Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data

Meeks, Derek W; Meyer, Ashley N. D.; Rose, Barbara; Walker, Yuri N; Singh, Hardeep

doi:10.1136/bmjqs-2014-003239

Cited by 11 publications

(12 citation statements)

References 43 publications

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“…For example, many organisations are conducting safety huddles46 and reviews of patient presentations, though we are unaware of any efforts to monitor these sources for diagnosis-related issues. Similarly, we found that peer review may be a useful tool for healthcare organisations when assessing their sharp-end clinical performance, particularly for diagnosis-related safety events 47. However, current peer review systems are inadequate and need to include root cause analysis approaches and performance improvement thinking to detect and address system issues 48.…”

Section: Challenges Of Real-world Diagnostic Error Measurementmentioning

confidence: 89%

“…Similarly, we found that peer review may be a useful tool for healthcare organisations when assessing their sharp-end clinical performance, particularly for diagnosis-related safety events. 47 However, current peer review systems are inadequate and need to include root cause analysis approaches and performance improvement thinking to detect and address system issues. 48 This enhancement of existing peer review programmes could greatly improve processes for diagnostic self-assessment, feedback and improvement.…”

Section: Challenges Of Real-world Diagnostic Error Measurementmentioning

confidence: 99%

“…48 This enhancement of existing peer review programmes could greatly improve processes for diagnostic self-assessment, feedback and improvement. 47 …”

Section: Challenges Of Real-world Diagnostic Error Measurementmentioning

confidence: 99%

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Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework

Singh¹,

2015

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Diagnostic errors are major contributors to harmful patient outcomes, yet they remain a relatively understudied and unmeasured area of patient safety. Although they are estimated to affect about 12 million Americans each year in ambulatory care settings alone, both the conceptual and pragmatic scientific foundation for their measurement is under-developed. Health care organizations do not have the tools and strategies to measure diagnostic safety and most have not integrated diagnostic error into their existing patient safety programs. Further progress toward reducing diagnostic errors will hinge on our ability to overcome measurement-related challenges. In order to lay a robust groundwork for measurement and monitoring techniques to ensure diagnostic safety, we recently developed a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). In this paper, we describe how the framework serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. The framework accounts for the complex adaptive sociotechnical system in which diagnosis takes place (the structure), the distributed process dimensions in which diagnoses evolve beyond the doctor's visit (the process) and the outcomes of a correct and timely “safe diagnosis” as well as patient and health care outcomes (the outcomes). We posit that the Safer Dx framework can be used by a variety of stakeholders including researchers, clinicians, health care organizations and policymakers, to stimulate both retrospective and more proactive measurement of diagnostic errors. The feedback and learning that would result will help develop subsequent interventions that lead to safer diagnosis, improved value of health care delivery and improved patient outcomes.

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Section: Challenges Of Real-world Diagnostic Error Measurementmentioning

confidence: 89%

Section: Challenges Of Real-world Diagnostic Error Measurementmentioning

confidence: 99%

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Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework

Singh¹,

2015

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“…The sharing of knowledge was highlighted as a positive part of this project by some participants. Peer review has been shown by others to be useful to shed light on provider-related errors and associated safety concerns, some of which may be modifiable [ 27 ]. This is of course useful for a single primary care unit, but also at an aggregated level to see patterns at, for example, the national level [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

“…Peer review has been shown by others to be useful to shed light on provider-related errors and associated safety concerns, some of which may be modifiable [ 27 ]. This is of course useful for a single primary care unit, but also at an aggregated level to see patterns at, for example, the national level [ 27 ]. In this study all units got suggestions in their written feedback that they felt was at a higher level and not within their scope.…”

Section: Discussionmentioning

confidence: 99%

Healthcare system intervention for safer use of medicines in elderly patients in primary care—a qualitative study of the participants’ perceptions of self-assessment, peer review, feedback and agreement for change

et al. 2015

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BackgroundThe elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants’ perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care.MethodsThis is a qualitative study within the SÄKLÄK project. The SÄKLÄK project is a multi-professional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. A total of 17 participants from the intervention’s primary care units were interviewed. Most of the interviews were done on a one-to-one basis. The interviews were recorded and transcribed verbatim. A survey was also sent to the primary care unit heads. Qualitative content analysis was used to explore the participants’ perceptions.ResultsThe analysis of the interviews yielded six categories: multi-professional co-operation, a focus on areas of improvement, the joy of sharing knowledge, disappointment with the focus of the feedback, spend time to save time and impact on work. From these categories a theme developed: “Medication safety is a large area. In order to make improvements time needs to be invested and different professions must contribute.”ConclusionsThis study shows that our studied intervention method is feasible to use in primary care and that the multi-professional approach was perceived as being very positive by the participants. Multi-professional co-operation was time consuming, but was also deemed as an investment and an opportunity to share knowledge. Some points of improvement of the method were identified such as simplification of the self-assessment form and clearer instructions for reviewers. In addition, to have an impact on work the focus must lie in areas within the primary care units’ scope.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0334-6) contains supplementary material, which is available to authorized users.

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Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

Fischer¹,

Hu²,

Wescott³

et al. 2021

Journal of the American College of Surgeons

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After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

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Exploring new avenues to assess the sharp end of patient safety: an analysis of nationally aggregated peer review data

Cited by 11 publications

References 43 publications

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework

Healthcare system intervention for safer use of medicines in elderly patients in primary care—a qualitative study of the participants’ perceptions of self-assessment, peer review, feedback and agreement for change

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

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