Targeted protein degradation using intracellular antibodies and its application to neurodegenerative disease.

Antibodies mediate the majority of their effects in the extracellular domain, or in intracellular compartments isolated from the cytosol. Under a growing list of circumstances, however, antibodies are found to gain access to the cytoplasm. Cytosolic immune complexes are bound by the atypical antibody receptor TRIM21, which mediates the rapid degradation of the immune complexes at the proteasome. These discoveries have informed the development of TRIM-Away, a technique to selectively deplete proteins using delivery of antibodies into cells. A range of related approaches that elicit selective protein degradation using intracellular constructs linking antibody fragments to degradative effector functions have also been developed. These methods hold promise for inducing the degradation of proteins as both research tools and as a novel therapeutic approach. Protein aggregates are a pathophysiological feature of neurodegenerative diseases and are considered to have a causal role in pathology. Immunotherapy is emerging as a promising route towards their selective targeting, and a role of antibodies in the cytosol has been demonstrated in cell-based assays. This review will explore the mechanisms by which therapeutic antibodies engage and eliminate intracellularly aggregated proteins. We will discuss how future developments in intracellular antibody technology may enhance the therapeutic potential of such antibody-derived therapies.

Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom.

BACKGROUND: In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making. OBJECTIVE: To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing. DESIGN: Experience-based co-design is an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed. SETTING AND PARTICIPANTS: Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care. RESULTS: The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations. CONCLUSIONS: Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing. PATIENT OR PUBLIC CONTRIBUTION: Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

The impact of hospital command centre on patient flow and data quality: findings from the UK National Health Service.

In the last 6 years, hospitals in developed countries have been trialling the use of command centres for improving organizational efficiency and patient care. However, the impact of these command centres has not been systematically studied in the past. It is a retrospective population-based study. Participants were patients who visited the Bradford Royal Infirmary hospital, Accident and Emergency (A&E) Department, between 1 January 2018 and 31 August 2021. Outcomes were patient flow (measured as A&E waiting time, length of stay, and clinician seen time) and data quality (measured by the proportion of missing treatment and assessment dates and valid transition between A&E care stages). Interrupted time-series segmented regression and process mining were used for analysis. A&E transition time from patient arrival to assessment by a clinician marginally improved during the intervention period; there was a decrease of 0.9 min [95% confidence interval (CI): 0.35-1.4], 3 min (95% CI: 2.4-3.5), 9.7 min (95% CI: 8.4-11.0), and 3.1 min (95% CI: 2.7-3.5) during 'patient flow program', 'command centre display roll-in', 'command centre activation', and 'hospital wide training program', respectively. However, the transition time from patient treatment until the conclusion of consultation showed an increase of 11.5 min (95% CI: 9.2-13.9), 12.3 min (95% CI: 8.7-15.9), 53.4 min (95% CI: 48.1-58.7), and 50.2 min (95% CI: 47.5-52.9) for the respective four post-intervention periods. Furthermore, the length of stay was not significantly impacted; the change was -8.8 h (95% CI: -17.6 to 0.08), -8.9 h (95% CI: -18.6 to 0.65), -1.67 h (95% CI: -10.3 to 6.9), and -0.54 h (95% CI: -13.9 to 12.8) during the four respective post-intervention periods. It was a similar pattern for the waiting and clinician seen times. Data quality as measured by the proportion of missing dates of records was generally poor (treatment date = 42.7% and clinician seen date = 23.4%) and did not significantly improve during the intervention periods. The findings of the study suggest that a command centre package that includes process change and software technology does not appear to have a consistent positive impact on patient safety and data quality based on the indicators and data we used. Therefore, hospitals considering introducing a command centre should not assume there will be benefits in patient flow and data quality.

The role of feedback in emergency ambulance services: a qualitative interview study.

BACKGROUND: Several international studies suggest that the feedback that emergency ambulance service (EMS) personnel receive on the care they have delivered lacks structure, relevance, credibility and routine implementation. Feedback in this context can relate to performance or patient outcomes, can come from a variety of sources and can be sought or imposed. Evidence from health services research and implementation science, suggests that feedback can change professional behavior, improve clinical outcomes and positively influence staff mental health. The current study aimed to explore the experience of EMS professionals regarding current feedback provision and their views on how feedback impacts on patient care, patient safety and staff wellbeing. METHODS: This qualitative study was conducted as part of a wider study of work-related wellbeing in EMS professionals. We used purposive sampling to select 24 frontline EMS professionals from one ambulance service in the United Kingdom and conducted semi-structured interviews. The data was analyzed in iterative cycles of inductive and deductive reasoning using Abductive Thematic Network Analysis. The analysis was informed by psychological theory, as well as models from the wider feedback effectiveness and feedback-seeking behavior literature. RESULTS: Participants viewed current feedback provision as inadequate and consistently expressed a desire for increased feedback. Reported types of prehospital feedback included patient outcome feedback, patient-experience feedback, peer-to-peer feedback, performance feedback, feedforward: on-scene advice, debriefing and investigations and coroners' reports. Participants raised concerns that inadequate feedback could negatively impact on patient safety by preventing learning from mistakes. Enhancing feedback provision was thought to improve patient care and staff wellbeing by supporting personal and professional development. CONCLUSIONS: In line with previous research in this area, this study highlights EMS professionals' strong desire for feedback. The study advances the literature by suggesting a typology of prehospital feedback and presenting a unique insight into the motives for feedback-seeking using psychological theory. A logic model for prehospital feedback interventions was developed to inform future research and development into prehospital feedback.

Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory.

BACKGROUND: Global evidence suggests a range of benefits for introducing electronic health record (EHR) systems to improve patient care. However, implementing EHR within healthcare organisations is complex and, in the United Kingdom (UK), uptake has been slow. More research is needed to explore factors influencing successful implementation. This study explored staff expectations for change and outcome following procurement of a commercial EHR system by a large academic acute NHS hospital in the UK. METHODS: Qualitative interviews were conducted with 14 members of hospital staff who represented a variety of user groups across different specialities within the hospital. The four components of Normalisation Process Theory (Coherence, Cognitive participation, Collective action and Reflexive monitoring) provided a theoretical framework to interpret and report study findings. RESULTS: Health professionals had a common understanding for the rationale for EHR implementation (Coherence). There was variation in willingness to engage with and invest time into EHR (Cognitive participation) at an individual, professional and organisational level. Collective action (whether staff feel able to use the EHR) was influenced by context and perceived user-involvement in EHR design and planning of the implementation strategy. When appraising EHR (Reflexive monitoring), staff anticipated short and long-term benefits. Staff perceived that quality and safety of patient care would be improved with EHR implementation, but that these benefits may not be immediate. Some staff perceived that use of the system may negatively impact patient care. The findings indicate that preparedness for EHR use could mitigate perceived threats to the quality and safety of care. CONCLUSIONS: Health professionals looked forward to reaping the benefits from EHR use. Variations in level of engagement suggest early components of the implementation strategy were effective, and that more work was needed to involve users in preparing them for use. A clearer understanding as to how staff groups and services differentially interact with the EHR as they go about their daily work was required. The findings may inform other hospitals and healthcare systems on actions that can be taken prior to EHR implementation to reduce concerns for quality and safety of patient care and improve the chance of successful implementation.

Secondary use of data from hospital electronic prescribing and pharmacy systems to support the quality and safety of antimicrobial use: a systematic review.

Background: Electronic prescribing (EP) and electronic hospital pharmacy (EHP) systems are increasingly common. A potential benefit is the extensive data in these systems that could be used to support antimicrobial stewardship, but there is little information on how such data are currently used to support the quality and safety of antimicrobial use. Objectives: To summarize the literature on secondary use of data (SuD) from EP and EHP systems to support quality and safety of antimicrobial use, to describe any barriers to secondary use and to make recommendations for future work in this field. Methods: We conducted a systematic search within four databases; we included original research studies that were (1) based on SuD from hospital EP or EHP systems and (2) reported outcomes relating to quality and/or safety of antimicrobial use and/or qualitative findings relating to SuD in this context. Results: Ninety-four full-text articles were obtained; 14 met our inclusion criteria. Only two described interventions based on SuD; seven described SuD to evaluate other antimicrobial stewardship interventions and five described descriptive or exploratory studies of potential applications of SuD. Types of data used were quantitative antibiotic usage data ( n = 9 studies), dose administration data ( n = 4) and user log data from an electronic dashboard ( n = 1). Barriers included data access, data accuracy and completeness, and complexity when using data from multiple systems or hospital sites. Conclusions: The literature suggests that SuD from EP and EHP systems is potentially useful to support or evaluate antimicrobial stewardship activities; greater system functionality would help to realize these benefits.

Secondary uses of electronic prescribing and pharmacy data in UK hospital care: a national survey.

Electronic hospital pharmacy (EHP) systems are ubiquitous in today's hospitals, with many also implementing electronic prescribing (EP) systems; both contain a potential wealth of medication-related data to support quality improvement. The reasons for reuse and users of this data are generally unknown. Our objectives were to survey secondary use of data (SUD) from EHP and EP systems in UK hospitals, to identify users of and factors influencing SUD.A national postal survey was sent out to all hospital chief pharmacists with pre-notifications and follow-up reminders. Descriptive statistical analysis was performed.Of 187 hospital organisations, 65 (35%) responded. All had EHP systems (for ≥20 years) and all reused data; 50 (77%) had EP systems (established 1-10 years) but only 40 (80%) reused data. Reported facilitators for SUD included medication safety, providing feedback, benchmarking, saving time and patient experience. The purposes of SUD included audits, quality improvement, risk management and general medication-related reporting. Earlier introduction of SUD could provide an opportunity to heighten local improvement initiatives.Data from EHP systems is reused for multiple purposes. Evaluating SUD and sharing experiences could provide richer insight into potential SUD and barriers/factors to consider when implementing or upgrading EP/EHP systems.

Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology.

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis.

BACKGROUND: Extensive research has been conducted into the effects of feedback interventions within many areas of healthcare, but prehospital emergency care has been relatively neglected. Exploratory work suggests that enhancing feedback and follow-up to emergency medical service (EMS) staff might provide staff with closure and improve clinical performance. Our aim was to summarise the literature on the types of feedback received by EMS professionals and its effects on the quality and safety of patient care, staff well-being and professional development. METHODS: A systematic review and meta-analysis, including primary research studies of any method published in peer-reviewed journals. Studies were included if they contained information on systematic feedback to emergency ambulance staff regarding their performance. Databases searched from inception were MEDLINE, Embase, AMED, PsycINFO, HMIC, CINAHL and Web of Science, with searches last updated on 2 August 2022. Study quality was appraised using the Mixed Methods Appraisal Tool. Data analysis followed a convergent integrated design involving simultaneous narrative synthesis and random effects multilevel meta-analyses. RESULTS: The search strategy yielded 3183 articles, with 48 studies meeting inclusion criteria after title/abstract screening and full-text review. Interventions were categorised as audit and feedback (n=31), peer-to-peer feedback (n=3), postevent debriefing (n=2), incident-prompted feedback (n=1), patient outcome feedback (n=1) or a combination thereof (n=4). Feedback was found to have a moderate positive effect on quality of care and professional development with a pooled effect of d=0.50 (95% CI 0.34, 0.67). Feedback to EMS professionals had large effects in improving documentation (d=0.73 (0.00, 1.45)) and protocol adherence (d=0.68 (0.12, 1.24)), as well as small effects in enhancing cardiac arrest performance (d=0.46 (0.06, 0.86)), clinical decision-making (d=0.47 (0.23, 0.72)), ambulance times (d=0.43 (0.12, 0.74)) and survival rates (d=0.22 (0.11, 0.33)). The between-study heterogeneity variance was estimated at σ2=0.32 (95% CI 0.22, 0.50), with an I2 value of 99% (95% CI 98%, 99%), indicating substantial statistical heterogeneity. CONCLUSION: This review demonstrated that the evidence base currently does not support a clear single point estimate of the pooled effect of feedback to EMS staff as a single intervention type due to study heterogeneity. Further research is needed to provide guidance and frameworks supporting better design and evaluation of feedback interventions within EMS. PROSPERO REGISTRATION NUMBER: CRD42020162600.

Implementation and clinical utility of a Computer-Aided Risk Score for Mortality (CARM): a qualitative study.

OBJECTIVES: The Computer-Aided Risk Score for Mortality (CARM) estimates the risk of in-hospital mortality following acute admission to the hospital by automatically amalgamating physiological measures, blood tests, gender, age and COVID-19 status. Our aims were to implement the score with a small group of practitioners and understand their first-hand experience of interacting with the score in situ. DESIGN: Pilot implementation evaluation study involving qualitative interviews. SETTING: This study was conducted in one of the two National Health Service hospital trusts in the North of England in which the score was developed. PARTICIPANTS: Medical, older person and ICU/anaesthetic consultants and specialist grade registrars (n=116) and critical outreach nurses (n=7) were given access to CARM. Nine interviews were conducted in total, with eight doctors and one critical care outreach nurse. INTERVENTIONS: Participants were given access to the CARM score, visible after login to the patients' electronic record, along with information about the development and intended use of the score. RESULTS: Four themes and 14 subthemes emerged from reflexive thematic analysis: (1) current use (including support or challenge clinical judgement and decision making, communicating risk of mortality and professional curiosity); (2) barriers and facilitators to use (including litigation, resource needs, perception of the evidence base, strengths and limitations), (3) implementation support needs (including roll-out and integration, access, training and education); and (4) recommendations for development (including presentation and functionality and potential additional data). Barriers and facilitators to use, and recommendations for development featured highly across most interviews. CONCLUSION: Our in situ evaluation of the pilot implementation of CARM demonstrated its scope in supporting clinical decision making and communicating risk of mortality between clinical colleagues and with service users. It suggested to us barriers to implementation of the score. Our findings may support those seeking to develop, implement or improve the adoption of risk scores.

Effect of a hospital command centre on patient safety: an interrupted time series study.

BACKGROUND: Command centres have been piloted in some hospitals across the developed world in the last few years. Their impact on patient safety, however, has not been systematically studied. Hence, we aimed to investigate this. METHODS: This is a retrospective population-based cohort study. Participants were patients who visited Bradford Royal Infirmary Hospital and Calderdale & Huddersfield hospitals between 1 January 2018 and 31 August 2021. A five-phase, interrupted time series, linear regression analysis was used. RESULTS: After introduction of a Command Centre, while mortality and readmissions marginally improved, there was no statistically significant impact on postoperative sepsis. In the intervention hospital, when compared with the preintervention period, mortality decreased by 1.4% (95% CI 0.8% to 1.9%), 1.5% (95% CI 0.9% to 2.1%), 1.3% (95% CI 0.7% to 1.8%) and 2.5% (95% CI 1.7% to 3.4%) during successive phases of the command centre programme, including roll-in and activation of the technology and preparatory quality improvement work. However, in the control site, compared with the baseline, the weekly mortality also decreased by 2.0% (95% CI 0.9 to 3.1), 2.3% (95% CI 1.1 to 3.5), 1.3% (95% CI 0.2 to 2.4), 3.1% (95% CI 1.4 to 4.8) for the respective intervention phases. No impact on any of the indicators was observed when only the software technology part of the Command Centre was considered. CONCLUSION: Implementation of a hospital Command Centre may have a marginal positive impact on patient safety when implemented as part of a broader hospital-wide improvement programme including colocation of operations and clinical leads in a central location. However, improvement in patient safety indicators was also observed for a comparable period in the control site. Further evaluative research into the impact of hospital command centres on a broader range of patient safety and other outcomes is warranted.

The use of a consultant-led ward round checklist to improve paediatric prescribing: an interrupted time series study.

UNLABELLED: A Check and Correct checklist has previously been developed to increase feedback on prescribing quality and enhance physicians' focus on patients' drug charts during ward rounds. Our objective was to assess the impact of introducing such a prescribing checklist on the quality and safety of inpatient prescribing in two paediatric wards in a London teaching hospital. Between 15 March 2011 and 15 May 2011 (pre-intervention) and between 23 May 2011 and 23 July 2011 (post-intervention), we recorded rates of both technical prescription writing errors and clinical prescribing errors twice a week. During the pre-intervention period, the overall technical error rate was 10.8 % (95 % confidence interval 10.3 %-11.2 %); the clinical error rate was 4.7 % (3.4 %-6.6 %). The most common errors were absence of prescriber's contact details and dose omissions. After the implementation of Check and Correct, error rates were 7.3 % (6.9 %-7.8 %) and 5.5 % (3.9 %-7.9 %), respectively. Segmented regression analysis revealed a significant decrease of -5.0 % in the technical error rate (-7.1 to -2.9 %; -37.7 % relative decrease; R (2) = 0.604) following the intervention, independent of changes in overall medical records' documentation quality. Regarding clinical errors, no significant impact of the intervention could be detected. CONCLUSION: Implementing a Check and Correct checklist led to an improvement in the quality of prescription writing. Although a change in culture may be needed to maximise its potential, we would recommend its more widespread use and evaluation.

Strategies for sustaining a quality improvement collaborative and its patient safety gains.

OBJECTIVE: To identify strategies to facilitate the sustainability of a quality and safety improvement collaborative: the Safer Patients Initiative (SPI) and its successes. DESIGN: A qualitative interview study with a repeated sample at two time points. SETTING: Twenty organizations participating in the SPI programme in the UK. PARTICIPANTS: Twenty principal SPI programme coordinators took part in interviews towards the end of the supported phase of the programme, 12 of which were interviewed again a year later, along with another three replacement programme coordinators, totalling 35 interviewees across the two time points. MAIN OUTCOME MEASURES: Programme coordinators' perceptions of facilitating strategies to the sustainability of the collaborative and its gains. RESULTS: Qualitative analysis identified three overarching factors for the sustainability of SPI: (i) using programme improvement methodology and measurement of its outcomes; (ii) organizational strategies to ensure sustainability and (iii) alignment of goals with external requirements. Within these were eight themes identified by the coordinators as helping to sustain the efforts of the SPI programme and its successes. CONCLUSIONS: This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention.

Patient Safety Informatics: Meeting the Challenges of Emerging Digital Health.

The fourth industrial revolution is based on cyber-physical systems and the connectivity of devices. It is currently unclear what the consequences are for patient safety as existing digital health technologies become ubiquitous with increasing pace and interact in unforeseen ways. In this paper, we describe the output from a workshop focused on identifying the patient safety challenges associated with emerging digital health technologies. We discuss six challenges identified in the workshop and present recommendations to address the patient safety concerns posed by them. A key implication of considering the challenges and opportunities for Patient Safety Informatics is the interdisciplinary contribution required to study digital health technologies within their embedded context. The principles underlying our recommendations are those of proactive and systems approaches that relate the social, technical and regulatory facets underpinning patient safety informatics theory and practice.

Evaluating the safety and patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods protocol.

INTRODUCTION: This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap. METHODS AND ANALYSIS: We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records. ETHICS AND DISSEMINATION: This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.

A quality improvement programme to increase compliance with an anti-infective prescribing policy.

OBJECTIVES: The UK Department of Health has made recommendations on safe and appropriate prescribing of anti-infectives. In response, we reviewed our anti-infective policies to ensure they were in line with best practice. As a result, a new adult anti-infective policy was launched. To help facilitate its implementation, a quality improvement programme was established, with the aim of achieving >90% compliance with the new policy. METHODS: Patients under the care of the medical admissions teams who had been prescribed one or more systemic anti-infectives between January and November 2008 were included in the study. Study pharmacists collected data daily on all patients, including the anti-infective(s) prescribed and indication(s) documented on either the patient's drug prescription chart or health records. A definition of compliance was developed, which required documented indication(s) and associated anti-infectives to match the anti-infective policy. A baseline compliance level was established; we then implemented a series of interventions using the plan-do-study-act ('PDSA') approach to monitor and improve compliance. Three overlapping intervention phases were retrospectively identified: raising awareness; education; and weekly feedback of results in the form of run charts distributed to medical teams. RESULTS: Over the 11 month study period, compliance with the policy increased from 30% to 71%. Since 2008, we have seen the average compliance increase year-on-year to over 90% in 2010 using a sustainable once weekly data collection model. CONCLUSIONS: This study shows that it is possible to use quality improvement methodology to support antimicrobial stewardship within existing resources and suggests that an improvement in policy compliance can be both achieved and sustained.

Predictors of the perceived impact of a patient safety collaborative: an exploratory study.

OBJECTIVE: The aim of this study was to evaluate the influence of various factors on the perceived impact of a patient safety improvement collaborative in the UK, the Safer Patients Initiative (SPI). STUDY DESIGN: A cross-sectional survey design was used. Study setting Twenty National Health Service organizations from the UK that participated in the main phase of the SPI programme, which ran from September 2007 to 2008. PARTICIPANTS: Senior executive leads, clinical operational leads in the four clinical areas targeted by the programme, programme coordinators and any other staff involved in the SPI (n = 635). INTERVENTION: The SPI is a patient safety improvement intervention based on the Breakthrough Series Collaborative model (Institute of Healthcare Improvement, 2004) aimed at improving patient safety in four clinical areas (general ward care, intensive care, perioperative care and pharmacy) through implementing a number of evidence-based clinical practices and a focus on organizational leadership. Outcome measures Participant perceptions of the impact of the programme on their organizations. RESULTS: Exploratory regression analysis showed that programme management, the value assigned to programme methodology and length of data collection contributed the largest variance in perceived impact of the SPI followed by perceived support from junior doctors, inter-professional collaboration, difference of the programme from existing safety improvement practices and organizational readiness. CONCLUSIONS: The resulting model suggests hierarchical importance for a range of variables to support future research concerning the mechanisms by which large-scale organizational programmes, such as the SPI, impact on the care systems they are designed to influence.

The Secondary Use of Data to Support Medication Safety in the Hospital Setting: A Systematic Review and Narrative Synthesis.

OBJECTIVES: To conduct a systematic review and narrative synthesis of interventions based on secondary use of data (SUD) from electronic prescribing (EP) and electronic hospital pharmacy (EHP) systems and their effectiveness in secondary care, and to identify factors influencing SUD. METHOD: The search strategy had four facets: 1. Electronic databases, 2. Medication safety, 3. Hospitals and quality/safety, and 4. SUD. Searches were conducted within EMBASE, Medline, CINAHL, and International Pharmaceutical Abstracts. Empirical SUD intervention studies that aimed to improve medication safety and/or quality, and any studies providing insight into factors affecting SUD were included. RESULTS: We identified nine quantitative studies of SUD interventions and five qualitative studies. SUD interventions were complex and fell into four categories, with 'provision of feedback' the most common. While heterogeneous, the majority of quantitative studies reported positive findings in improving medication safety but little detail was provided on the interventions implemented. The five qualitative studies collectively provide an overview of the SUD process, which typically comprised nine steps from data identification to analysis. Factors influencing the SUD process were electronic systems implementation and level of functionality, knowledge and skills of SUD users, organisational context, and policies around data reuse and security. DISCUSSION AND CONCLUSION: The majority of the SUD interventions were successful in improving medication safety, however, what contributes to this success needs further exploration. From synthesis of research evidence in this review, an integrative framework was developed to describe the processes, mechanisms, and barriers for effective SUD.

Defining a Healthy Organisation in Primary Care: A Qualitative Interview Study.

This study aimed to qualitatively develop a conceptual framework for organizational health, within the setting of GP practices in the UK, through a qualitative interview study utilizing aspects from grounded theory. Data saturation was reached after 33 interviews revealing six themes: Strategy, Resources, Leadership, Staff Wellbeing, Capacity for change and Ways of working. The structure of each theme is discussed in detail. By unpicking the elements of organizational health in GP practices in this way, we hope to shift focus from considering down-stream clinical outcomes in isolation to practices taking a more long-term view centered around fostering ongoing high performance.