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

BackgroundEnsuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.MethodsIn a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis.ResultsFourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed.ConclusionsTraditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1164-x) contains supplementary material, which is available to authorized users.

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

BackgroundThe use of checklists to minimise errors is well established in high reliability, safety-critical industries. In health care there is growing interest in checklists to standardise checking processes and ensure task completion, and so provide further systemic defences against error and patient harm. However, in UK general practice there is limited experience of safety checklist use. AimTo identify workplace hazards that impact on safety, health and wellbeing, and performance, and codesign a standardised checklist process. Design and settingApplication of mixed methods to identify system hazards in Scottish general practices and develop a safety checklist based on human factors design principles. MethodA multiprofessional 'expert' group (n = 7) and experienced front-line GPs, nurses, and practice managers (n = 18) identified system hazards and developed and validated a preliminary checklist using a combination of literature review, documentation review, consensus building workshops using a mini-Delphi process, and completion of content validity index exercise. ResultsA prototype safety checklist was developed and validated consisting of six safety domains (for example, medicines management), 22 sub-categories (for example, emergency drug supplies) and 78 related items (for example, stock balancing, secure drug storage, and cold chain temperature recording). ConclusionHazards in the general practice work system were prioritised that can potentially impact on the safety, health and wellbeing of patients, GP team members, and practice performance, and a necessary safety checklist prototype was designed. However, checklist efficacy in improving safety processes and outcomes is dependent on user commitment, and support from leaders and promotional champions. Although further usability development and testing is necessary, the concept should be of interest in the UK and internationally.

Checklists have been shown to improve care and reduce morbidity and mortality in the healthcare setting.[1] Their application in safety-critical industries outside of medicine continues to offer a strong argument for their application to medicine.[2] The daily in-patient medical ward round is a complex process and includes multiple potential risks to patient safety. This project aims to evaluate the effectiveness of a ward round review checklist on one general medical ward in a district general hospital in the UK.A baseline audit was performed, examining case-notes for a set of pre-defined outcome measures relevant to patient safety. Compliance with documentation of each outcome measure was assessed prior to the introduction of a ward round checklist. This was followed by a quality improvement project through the use of PDSA cycles, with the aim of introducing and developing a ward round checklist over a nine month period. Following the introduction of a checklist, overall compliance with documentation of each outcome measure improved from 45% to 89%.In conclusion, a quality improvement project involving the introduction of a ward round checklist for daily use has resulted in improved documentation of outcome measures that are relevant to patient safety. Teamwork and leadership skills from clinicians committed to improving patient safety is essential to sustaining improvements in traditional ward round practice.

. (2016) Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems. Education for Primary Care, 27(6), pp. 443-450. (doi:10.1080Care, 27(6), pp. 443-450. (doi:10. /14739879.2016 This is the author's final accepted version.There may be differences between this version and the published version. You are advised to consult the publisher's version if you wish to cite from it.http://eprints.gla.ac.uk/131620/ AbstractPatient safety education and participation are key components of general practice (GP) specialty training, appraisal and revalidation. Priorities for GP education at all career stages are described in the Royal College of General Practitioners curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify 'malfunctioning' components of a system (including humans) and introduce change to improve performance -often by attempting to increase conformity with protocols and guidelines. The complex interactions and inter-dependence between components found in healthcare systems mean that 'cause and effect' are not always linked in a predictable manner, meaning this approach does not always improve performance.The Safety-II approach is considered a new way to understand how safety is achieved in complex systems. Understanding and applying this approach may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and variousways to achieve success, dependent on work conditions, may be possible. Understanding and managing variability, rather than constraining it, may be a more beneficial approach.The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.3

Objectives(1) To ascertain from patients what really matters to them on a personal level of such high importance that it should ‘always happen’ when they interact with healthcare professionals and staff groups. (2) To critically review existing criteria for selecting ‘always events’ (AEs) and generate a candidate list of AE examples based on the patient feedback data.DesignMixed methods study informed by participatory design principles.Subjects and settingConvenience samples of patients with a long-term clinical condition in Scottish general practices.Results195 patients from 13 general practices were interviewed (n=65) or completed questionnaires (n=130). 4 themes of high importance to patients were identified from which examples of potential ‘AEs’ (n=8) were generated: (1) emotional support, respect and kindness (eg, “I want all practice team members to show genuine concern for me at all times”); (2) clinical care management (eg, “I want the correct treatment for my problem”); (3) communication and information (eg, “I want the clinician who sees me to know my medical history”) and (4) access to, and continuity of, healthcare (eg, “I want to arrange appointments around my family and work commitments”). Each ‘AE’ was linked to a system process or professional behaviour that could be measured to facilitate improvements in the quality of patient care.ConclusionsThis study is the first known attempt to develop the AE concept as a person-centred approach to quality improvement in primary care. Practice managers were able to collect data from patients on what they ‘always want’ in terms of expectations related to care quality from which a list of AE examples was generated that could potentially be used as patient-driven quality improvement (QI) measures. There is strong implementation potential in the Scottish health service. However, further evaluation of the utility of the method is also necessary.

BackgroundIn general practice internationally, many care teams handle large numbers of laboratory test results relating to patients in their care. Related research about safety issues is limited with most of the focus on this workload from secondary care and in North American settings. Little has been published in relation to primary health care in the UK and wider Europe. This study aimed to explore experiences and perceptions of patients with regards to the handling of test results by general practices.MethodsA qualitative research approach was used with patients. The setting was west of Scotland general practices from one National Health Service territorial board area. Patients were purposively sampled from practice held lists of patients who received a number of laboratory tests because of chronic medical problems or surveillance of high risk medicines. Focus groups were held and were audio-recorded. Tapes were transcribed and subjected to qualitative analysis. Transcripts were coded and codes merged into themes by two of the researchers.Results19 participants from four medical practices took part in four focus groups. The main themes identified were: 1. Patients lacked awareness of the results handling process in their practice. 2. Patients usually did not contact their practice for test results, unless they considered themselves to be ill. 3. Patients were concerned about the appropriateness of administrators being involved in results handling. 4. Patients were concerned about breaches of confidentiality when administrators were involved in results handling. 5. Patients valued the use of dedicated results handling staff. 6. Patients welcomed the use of technology to alert them to results being available, and valued the ability to choose how this happened.ConclusionsThe study confirms the quality and safety of care problems associated with results handling systems and adds to our knowledge of the issues that impact in these areas. Practices need to be aware that patients may not contact them about results, and they need to publicise their results handling processes to patients and take steps to reassure patients about confidentiality with regards to administrators.