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Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Journal Article > Study
Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation.
Benning A, Ghaleb M, Suokas A, et al. BMJ. 2011;342:d195.
The United Kingdom's Safer Patients Initiative (SPI) is a large-scale effort to improve patient safety, with past studies demonstrating positive perceptions of the program among participants. In this phase one study, the SPI focused efforts in 4 hospitals, where a $1.2 million investment was made in each to secure improvements across a wide range of aims, including a 50% reduction in adverse events. The multifaceted interventions targeted organizational factors, such as safety culture and specific clinical issues (e.g., medication errors and communication), through continuous quality improvement methods. The robust program, including this independently requested evaluation, demonstrated a few improvements associated with introduction of SPI, but no additional benefit on many other targeted issues. An accompanying editorial [see link below] discusses the study findings, and emphasizes the continued need to run toward science rather than away from it in evaluating quality improvement efforts.
Journal Article > Review
Identifying potential prescribing safety indicators related to mental health disorders and medications: a systematic review.
Khawagi WY, Steinke DT, Nguyen J, Keers RN. PLoS One. 2019;14:e0217406.