 absolute percentage change, p = 0.006, p = 0.01 respectively). PEM reduced the proportion of prescriptions containing cefixime (0.93 absolute percentage change p = 0.04). Other primary outcomes had no significant differences. A secondary outcome measure showed overall prescribing of injectables also reduced (absolute risk reduction: 3%). Overally, the study provides strong evidence that using theoretical insights in the development of the intervention improved prescribing behavior that lasted at least three months after the intervention. The design, format, and presentation of messages in feedback forms significantly influence the impact of audit and feedback on physician prescribing. While the interventions were effective, the impacts on inappropriate prescribing were modest and limited. In settings with rampant problems of overprescribing, intensive interventions are required to substantially improve prescribing patterns. Graphical abstract Graphical abstract.

Non-indicated acid-suppression prescribing in a tertiary paediatric hospital: An audit and costing study.

AIM: To quantify (i) indicated versus non-indicated prescribing of acid-suppression therapies (AST) in a tertiary paediatric hospital; (ii) patient, provider and hospital factors associated with non-indicated prescribing; and (iii) medication costs. METHODS: This was a prospective, electronic medical audit conducted at The Royal Children's Hospital (RCH) Melbourne in August-September 2016. Proton pump inhibitor (PPI) and histamine-2 receptor antagonist (H2 RA) prescriptions were extracted, with relevant patient, provider and hospital data. Logistic regression analysis of variables associated with indicated and non-indicated prescribing was undertaken. Costs of indicated and non-indicated prescriptions were estimated, with annual costs projected. RESULTS: There was more non-indicated than indicated prescribing across inpatient, outpatient and emergency department settings. Of the total 303 prescriptions analysed, 238 (78.5%) were non-indicated. Gastrostomy presence (odds ratio (OR) 5.51 (1.96-15.46), P = 0.001), consultant providers (OR 2.69 (1.23-5.87), P = 0.01) and inpatient setting (OR 2.35 (1.16-4.77), P = 0.02) were all associated with a higher likelihood of non-indicated prescribing. The child having a predisposing diagnosis was significantly associated with indicated prescribing (OR 0.41 (0.21-0.80), P = 0.009). A total of 75% of hospital and patient spending was for non-indicated prescriptions. Annual costs of non-indicated AST for Melbourne's RCH were projected to be $15 493. CONCLUSIONS: Non-indicated acid-suppression prescribing is common in a tertiary paediatric hospital and associated with gastrostomy presence, consultant providers and inpatient status. Future research should use qualitative methods to understand clinician and patient drivers of prescribing and use this information to develop and test targeted solutions to reduce non-indicated AST prescribing.

Incidence and characteristics of ventilator-associated pneumonia in a regional non-tertiary Australian intensive care unit: protocol for a retrospective clinical audit study.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is a medical complication associated with prolonged mechanical ventilation. Most studies looking at VAP originate from major, tertiary intensive care units (ICUs). Our understanding of VAP in regional hospitals is limited. Given that patient characteristics often differ between metropolitan and regional centres, it is important to investigate VAP in a regional non-tertiary ICU. This project will establish and report the incidence, case characteristics and outcomes including mortality and length of stay related to VAP in a regional non-tertiary Australian ICU. Furthermore, it will compare the incidence of VAP in accordance with consultant diagnosed cases in the medical record, and by a post hoc screening of all cases against a list of previously published diagnostic criteria. METHODS AND ANALYSIS: This retrospective clinical audit study will screen medical records from the period 1 January 2013 to 31 December 2016. All cases requiring mechanical ventilation for ≥72 hours will be screened against previously reported diagnostic criteria for VAP. At the same time, their medical records will be screened for a documented diagnosis of VAP. ETHICS AND DISSEMINATION: This study has been granted ethical approval from the Central Queensland Hospital and Health Service (CQHHS) Human Research Ethics Committee (HREC/17/QCQ/11) and the Central Queensland University Human Research Ethics Committee (H17/05-102). This study will be submitted for publication in a peer-reviewed scientific journal and presented at internal workshops (within Queensland Health) and national and/or international scientific conferences.

Hospitalizations With Observation Services and the Medicare Part A Complex Appeals Process at Three Academic Medical Centers.

Hospitalists and other providers must classify hospitalized patients as inpatient or outpatient, the latter of which includes all observation stays. These orders direct hospital billing and payment, as well as patient out-of-pocket expenses. The Centers for Medicare & Medicaid Services (CMS) audits hospital billing for Medicare beneficiaries, historically through the Recovery Audit program. A recent U.S. Government Accountability Office (GAO) report identified problems in the hospital appeals process of Recovery Audit program audits to which CMS proposed reforms. In the context of the GAO report and CMS's proposed improvements, we conducted a study to describe the time course and process of complex Medicare Part A audits and appeals reaching Level 3 of the 5-level appeals process as of May 1, 2016 at 3 academic medical centers. Of 219 appeals reaching Level 3, 135 had a decision--96 (71.1%) successful for the hospitals. Mean total time since date of service was 1663.3 days, which includes mean days between date of service and audit (560.4) and total days in appeals (891.3). Government contractors were responsible for 70.7% of total appeals time. Overall, government contractors and judges met legislative timeliness deadlines less than half the time (47.7%), with declining compliance at successive levels (discussion, 92.5%; Level 1, 85.4%; Level 2, 38.8%; Level 3, 0%). Most Level 1 and Level 2 decision letters (95.2%) cited time-based (24-hour) criteria for determining inpatient status, despite 70.3% of denied appeals meeting the 24-hour benchmark. These findings suggest that the Medicare appeals system merits process improvement beyond current proposed reforms. Journal of Hospital Medicine 2017;12:251-255.

Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center.

STUDY OBJECTIVE: To evaluate the quality of postoperative pain relief during the first 3 days after surgery and to evaluate with the incidence of persistent pain at 6 months after surgery. DESIGN: Retrospective single-center audit. SETTING: University hospital. PATIENTS: Five hundred four patients who underwent thoracotomy. INTERVENTIONS: Review of patient records, questionnaire, and telephone review. RESULTS: Of the 364 survivors, 306 were contacted. Five or more episodes of severe pain (numerical rating scale >6/10 at rest or movement) during the first 72 hours after surgery occurred in 133 patients. Persistent postsurgical pain at 6 months was present in 82% (109/133) of these patients. Patient satisfaction with acute postoperative pain management was excellent (36%), good (43%), and fair or poor (21%).The incidence of postthoracotomy pain was 56% (mild 32%, moderate 18%, and severe 6%). CONCLUSIONS: Poorly controlled acute postoperative pain correlated with persistent postsurgical pain at 6 months. In view of such a high incidence in thoracotomy patients, preventative strategies assume great significance.

A multicentre snapshot study of the incidence of serious procedural complications secondary to central venous catheterisation.

Despite the high number of central venous access devices inserted annually, there are limited data on the incidence of the associated procedural complications, many of which carry substantial clinical risk. This point was highlighted in the recently published Association of Anaesthetists of Great Britain and Ireland 'Safe vascular access 2016' guidelines. This trainee-led snapshot study aimed to identify the number of central venous catheter insertions and the incidence of serious complications across multiple hospital sites within a fixed two-week period. Secondary aims were to identify the availability of resources and infrastructure to facilitate safe central venous catheter insertion and management of potential complications. Fifteen hospital sites participated, completing an initial resource survey and daily identification of all adult central venous catheter insertions, with subsequent review of any complications detected. A total of 487 central venous catheter insertions were identified, of which 15 (3.1%) were associated with a significant procedural complication. The most common complication was failure of insertion, which occurred in seven (1.4%) cases. Facilities to enable safer central venous catheter insertion and manage complications varied widely between hospitals, with little evidence of standardisation of guidelines or protocols.

Venous thromboembolism prophylaxis risk assessment in a general surgery cohort: a closed-loop audit.

BACKGROUND AND AIMS: Venous thromboembolism (VTE) is a potential source of morbidity and mortality in surgical in-patients. A number of guidelines exist that advise on prophylactic measures. We aimed to assess VTE prophylaxis prescribing practices and compliance with a kardex-based risk assessment tool in a general surgery population. METHODS: Data on general surgery in-patients were collected on two separate wards on two separate days. Drug kardexes were assessed for VTE prophylaxis measures and use of the risk assessment tool. NICE and SIGN guidelines were adopted as a gold standard. The audit results and information on the risk assessment tool were presented as an educational intervention at two separate departmental teaching sessions. A re-audit was completed after 3 months. RESULTS: In Audit A, 74 patients were assessed. 70% were emergency admissions. The risk assessment tool was completed in 2.7%. 75 and 97% of patients were correctly prescribed anti-embolic stockings (AES) and low-molecular weight heparin (LMWH), respectively. 30 patients were included in Audit B, 56% of whom were emergency admissions. 66% had a risk assessment performed, a statistically significant improvement (p < 0.0001). Rates of LMWH prescribing were similar (96%), but AES prescribing was lower (36%). CONCLUSION: Rates of LMWH prescribing are high in this general surgical population, although AES prescribing rates vary. Use of the VTE risk assessment tool increased following the initial audit and intervention.

Obstetric Care Consensus No. 5: Severe Maternal Morbidity: Screening and Review.

This document builds upon recommendations from peer organizations and outlines a process for identifying maternal cases that should be reviewed. Severe maternal morbidity is associated with a high rate of preventability, similar to that of maternal mortality. It also can be considered a near miss for maternal mortality because without identification and treatment, in some cases, these conditions would lead to maternal death. Identifying severe morbidity is, therefore, important for preventing such injuries that lead to mortality and for highlighting opportunities to avoid repeat injuries. The two-step screen and review process described in this document is intended to efficiently detect severe maternal morbidity in women and to ensure that each case undergoes a review to determine whether there were opportunities for improvement in care. Like cases of maternal mortality, cases of severe maternal morbidity merit quality review. In the absence of consensus on a comprehensive list of conditions that represent severe maternal morbidity, institutions and systems should either adopt an existing screening criteria or create their own list of outcomes that merit review.

An Objective Assessment of the Surgical Trainee in an Urban Trauma Unit in South Africa: A Pilot Study.

BACKGROUND: Surgical outcomes are provider specific. This prospective audit describes the surgical activity of five general surgery residents on their trauma surgery rotation. It was hypothesized that the operating surgical trainee is an independent risk factor for adverse outcomes following major trauma. MATERIALS AND METHODS: This is a prospective cohort study. All patients admitted, over a 6-month period (August 2014-January 2015), following trauma requiring a major operation performed by a surgical trainee at Groote Schuur Hospital's trauma unit in South Africa were included. Multiple logistic regression models were built to compare risk-adjusted surgical outcomes between trainees. The primary outcome measure was major in-hospital complications. RESULTS: A total of 320 major operations involving 341 procedures were included. The mean age was 28.49 years (range 13-64), 97.2 % were male with a median ISS of 9 (IQR 1-41). Mechanism of injury was penetrating in 93.42 % of cases of which 51.86 % were gunshot injuries. Surgeon A consistently had the lowest risk-adjusted outcomes and was used as the reference for all outcomes in the regression models. Surgeon B, D, and E had statistically significant higher rates of major in-hospital complications than Surgeon A and C, after adjusting for multiple confounders. The final model used to calculate the risk estimates for the primary outcome had a ROC of 0.8649. CONCLUSION: Risk-adjusted surgical outcomes vary by operating surgical trainee. The analysis thereof can add value to the objective assessment of a surgical trainee.

Pressure ulcer and wounds reporting in NHS hospitals in England part 1: Audit of monitoring systems.

Internationally, health-care systems have attempted to assess the scale of and demonstrate improvement in patient harms. Pressure ulcer (PU) monitoring systems have been introduced across NHS in-patient facilities in England, including the Safety Thermometer (STh) (prevalence), Incident Reporting Systems (IRS) and the Strategic Executive Information System (STEIS) for serious incidents. This is the first of two related papers considering PU monitoring systems across NHS in-patient facilities in England and focusses on a Wound Audit (PUWA) to assess the accuracy of these systems. Part 2 of this work and recommendations are reported pp *-*. The PUWA was undertaken in line with 'gold-standard' PU prevalence methods in a stratified random sample of NHS Trusts; 24/34 (72.7%) invited NHS Trusts participated, from which 121 randomly selected wards and 2239 patients agreed to participate. PREVALENCE OF EXISTING PUS: The PUWA identified 160 (7.1%) patients with an existing PU, compared to 105 (4.7%) on STh. STh had a weighted sensitivity of 48.2% (95%CI 35.4%-56.7%) and weighted specificity of 99.0% (95%CI 98.99%-99.01%). EXISTING/HEALED PUS: The PUWA identified 189 (8.4%) patients with an existing/healed PU compared to 135 (6.0%) on IRS. IRS had an unweighted sensitivity of 53.4% (95%CI 46.3%-60.4%) and unweighted specificity of 98.3% (95%CI 97.7%-98.8%). 83 patients had one or more potentially serious PU on PUWA and 8 (9.6%) of these patients were reported on STEIS. The results identified high levels of under-reporting for all systems and highlighted data capture challenges, including the use of clinical staff to inform national monitoring systems and the completeness of clinical records for PUs.

Healthcare Databases in Thailand and Japan: Potential Sources for Health Technology Assessment Research.

BACKGROUND: Health technology assessment (HTA) has been continuously used for value-based healthcare decisions over the last decade. Healthcare databases represent an important source of information for HTA, which has seen a surge in use in Western countries. Although HTA agencies have been established in Asia-Pacific region, application and understanding of healthcare databases for HTA is rather limited. Thus, we reviewed existing databases to assess their potential for HTA in Thailand where HTA has been used officially and Japan where HTA is going to be officially introduced. METHOD: Existing healthcare databases in Thailand and Japan were compiled and reviewed. Databases' characteristics e.g. name of database, host, scope/objective, time/sample size, design, data collection method, population/sample, and variables were described. Databases were assessed for its potential HTA use in terms of safety/efficacy/effectiveness, social/ethical, organization/professional, economic, and epidemiological domains. Request route for each database was also provided. RESULTS: Forty databases- 20 from Thailand and 20 from Japan-were included. These comprised of national censuses, surveys, registries, administrative data, and claimed databases. All databases were potentially used for epidemiological studies. In addition, data on mortality, morbidity, disability, adverse events, quality of life, service/technology utilization, length of stay, and economics were also found in some databases. However, access to patient-level data was limited since information about the databases was not available on public sources. CONCLUSION: Our findings have shown that existing databases provided valuable information for HTA research with limitation on accessibility. Mutual dialogue on healthcare database development and usage for HTA among Asia-Pacific region is needed.

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

BACKGROUND: Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback METHODS/DESIGN: A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Review of critical incidents in a university department of anaesthesia.

In 2011, our hospital started a new system of 100% procedural audit of anaesthesia work, in which we incorporated the reporting of critical incidents. This monitoring of critical incidents has enabled identification of the spectrum of incidents and risk factors and helped in the education of trainees and specialists. In this review, we analyse 379 incidents that had been reported among 44,915 anaesthetics administered in a two-year period. The risk of incidents was higher in patients of lower American Society of Anesthesiologists physical status, anaesthesia of long duration and anaesthesia carried out after-hours. The most common incidents were airway problems and drug administration problems. Fifty-nine percent of incidents were evaluated to be preventable and adverse outcomes occurred in 48% of cases. Human factors were the major contributors to incidents. We suggest that incorporating critical incident reporting as part of a 100% procedural audit facilitated, rather than discouraged, the reporting of critical incidents, even though reporting was not anonymous. The rate of incident reporting increased from 0.37% to 0.84%.