Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts.

Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

OBJECTIVE: To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. DESIGN: A qualitative content analysis of root cause analysis investigation reports. SETTING: Public health services in Victoria, Australia, 2010-2015. PARTICIPANTS: Incidents of retained surgical items as described by 31 root cause analysis investigation reports. MAIN OUTCOME MEASURE(S): The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. RESULTS: Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. CONCLUSION: Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.

Does health information technology improve acknowledgement of radiology results for discharged Emergency Department patients? A before and after study.

BACKGROUND: The inadequate follow-up of test results is a key patient safety concern, carrying severe consequences for care outcomes. Patients discharged from the emergency department are at particular risk of having test results pending at discharge due to their short lengths of stay, with many hospitals acknowledging that they do not have reliable systems for managing such results. Health information technology hold the potential to reducing errors in the test result management process. This study aimed to measure changes in the proportion of acknowledged radiology reports pre and post introduction of an electronic result acknowledgement system and to determine the proportion of reports with abnormal results, including clinically significant abnormal results requiring follow-up action. METHODS: A before and after study was conducted in the emergency department of a 450-bed metropolitan teaching hospital in Australia. All radiology reports for discharged patients for a one-month period before and after implementation of the electronic result acknowledgement system were reviewed to determine; i) those that reported abnormal results; ii) evidence of test result acknowledgement. All unacknowledged radiology results with an abnormal finding were assessed by an independent panel of two senior emergency physicians for clinical significance. RESULTS: Of 1654 radiology reports in the pre-implementation period 70.6% (n = 1167) had documented evidence of acknowledgement by a clinician. For reports with abnormal results, 71.6% (n = 396) were acknowledged. Of 157 unacknowledged abnormal radiology reports reviewed by an independent emergency physician panel, 34.4% (n = 54) were identified as clinically significant and 50% of these (n = 27) were deemed to carry a moderate likelihood of patient morbidity if not followed up. Electronic acknowledgement occurred for all radiology reports in the post period (n = 1423), representing a 30.4% (95% CI: 28.1-32.6%) increase in acknowledgement rate, and an increase of 28.4% (95% CI: 24.6-32.2%) for abnormal radiology results. CONCLUSIONS: The findings of this study demonstrate the potential of health information technology to improve the safety and effectiveness of the diagnostic process by increasing the rate of follow up of results pending at hospital discharge.

Are root cause analyses recommendations effective and sustainable? An observational study.

OBJECTIVE: To assess the strength of root cause analysis (RCA) recommendations and their perceived levels of effectiveness and sustainability. DESIGN: All RCAs related to sentinel events (SEs) undertaken between the years 2010 and 2015 in the public health system in Victoria, Australia were analysed. The type and strength of each recommendation in the RCA reports were coded by an expert patient safety classifier using the US Department of Veteran Affairs type and strength criteria. PARTICIPANTS AND SETTING: Thirty-six public health services. MAIN OUTCOME MEASURE(S): The proportion of RCA recommendations which were classified as 'strong' (more likely to be effective and sustainable), 'medium' (possibly effective and sustainable) or 'weak' (less likely to be effective and sustainable). RESULTS: There were 227 RCAs in the period of study. In these RCAs, 1137 recommendations were made. Of these 8% were 'strong', 44% 'medium' and 48% were 'weak'. In 31 RCAs, or nearly 15%, only weak recommendations were made. In 24 (11%) RCAs five or more weak recommendations were made. In 165 (72%) RCAs no strong recommendations were made. The most frequent recommendation types were reviewing or enhancing a policy/guideline/documentation, and training and education. CONCLUSIONS: Only a small proportion of recommendations arising from RCAs in Victoria are 'strong'. This suggests that insights from the majority of RCAs are not likely to inform practice or process improvements. Suggested improvements include more human factors expertise and independence in investigations, more extensive application of existing tools that assist teams to prioritize recommendations that are likely to be effective, and greater use of observational and simulation techniques to understand the underlying systems factors. Time spent in repeatedly investigating similar incidents may be better spent aggregating and thematically analysing existing sources of information about patient safety.

Quality of Health Care for Children in Australia, 2012-2013.

Importance: The quality of routine care for children is rarely assessed, and then usually in single settings or for single clinical conditions. Objective: To estimate the quality of health care for children in Australia in inpatient and ambulatory health care settings. Design, Setting, and Participants: Multistage stratified sample with medical record review to assess adherence with quality indicators extracted from clinical practice guidelines for 17 common, high-burden clinical conditions (noncommunicable [n = 5], mental health [n = 4], acute infection [n = 7], and injury [n = 1]), such as asthma, attention-deficit/hyperactivity disorder, tonsillitis, and head injury. For these 17 conditions, 479 quality indicators were identified, with the number varying by condition, ranging from 9 for eczema to 54 for head injury. Four hundred medical records were targeted for sampling for each of 15 conditions while 267 records were targeted for anxiety and 133 for depression. Within each selected medical record, all visits for the 17 targeted conditions were identified, and separate quality assessments made for each. Care was evaluated for 6689 children 15 years of age and younger who had 15 240 visits to emergency departments, for inpatient admissions, or to pediatricians and general practitioners in selected urban and rural locations in 3 Australian states. These visits generated 160 202 quality indicator assessments. Exposures: Quality indicators were identified through a systematic search of local and international guidelines. Individual indicators were extracted from guidelines and assessed using a 2-stage Delphi process. Main Outcomes and Measures: Quality of care for each clinical condition and overall. Results: Of 6689 children with surveyed medical records, 53.6% were aged 0 to 4 years and 55.5% were male. Adherence to quality of care indicators was estimated at 59.8% (95% CI, 57.5%-62.0%; n = 160 202) across the 17 conditions, ranging from a high of 88.8% (95% CI, 83.0%-93.1%; n = 2638) for autism to a low of 43.5% (95% CI, 36.8%-50.4%; n = 2354) for tonsillitis. The mean adherence by condition category was estimated as 60.5% (95% CI, 57.2%-63.8%; n = 41 265) for noncommunicable conditions (range, 52.8%-75.8%); 82.4% (95% CI, 79.0%-85.5%; n = 14 622) for mental health conditions (range, 71.5%-88.8%); 56.3% (95% CI, 53.2%-59.4%; n = 94 037) for acute infections (range, 43.5%-69.8%); and 78.3% (95% CI, 75.1%-81.2%; n = 10 278) for injury. Conclusions and Relevance: Among a sample of children receiving care in Australia in 2012-2013, the overall prevalence of adherence to quality of care indicators for important conditions was not high. For many of these conditions, the quality of care may be inadequate.

Linking clinical quality indicators to research evidence - a case study in asthma management for children.

BACKGROUND: Clinical quality indicators are used to monitor the performance of healthcare services and should wherever possible be based on research evidence. Little is known however about the extent to which indicators in common use are based on research. The objective of this study is to measure the extent to which clinical quality indicators used in asthma management in children with outcome measurements can be linked to results in randomised controlled clinical trial (RCT) reports. This work is part of a broader research program to trial methods that improve the efficiency and accuracy of indicator development. METHODS: National-level indicators for asthma management in children were extracted from the National Quality Measures Clearinghouse database and the National Institute for Health and Care Excellence quality standards by two independent appraisers. Outcome measures were extracted from all published English language RCT reports for asthma management in children below the age of 12 published between 2005 and 2014. The two sets were then linked by manually mapping both to a common set of Unified Medical Language System (UMLS) concepts. RESULTS: The analysis identified 39 indicators and 562 full text RCTs dealing with asthma management in children. About 95% (37/39) of the indicators could be linked to RCT outcome measures. CONCLUSIONS: It is possible to identify relevant RCT reports for the majority of indicators used to assess the quality of asthma management in childhood. The methods reported here could be automated to more generally support assessment of candidate indicators against the research evidence.

Linking quality indicators to clinical trials: an automated approach.

OBJECTIVE: Quality improvement of health care requires robust measurable indicators to track performance. However identifying which indicators are supported by strong clinical evidence, typically from clinical trials, is often laborious. This study tests a novel method for automatically linking indicators to clinical trial registrations. DESIGN: A set of 522 quality of care indicators for 22 common conditions drawn from the CareTrack study were automatically mapped to outcome measures reported in 13 971 trials from ClinicalTrials.gov. INTERVENTION: Text mining methods extracted phrases mentioning indicators and outcome phrases, and these were compared using the Levenshtein edit distance ratio to measure similarity. MAIN OUTCOME MEASURE: Number of care indicators that mapped to outcome measures in clinical trials. RESULTS: While only 13% of the 522 CareTrack indicators were thought to have Level I or II evidence behind them, 353 (68%) could be directly linked to randomized controlled trials. Within these 522, 50 of 70 (71%) Level I and II evidence-based indicators, and 268 of 370 (72%) Level V (consensus-based) indicators could be linked to evidence. Of the indicators known to have evidence behind them, only 5.7% (4 of 70) were mentioned in the trial reports but were missed by our method. CONCLUSIONS: We automatically linked indicators to clinical trial registrations with high precision. Whilst the majority of quality indicators studied could be directly linked to research evidence, a small portion could not and these require closer scrutiny. It is feasible to support the process of indicator development using automated methods to identify research evidence.

Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.

INTRODUCTION: Although incident reporting systems are widespread in health care as a strategy to reduce harm to patients, the focus has been on reporting incidents rather than responding to them. Systems containing large numbers of incidents are uniquely placed to raise awareness of, and then characterize and respond to infrequent, but significant risks. The aim of this paper is to outline a framework for the surveillance of such risks, their systematic analysis, and for the development and dissemination of population-based preventive and corrective strategies using clinical and human factors expertise. REQUIREMENTS FOR A POPULATION-LEVEL RESPONSE: The framework outlines four system requirements: to report incidents; to aggregate them; to support and conduct a risk surveillance, review and response process; and to disseminate recommendations. Personnel requirements include a non-hierarchical multidisciplinary team comprising clinicians and subject-matter and human factors experts to provide interpretation and high-level judgement from a range of perspectives. The risk surveillance, review and response process includes searching of large incident and other databases for how and why things have gone wrong, narrative analysis by clinical experts, consultation with the health care sector, and development and pilot testing of corrective strategies. Criteria for deciding which incidents require a population-level response are outlined. DISCUSSION: The incremental cost of a population-based response function is modest compared with the 'reporting' element. Combining clinical and human factors expertise and a systematic approach underpins the creation of credible risk identification processes and the development of preventive and corrective strategies.

The application of the Global Trigger Tool: a systematic review.

PURPOSE: This study describes the use of, and modifications and additions made to, the Global Trigger Tool (GTT) since its first release in 2003, and summarizes its findings with respect to counting and characterizing adverse events (AEs). DATA SOURCES: Peer-reviewed literature up to 31st December 2014. STUDY SELECTION: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA EXTRACTION: Two authors extracted and compiled the demographics, methodologies and results of the selected studies. RESULTS OF DATA SYNTHESIS: Of the 48 studies meeting the eligibility criteria, 44 collected data from inpatient medical records and four from general practice records. Studies were undertaken in 16 countries. Over half did not follow the standard GTT protocol regarding the number of reviewers used. 'Acts of omission' were included in one quarter of studies. Incident reporting detected between 2% and 8% of AEs that were detected with the GTT. Rates of AEs varied in general inpatient studies between 7% and 40%. Infections, problems with surgical procedures and medication were the most common incident types. CONCLUSION: The GTT is a flexible tool used in a range of settings with varied applications. Substantial differences in AE rates were evident across studies, most likely associated with methodological differences and disparate reviewer interpretations. AE rates should not be compared between institutions or studies. Recommendations include adding 'omission' AEs, using preventability scores for priority setting, and re-framing the GTT's purpose to understand and characterize AEs rather than just counting them.

Australian general practitioner attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice.

Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. This study sought to explore general practitioner (GP) attitudes towards CPGs, in general and specifically for osteoarthritis (OA), with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 with a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision-making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided among respondents for short, 2-3-page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor, with most respondents either not aware of it (30%; 95% confidence interval (CI) 27 - 41%), had never used it (19%; 95% CI 12 - 29%) or rarely used it (34%; 95% CI 25-45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use.

Bradycardia as an early warning sign for cardiac arrest during routine laparoscopic surgery.

OBJECTIVES: The aim of this study was to identify clinical patterns of occurrence, management and outcomes surrounding cardiac arrest during laparoscopic surgery using the Australian Incident Monitoring Study (AIMS) database to guide possible prevention and treatment. SETTING: The AIMS database includes incident reports from participating clinicians from secondary and tertiary healthcare centres across Australia and New Zealand. PARTICIPANTS: The AIMS database holds over 11 000 peri- and intraoperative incidents. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was to characterize the pattern of events surrounding cardiac arrest. The secondary outcome was to identify successful management strategies in the possible prevention and treatment of cardiac arrest during laparoscopic surgery. RESULTS: Fourteen cases of cardiac arrest during laparoscopic surgery were identified. The majority of cases occurred in 'fit and healthy' patients during elective gynaecological and general surgical procedures. Twelve cases of cardiac arrest were directly associated with pneumoperitoneum with bradycardia preceding cardiac arrest in 75% of these. Management included deflation of pneumoperitoneum, atropine administration and cardiopulmonary resuscitation with circulatory restoration in all cases. The results imply vagal mechanisms associated with peritoneal distension as the predominant contributor to bradycardia and subsequent cardiac arrest during laparoscopy. CONCLUSIONS: Bradycardia during gas insufflation is not necessarily a benign event and appears to be a critical early warning sign for possible impending and unexpected cardiac arrest. Immediate deflation of pneumoperitoneum and atropine administration are effective measures that may alleviate bradycardia and possibly avert progression to cardiac arrest.

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the Internet: a multisite survey.

BACKGROUND: Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital's electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians' opinions. OBJECTIVE: The aim was to explore emergency physicians' current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. METHODS: A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. RESULTS: The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). CONCLUSIONS: Although patients' direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians' concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

The management of severe hypertension in Australian general practice.

BACKGROUND: Severe hypertension (SHT) (Blood Pressure, BP ≥ 180/110 mmHg) is associated with considerable morbidity and mortality, yet little is known about how it is managed. The purpose of this study is to examine the management of SHT by Australian general practitioners (GPs) and to explore its variance across patient characteristics and clinical practices. METHODS: Review of electronic medical records for a year before and after a recorded measure of SHT in 7,499 patients by 436 GPs in 167 clinics throughout Australia during 2008-2009. Outcome measures included follow-up, referral, changes to antihypertensive drug treatment, and BP control (normotensive reading, BP < 140/90 mmHg, and whether subsequent recorded measures were also in the normal range--sustained normotension). RESULTS: Of 7,499 patients with an electronic BP record of SHT, 94% were followed up (median time 14 days); 8% were referred to an appropriate specialist (median time 89 days--2% within 7 days) and 86% were managed by GPs. GPs initiated or changed antihypertensive drugs in 5,398 patients (72% of cohort); of these, 46% remained hypertensive (4% with SHT) and 7% achieved sustained normotension; 6% had no further electronic BP records. The remaining 14% had no medication changes; among these, 43% remained hypertensive (5% with SHT) and 3% achieved sustained normotension; 32% had no further electronic BP records. Some outcome measures displayed a variance across GP clinics that was mostly unexplained by patient or practice characteristics. CONCLUSIONS: Most patients with SHT had at least one follow-up visit and 72% had initiation of, or changes to, antihypertensive drug treatment. Although most of the patients experienced some improvement, blood pressure control was poor. Some clinics showed better performance. Suggestions are made for the development of clinical standards to facilitate appropriate management of this dangerous condition.

Treating persistent pain after breast cancer: practice gaps and future directions.

This paper discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain-related outcomes for this group. We discuss the dominant treatment approach for persisting pain post-breast cancer treatment and draw contrasts with contemporary treatment approaches to persistent pain in non-cancer-related populations. We discuss modern application of the biopsychosocial model of pain and the notion of variable sensitivity within the pain system, moment by moment and over time. We present the implications of increasing sensitivity over time for treatment selection and implementation. By drawing on transformative changes in treatment approaches to persistent non-cancer-related pain, we describe the potentially powerful role that an intervention called pain science education, which is now recommended in clinical guidelines for musculoskeletal pain, may play in improving pain and disability outcomes after successful breast cancer treatment. Finally, we present several research recommendations that centre around adaptation of the content and delivery models of contemporary pain science education, to the post-breast cancer context.

Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study.

BACKGROUND: Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error. METHODS AND RESULTS: We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention "system-related" errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%-78.3%]; 57.5% [33.8%-81.2%]; and 60.5% [48.5%-72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23-7.28) to 2.12 (95% CI 1.71-2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30-3.93) to 1.46 (95% CI 1.20-1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively -12.8% [95% CI -41.1% to 15.5%]; -11.3% [-40.1% to 17.5%]; -20.1% [-52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30-0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors. CONCLUSIONS: Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.

CareTrack: assessing the appropriateness of health care delivery in Australia.

OBJECTIVE: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence-based or consensus-based guidelines). DESIGN, SETTING AND PARTICIPANTS: Computer-assisted telephone interviews and retrospective review of the medical records (for 2009-2010) of a sample of at least 1000 Australian adults to measure compliance with 522 expert consensus indicators representing appropriate care for 22 common conditions. Participants were selected from households in areas of South Australia and New South Wales chosen to be representative of the socioeconomic profile of Australians. Health care encounters occurred in health care practices and hospitals with general practitioners, specialists, physiotherapists, chiropractors, psychologists and counsellors. MAIN OUTCOME MEASURE: Percentage of health care encounters at which the sample received appropriate care. RESULTS: From 15 292 households contacted by telephone, 7649 individuals agreed to participate, 3567 consented, 2638 proved eligible, and 1154 were included after gaining the consent of their health care providers. The adult Australians in this sample received appropriate care at 57% (95% CI, 54%-60%) of 35 573 eligible health care encounters. Compliance with indicators of appropriate care at condition level ranged from 13% (95% CI, 1%-43%) for alcohol dependence to 90% (95% CI, 85%-93%) for coronary artery disease. For health care providers with more than 300 eligible encounters each, overall compliance ranged from 32% to 86%. CONCLUSIONS: Although there were pockets of excellence and some aspects of care were well managed across health care providers, the consistent delivery of appropriate care needs improvement, and gaps in care should be addressed. There is a need for national agreement on clinical standards and better structuring of medical records to facilitate the delivery of more appropriate care.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project).

STUDY DESIGN: Multiround wiki-based Delphi expert panel survey. OBJECTIVE: To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care." METHODS: Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators. RESULTS: From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided. CONCLUSION: These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Mapping the limits of safety reporting systems in health care--what lessons can we actually learn?

OBJECTIVES: To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system. DESIGN AND SETTING: Incidents relating to patient misidentification occurring between 2004 and 2008 were selected from a sample extracted from a number of Australian health services' incident reporting systems using a manual search function. MAIN OUTCOME MEASURES: Incident type, aetiology (error type) and recovery (error-detection mechanism). Analyses were performed to determine category saturation. RESULTS: All 487 selected incidents could be classified according to incident type. The most prevalent incident type was medication being administered to the wrong patient (25.7%, 125), followed by incidents where a procedure was performed on the wrong patient (15.2%, 74) and incidents where an order for pathology or medical imaging was mislabelled (7.0%, 34). Category saturation was achieved quickly, with about half the total number of incident types identified in the first 13.5% of the incidents. All 43 incident types were classified within 76.2% of the dataset. Fifty-two incident reports (10.7%) included sufficient information to classify specific incident aetiology, and 288 reports (59.1%) had sufficient detailed information to classify a specific incident recovery mechanism. CONCLUSIONS: Incident reporting systems enable the classification of the surface features of an incident and identify common incident types. However, current systems provide little useful information on the underlying aetiology or incident recovery functions. Our study highlights several limitations of incident reporting systems, and provides guidance for improving the use of such systems in quality and safety improvement.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study.

BACKGROUND: In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities. METHODS: Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care. RESULTS: From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit). CONCLUSION: A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

CareTrack Aged: the appropriateness of care delivered to Australians living in residential aged care facilities: a study protocol.

INTRODUCTION: The aged population is increasing rapidly across the world and this is expected to continue. People living in residential aged care facilities (RACFs) represent amongst the sickest and frailest cohort of the aged population, with a high prevalence of chronic conditions and complex comorbidities. Given the vulnerability of RACF residents and the demands on the system, there is a need to determine the extent that care is delivered in line with best practice ('appropriate care') in RACFs. There is also a recognition that systems should provide care that optimises quality of life (QoL), which includes support for physical and psychological well-being, independence, social relationships, personal beliefs and a caring external environment. The aims of CareTrack Aged are to develop sets of indicators for appropriate care and processes of care for commonly managed conditions, and then assess the appropriateness of care delivered and QoL of residents in RACFs in Australia. METHODS AND ANALYSIS: We will extract recommendations from clinical practice guidelines and, using expert review, convert these into sets of indicators for 15 common conditions and processes of care for people living in RACFs. We will recruit RACFs in three Australian states, and residents within these RACFs, using a stratified multistage sampling method. Experienced nurses, trained in the CareTrack Aged methods ('surveyors'), will review care records of recruited residents within a 1-month period in 2019 and 2020, and assess the care documented against the indicators of appropriate care. Surveyors will concurrently assess residents' QoL using validated questionnaires. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Human Research Ethics Committee of Macquarie University (5201800386). The research findings will be published in international and national journals and disseminated through conferences and presentations to interested stakeholder groups, including consumers, national agencies, healthcare professionals, policymakers and researchers.