On the radar
21 March 2011
Once again, this issue of the On the Radar is a little longer than normal – the consequence of being
away for a week allied with the publication of issues of Health Affairs and BMJ Quality and Safety.
On the Radar is a summary of some of the recent publications in the areas of safety and quality in
health care. Inclusion in this document is not an endorsement or recommendation of any publication
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This week’s content
ARHQ reports study how community-acquired methicillin-resistant Staphylococcus aureus is
managed in health care settings
The US Agency for Healthcare Research and Quality (AHRQ) funded
three reports on community-acquired methicillin-resistant
Staphylococcus aureus (MRSA). The reports stem from two-year
projects conducted by AHRQ’s Practice-Based Research Networks.
The studies found:
• An intervention to optimize treatment for skin and soft tissue
infections consistent with the community-acquired MRSA
guidelines intervention resulted in an increase in antibiotic use
and the proportion of prescribed antibiotics that covered MRSA.
• Rural primary care providers were more likely to prescribe
antibiotics that covered MRSA at the initial patient visit after
CDC guidelines were implemented.
• Recommend that primary care practices develop documentation
and coding presentations; integrate templates into electronic
medical records for describing skin and soft tissue infections;
and hold workshops in the management of skin and soft tissue
infections and that these improve the quality of care for
individuals with skin or soft tissue infections.
On the Radar Issue 33 1
For information on the Commission’s healthcare associated infection work, including a link to the
Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010), see
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement
From the Commonwealth Fund email:
It has been just over a decade since the Institute of Medicine (IOM)
issued To Err Is Human, the landmark report that vividly documented
the scope of patient safety problems within U.S. health care system.…
The Commonwealth Fund [has released]… a new set of case studies
exploring the progress made by four of these early leaders in patient
• Johns Hopkins Medicine, an academic medical centre and non-
profit integrated health care system that set a goal in 2002 of
making its care the safest in the world.
• Sentara Healthcare, an integrated system that developed a
systematic program to foster a culture of safety throughout its
• OSF HealthCare has promoted a collaborative approach to
patient safety improvement.
• U.S. Department of Veterans Affairs, which formed the National
Center for Patient Safety to instil an organizational culture of
safety within its nationwide network of hospitals and outpatient
Each of the cases describes the development of practical methods for
training, coaching, and motivating staff to engage in patient safety
work; the deployment of information systems, standardized clinical
processes, and other tools to facilitate clear communication; and the
system-wide adoption of safety as a chief priority.
Cardiovascular disease: Australian facts 2011
Australian Institute of Health and Welfare
Cardiovascular disease series no. 35. Cat. no. CVD 53. Canberra: AIHW.
From the AIHW email: ‘Cardiovascular disease (CVD) is a very
common and serious disease in Australia with about 3.5 million people
reporting having the condition in 2007-08. Despite significant advances
in the treatment of CVD and for some of its risk factors, it remains the
cause of more deaths than any other disease - about 50,000 in 2008 -
Notes and the most expensive, costing about $5.9 billion in 2004-05. And not
all sectors of Australian society are affected equally by CVD with
people in lower socioeconomic groups, Aboriginal and Torres Strait
Islander people and those living in the remote areas of Australia often
more likely to be hospitalised with, or to die from CVD than other
members of the population.’
On the Radar Issue 33 2
Patient Safety and Quality: An Evidence-Based Handbook for Nurses
Hughes RG (ed.)
AHRQ Publication No. 08-0043
Rockville, MD: Agency for Healthcare Research and Quality; March 2008.
Form the US ARHQ:
Nurses play a vital role in improving the safety and quality of patient
care—not only in the hospital or ambulatory treatment facility, but also
of community-based care and the care performed by family members.
Nurses need know what proven techniques and interventions they can
use to enhance patient outcomes.
To address this need, AHRQ, with additional funding from the Robert
Wood Johnson Foundation, has prepared this comprehensive, 1,400-
Notes page, handbook for nurses on patient safety and quality. Experts in the
field reviewed the literature, and their contributions are grouped into
• Patient Safety and Quality
• Evidence-based Practice
• Patient-centered Care
• Working Conditions—Work Environment
• Critical Opportunities for Patient Safety and Quality
Safer Hospital Care: Strategies for Continuous Innovation
New York: Productivity Press, 2011.
According to the ARHQ PSNet synopsis this book ‘provides various
Notes strategies to drive innovation in patient safety, including how to
eliminate unsafe practices’.
The development of quality indicators for community pharmacy care
De Bie J, Kijlstra NB, Daemen BJG, Bouvy ML
BMJ Quality & Safety 2011 [epub].
Paper describing the process and activities in the development of the
Dutch quality indicators for community pharmacy care. From a
preliminary list of 159 topics a final set of 42 indicators was developed.
This set includes indicators on patient counselling (6), clinical risk
management (10), compounding (7), dispensing (3), monitoring of
medication use (11) and quality management (5).
On the Radar Issue 33 3
For information on the Commission’s activities relating to indicators, see
The Need for Systems Integration in Health Care
Mathews SC, Pronovost PJ
JAMA: The Journal of the American Medical Association 2011;305(9):934-935.
A commentary by Simon Mathews and the prolific Peter Pronovost
advocating a systems approach for implementing technologies to
improve safety and efficiency in hospitals. They argue that to not do so
is in itself a safety issue. Their model of an integrator comes from
aviation in the form of Boeing. Whether Boeing is an integrator or a
manufacturer is something of a moot point. It is not clear whether the
authors see a role for a commercial entity to offer ‘integrated solutions’
or even completely integrated facilities.
Recognising that health is a sector made up of many players who wish
Notes to maintain their autonomy and decision-making role may mean a
systems integration approach may have greater traction within settings
where there is a substantial level of control over procurement and
standards setting. In concluding the commentary the authors suggest
that in the USA this may be more readily achieved in an academic
setting. They see that the collaboration between health care
professionals, administrators, researchers, human factors and systems
engineers, and industry can be encouraged in a ‘learning laboratory’ and
that ‘university-based academic medical centers, with schools of public
health and engineering, make the ideal conveners for such an entity’.
Effective quality improvement of thromboprophylaxis in acute medicine
Clark BM, d'Ancona G, Kinirons M, Hunt BJ, Hopper A
BMJ Quality & Safety 2011 [epub].
Paper describing the introduction and outcomes of venous
thromboembolism (VTE) guideline in a London NHS foundation trust.
The guidline was launched and implemented using a multidisciplinary
and multiple intervention approach involving education and feedback,
IT intervention, verbal and written reminders, regular audit and process
redesign. A 2008 showed that the rate of adherence had increased from
56% pre-guideline to 96%. However, a repeat audit in 2009 suggested
that even though the majority of patients were receiving appropriate
Notes thromboprophylaxis, risk assessment documentation was poor. This
resulted in treatment being provided to some low-risk patients when it
was not required.
The authors conclude that ‘the most effective means of achieving VTE
guideline adherence is to establish a thromboprophylaxis culture. This
can be accomplished through a multiple intervention and continuous
feedback approach. However, it is essential to ensure that a
comprehensive VTE risk assessment is carried out to ensure that those
not requiring treatment do not receive it unnecessarily.’
On the Radar Issue 33 4
For information on the 2009 Clinical Practice Guideline for the Prevention of Venous
Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to
Australian Hospitals, see http://www.nhmrc.gov.au/nics/programs/vtp/prevention.htm
Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally
versus externally led intervention
Scott IA, Wills R-A, Coory M, Watson MJ, Butler F, Waters M, et al.
BMJ Quality & Safety 2011 [epub].
Paper describing and contrasting the experiences of a number of
Queensland tertiary hospitals undergoing process re-design. In this
instance, demand for hospital beds had led to institution-wide clinical
process redesign for improving efficiency. The major contrast the
authors examined was that between external and internal-led
The authors assert the following results:
‘At one externally led redesign hospital, control charts indicated a
decrease in ED access block outside control limits which coincided with
the intervention, but this was not subsequently sustained. There were no
special-cause variations seen in the other hospital. In contrast, at the
Notes internally led redesign hospital, there were two decreases in access
block outside control limits during the intervention period, resulting in a
decrease from a baseline average of 55% to a post-intervention average
of 22%. All hospitals showed declines in elective surgery waits with
oscillations in data indicating the existence of special-cause factors
other than redesign.’
These led them to conclude that ‘Internally led …redesign led to
superior and sustained improvements in ED access block as a result of
major structural reforms that were driven by committed clinicians and
managers and cut across departmental boundaries.’
The role of clinician leadership, autonomy and culture are all important,
but so too are shared goals and expectations.
Defining Safe Use of Anesthesia in Children
Rappaport R, Mellon RD, Simone A, Woodcock J
New England Journal of Medicine 2011 [epub].
Article published in the NEJM’s ‘Perspectives’ section written by four
authors from the US FDA raising concerns about anaesthesia use for
children, but stressing that there is no conclusive evidence to support a
change in practice. The FDA’s Anesthetic and Life Support Drugs
Advisory Committee was to meet on 10 March 2011. The authors state
that ‘We need to definitively answer the questions of whether anesthetic
use in children poses a risk to their development and, if so, under what
circumstances. Although withholding anesthesia from children who
need surgery is unreasonable, obtaining more information about safe use
On the Radar Issue 33 5
BMJ Quality and Safety (Vol 20 Issue 3).
1 March saw the publication of the latest issue of BMJ Quality and
Safety (Vol 20 Issue 3). A number of the papers in this issue have been
discussed in previous issues of On the Radar (when they were published
online). This issue of BMJ Quality and Safety contains the following:
• Which factors are important for the successful development and
implementation of clinical pathways? A qualitative study
• Diagnosing a learning practice: the validity and reliability of a
learning practice inventory
• Evaluation of an instrument to measure teamwork in
multidisciplinary critical care teams
• Quality of after-hours primary care in the Netherlands:
adherence to national guidelines
• Guideline adaptation: an approach to enhance efficiency in
guideline development and improve utilisation
• The relationship of the emotional climate of work and threat to
patient outcome in a high-volume thoracic surgery operating
• Peri-operative medical emergency team activation in liver
• Three success factors for continual improvement in healthcare:
an analysis of the reports of improvement team members
• Assessing the adequacy of pressure ulcer prevention in hospitals:
a nationwide prevalence survey
• Descriptions of verbal communication errors between staff. An
analysis of 84 root cause analysis-reports from Danish hospitals
• Prevalence and outcomes of use of potentially inappropriate
medicines in older people: cohort study stratified by residence in
nursing home or in the community
• Better use of primary care laboratory services following
interventions to ‘market’ clinical guidelines in New Zealand
Local adaptation and evaluation of a falls risk prevention approach in acute hospitals
Walsh W, Hill KD, Bennell K, Vu M, Haines TP.
International Journal for Quality in Health Care 2011;23(2):134-141.
Paper reporting on the modification of a falls management approach in
two Melbourne hospitals. The project sought to examine if adapting a
falls risk factor assessment tool could produce an instrument with
clinimetric properties sufficient to support an acute hospital's falls
prevention program. The study sough to compare the new instrument
(Western Health Falls Risk Assessment, WHeFRA) and ‘gold standard
Of the 130 patients in the study, 7 fell, with the local instrument more
accurate at predicting fallers. The authors concluded that ‘adaptation of
an existing tool resulted in an instrument with favorable clinimetric
properties and may be a viable procedure for facilitating falls prevention
program development and implementation in acute hospital settings’.
On the Radar Issue 33 6
For information on the Falls Prevention Guidelines, see
Health Affairs (Vol 30, No. 3)
This issue of Health Affairs focuses on a number of US health care
systems that have launched care delivery innovations. Supported in part
by The Commonwealth Fund, the 15 innovation profiles describe how a
wide variety of organisations are working to overcome multiple
challenges in pursuit of the Triple Aim of improving population health
and patients' experience while reducing costs. One project included
placing clinics in supermarkets so as to offer better access to primary
care. The 15 profiles are:
• At UPMC, Improving Care Processes to Serve Patients Better
and Cut Costs
• Changing the Conversation in California About Care Near the
End of Life
• A New Care Paradigm Slashes Hospital Use and Nursing Home
Stays for the Elderly and the Physically and Mentally Disabled
• Using Teams, Real-Time Information, and Teleconferencing to
Improve Elders' Hospital Care
• A Health Plan Spurs Transformation of Primary Care Practices
into Better-Paid Medical Homes
Notes • Predictive Modeling and Team Care for High-Need Patients at
• At Martin's Point in Maine, Primary Care Teams for Chronic
• Restructuring Care in a Federally Qualified Health Center to
Better Meet Patients’ Needs
• Charting a Life-and-Health Cycle and Expanded Primary Care
Options for Patients in Wisconsin
• Redesigning Acute Care Processes in Wisconsin
• The 'GRACE' Model: In-Home Assessments Lead to Better Care
for Dual Eligibles
• Improving the Coordination of Care for Medicaid Beneficiaries
• Taking Public Health Approaches to Care in Massachusetts
• Vermont's Blueprint for Medical Homes, Community Health
Teams, and Better Health at Lower Cost
• Targeted Care Improvements Show Promising Results for
Treating Children with Asthma.
Improving Quality in Long-Term Care
Medical Care Research and Review 2010;67(4 suppl):141S-150S.
Paper by a Commonwealth Fund staff member looking at two
approaches to achieving higher quality in long-term care in the USA:
the regulatory process and culture change. She concludes that improving
the quality care in long-term care requires the survey, regulation, and
On the Radar Issue 33 7
enforcement system, as well as voluntary efforts, such as quality
campaigns and the culture change movement.
Clearly while the context may differ from that here, there are parallels.
Professional values and reported behaviours of doctors in the USA and UK: quantitative survey
Roland M, Rao SR, Sibbald B, Hann M, Harrison S, Walter A, et al
BMJ Quality & Safety 2011 [epub].
Paper reporting on the apparent differences in values and behaviours
between US and UK doctors, and the extent to which these vary with
the context of care. By surveying 1,891 US and 1,078 UK doctors
completed the survey (64.4% and 40.3% response rate respectively) the
authors found that UK doctors were more likely to have developed
practice guidelines (82.8% UK vs 49.6% US, p<0.001) and to have
taken part in a formal medical error-reduction programme (70.9% UK
vs 55.7% US, p<0.001).
US doctors were more likely to agree about the need for periodic
recertification (completely agree 23.4% UK vs 53.9% US, p<0.001).
Nearly a fifth of doctors had direct experience of an impaired or
incompetent colleague in the previous 3 years. Where the doctor had not
reported the colleague to relevant authorities, reasons included thinking
that someone else was taking care of the problem, believing that nothing
would happen as a result, or fear of retribution.
UK doctors were more likely than US doctors to agree that significant
medical errors should always be disclosed to patients. More US doctors
reported that they had not disclosed an error to a patient because they
were afraid of being sued.
The authors suggest that the context of care may influence both how
professional values are expressed and the extent to which behaviours are
in line with stated values.
Assessing patient safety culture in New Zealand primary care: a pilot study using a modified
Manchester Patient Safety Framework in Dunedin general practices
Wallis K, Dovey S
Journal of Primary Health Care 2011;3(1):35-40.u
New Zealand study reporting on the local adaptation and use of a UK
tool for assessing safety culture in primary care. The authors modified
the Manchester Patient Safety Framework (MaPSaF) and used it in 12
Dunedin general practices at baseline and at three months. Participants
were all practice personnel present in the practice on the day.
Notes Participants rated their practice on each of the nine MaPSaF dimensions
of safety culture, then discussed the dimensions and their scores and
chose a practice-wide consensus score for each dimension. The study
found that the framework directed team discussion about patient safety
issues and facilitated communication and prompted some practices to
On the Radar Issue 33 8
Safety issues related to the electronic medical record (EMR): synthesis of the literature from the
last decade, 2000-2009
Harrington L, Kennerly D, Johnson C
J Healthc Manag 2011;56(1):31-43; discussion 43-34.u
A review of technologies, including computerised physician order entry,
clinical decision support systems, and bar-coded medication
administration discusses the risks created by health care information
Notes technology. The authors seek to generate an appreciation of the
complexity surrounding the use of electronic records and an
understanding of the safety issues in order to mandate sound EMR
design, development, implementation, and use.
For information on the Commission’s activities relating to safety in e-health, see
What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?
Curry LA, Spatz E, Cherlin E, Thompson JW, Berg D, Ting HH, et al
Annals of Internal Medicine 2011;154(6):384-390.
This study examined the top and lowest rated hospitals for their
treatment of AMI in order to determine what it was that allowed the
better ranked hospitals to obtain better outcomes for AMI patients.
As the author’s noted, mortality rates for patients with acute myocardial
infarction (AMI) can vary substantially between hospitals, even when
adjusted for patient severity; however, little is known about hospital
factors that may influence this variation. This study sought to identify
factors that may be related to better performance in AMI care.
In 2009, the researchers conducted site visits and in-depth interviews
with 158 members of hospital staff, all of whom were involved with
AMI care at 11 US hospitals that had ranked in either the top or the
bottom 5% in risk-standardized mortality rates for 2 recent years of data
from the Centers for Medicare & Medicaid Services (2005 to 2006 and
2006 to 2007).
The authors concluded that:
‘High-performing hospitals were characterized by an organizational
culture that supported efforts to improve AMI care across the hospital.
Evidence-based protocols and processes, although important, may not
be sufficient for achieving high hospital performance in care for patients
Cognitive performance-altering effects of electronic medical records: an application of the human
factors paradigm for patient safety
Cognition, Technology & Work 2011;13(1):11-29.
On the Radar Issue 33 9
Paper reporting on a study into the impact of electronic health records
on cognitive performance, illustrating both desirable and undesirable
implications for patient safety.
From the abstract: ‘According to the human factors paradigm for patient
safety, health care work systems and innovations such as electronic
Notes medical records do not have direct effects on patient safety. Instead,
their effects are contingent on how the clinical work system, whether
computerized or not, shapes health care providers’ performance of
cognitive work processes.’ It would appear that one of the keys to the
successful implementation of technology is how it fits into the workflow
Improving patient safety in radiation oncology
Hendee WR, Herman MG
Medical Physics 2010;38(1):78-82.
A commentary piece on radiation safety issues that also describes
recommendations from a working meeting entitled ‘Safety in Radiation
Therapy: A Call to Action’ convened by the American Association of
Notes Physicists in Medicine and the American Society of Radiation
Oncology. The meeting yielded 20 recommendations that apparently
provide a pathway to reducing errors and improving patient safety in
radiation therapy facilities.
Partial do-not-resuscitate orders: a hazard to patient safety and clinical outcomes?
Sanders A, Schepp M, Baird M
Critical Care Medicine 2011;39:14-18.
A review piece on the potential risks that may arise from partial do-not-
Notes resuscitate orders, including misunderstandings that could create delays
Nurse Staffing and Inpatient Hospital Mortality
Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M
New England Journal of Medicine 2011;364(11):1037-1045.
The issue of nurse-patient ratios is a topical one, including a campaign
coinciding with the NSW election. This paper reports on a retrospective
observational study that used data from a US tertiary academic medical
centre involving 197,961 admissions and 176,696 nursing shifts of 8
hours each in 43 hospital units to examine the association between
Notes mortality and patient exposure to nursing shifts during which staffing by
RNs was 8 hours or more below the staffing target.
The authors conclude that there is a relationship between nursing levels
and inpatient mortality and that ‘staffing of RNs below target levels was
associated with increased mortality, which reinforces the need to match
staffing with patients' needs for nursing care’.
On the Radar Issue 33 10
IHI Expedition, Early Warning Systems: The Next Level of Rapid Response
From the US Institute for Healthcare Improvement (IHI): Many hospitals have implemented rapid
response teams and found that their quick reactions can help improve outcomes. While rapid
response teams are a valuable resource, there can be limits to what they can accomplish once called.
Because of this, many organizations have implemented early warning systems to identify
deteriorating patients earlier – getting them the care they need sooner.
The IHI is conducting its Expedition, Early Warning Systems: The Next Level of Rapid Response.
Over the course of six web-based sessions, expert faculty will provide the tools and guidance to
successfully implement an early warning system.
For information on the Commission’s work on recognising and responding to clinical deterioration,
ARHQ Health Care Innovations Exchange
Personal Electronic Health Records examples http://www.innovations.ahrq.gov/issue.aspx?id=97
The US Health Care Innovations Exchange website showcases three programs that have used
personal health record systems in various ways to improve care. In one program, physicians at the
Palo Alto Medical Foundation used a comprehensive, integrated electronic and personal health
record system to gain immediate access to each patient’s full medical record during visits, provide
patient education, write prescriptions, monitor patient progress, and complete other tasks. In another
program, Howard University’s Diabetes Treatment Center offers patients access to a free online
personal health record to assist in monitoring blood sugar, blood pressure, weight, cholesterol, and
other clinical indicators. In the third program, Wind Youth Services offers a Web-based personal
health information service to homeless and runaway adolescents aged 11 to 22 years. Also featured
on the website are three QualityTools—Health Shack™, Personal Health Record (PHR) Checklist,
and myPHR—that serve as resources to assist health care consumers in creating their own personal
Why not the best? http://www.whynotthebest.org/
To coincide with Patient Safety Awareness Week in the USA, WhyNotTheBest.org has updated and
expanded its data on the incidence of central line–associated bloodstream infections (CLABSIs),
one of the most lethal hospital-acquired complications. The site now includes standardized infection
ratios for some 1,050 U.S. hospitals—showing wide variation in CLABSI incidence, despite strong
evidence on how to prevent these infections. The goal of WhyNotTheBest.org is to foster health
care quality improvement by promoting transparency and public reporting, and by providing tools
and case studies of top performers to aid organizations in their own improvement efforts.
On the radar is an information resource of the Australian Commission on Safety and Quality in
Health Care. The Commission is not responsible for the content of, nor does it endorse, any articles
or sites listed. The Commission accepts no liability for the information or advice provided by these
external links. Links are provided on the basis that users make their own decisions about the
accuracy, currency and reliability of the information contained therein. Any opinions expressed are
not necessarily those of the Australian Commission on Safety and Quality in Health Care.
On the Radar Issue 33 11