Top 10 articles of 2022, #6-10

In this post, we’re offering summaries and comments on articles from BMJ Quality & Safety’s Top 10 Articles of 2022. To check out the full list of our 24 finalists, click here, and to learn more about the Top Article selection process, click here. To briefly summarize, the editors and the Editorial Board used data such as citation rates and social media engagement to create the finalist article list, which was then scored by the editorial team on novelty, generalizability/addition to understanding, rigor of methods, and importance to clinical practice to arrive at the Top 10. As in past years, these articles demonstrate the wonderful breadth of valuable articles published in BMJ Quality & Safety.

  1. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis by RS Bourne et al. BMJ Quality & Safety 2022;31:609-622. Accompanying editorial available here.

Despite recommendations to standardise handover procedures that include transfer of information about medication changes, both medication errors and adverse drug events frequently occur as patients transfer from an intensive care unit (ICU) to a general ward. Bourne and colleagues performed a systematic review and meta-analysis of studies to examine medication-related interventions within 48 hours of patient transfer and barriers and facilitators to their implementation. They analysed 17 studies with a range of interventions including staff education, medication review or reconciliation, and electronic handover tools, with half of interventions having multiple components. Overall, the most frequently noted facilitator to interventions intended to reduce medication errors was the availability of specialist ICU clinical pharmacists (in seven studies). Ultimately, the authors found low to very low quality of evidence that studies with deprescribing elements reduced the odds of inappropriate medication continuation by half at both ICU transfer and hospital discharge. Further analysis showed moderate evidence that multicomponent strategies could reduce the odds of inappropriate hospital discharge medication continuation by a factor of four. However, the team found no evidence that such interventions improved patient outcomes such as mortality, length of stay, or ICU readmission. Future work should therefore aim to identify specific components that may reduce negative medication-related outcomes and address current barriers to preventing medication errors.

  1. Communication about sexual orientation and gender between clinicians, LGBT+ people facing serious illness and their significant others: a qualitative interview study of experiences, preferences and recommendations by D Braybrook (@DEBraybrook) et al. BMJ Quality & Safety 2023;32:109-120. Accompanying editorial available here.

Although legal protections for LGBT+ people are in place in many countries, many continue to experience stigmatization and healthcare discrimination that can contribute to poorer healthcare access and health outcomes. Braybrook and colleagues conducted a qualitative study in England to investigate experiences and preferences regarding communication about sexual orientation, gender identity and gender history in the context of serious illness in LGBT+ patients, their informal caregivers, and clinicians. The research team reached pragmatic saturation after 74 interviews, which generated three overall themes: 1) Creating positive first impressions and building rapport; 2) Enhancing care by actively exploring and explaining the relevance of sexual orientation and gender identity; and 3) Visible and consistent LGBT+ inclusiveness in care systems. The authors then share 10 evidence-based recommendations for providing inclusive, person-centred healthcare corresponding to these three thematic areas, including tips for how to practically incorporate these recommendations into clinical encounters.

  1. Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation by Q Lohmeyer et al. BMJ Quality & Safety 2023;32:26-33. Accompanying editorial available here.

Medication errors also happen prior to transfer from the ICU, and of particular concern are drug incidents related to look-alike, sound-alike (LASA) medications. In this study in a Swiss ICU, Lohmeyer and colleagues led a randomised in-situ simulation study using tall man lettering (TML) to distinguish different portions of LASA drug names (such as ePHEDrin versus EPINEPHrin) involving 30 ICU nurses with a median ICU experience of six years. Nurses were asked to select the correct syringes of a drug name and concentration over the course of the experiment. Overall, TML significantly reduced the overall error rate in this simulation of practice by approximately 85%. Using eye-tracking technology, TML was also found to lead to significantly longer visual dwell time on the label, higher fixation count, and higher fixation duration (roughly three times as long or as many views as the non-TML options). Additionally, placing the TML within the middle or end of the drug name led to increases in all the eye tracking metrics relative to placement at the beginning of the drug name. Thus, TML reduced simulated errors and changed visual attention. Although this study shows potential benefit for care team members who physically interact with LASA medications, other multimodal efforts are likely necessary to further reduce errors across all aspects of the drug use process, including across computerised prescriber order entry systems and in different physical work environments.

  1. Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders by L Hinton (@LisaHinton4) et al. Published Online First: 12 May 2022. Accompanying blog post available here.

One consequence of the pandemic was the shift in many healthcare services, such as antenatal care, to remote technology platforms. Hinton and colleagues followed this pragmatic transition with qualitative work involving more than 200 self-identifying women ≥ 16 years of age who were pregnant on or after March 2020, healthcare professionals delivering maternity services, and managers of these services and systems-level stakeholders from 9 NHS England maternity units. The authors studied this group to begin defining what ‘quality’ remote antenatal care should look like going forward. The results were mapped roughly to the Institute of Medicine’s six domains of quality care, with multiple benefits identified around potential time and travel costs for patients, work flexibility for providers, and efficiency and care timeliness. However, several concerns related to provider workload, patient-centredness, team and relationship-building, safety and equity were voiced, especially concerning patients from vulnerable and lower socio-economic groups especially at risk of digital exclusion. Thus, ongoing implementation efforts for remote care should be continuously evaluated for possible gaps in quality, safety, and access related to use of these technologies and intersecting structural inequities.

  1. Optimising GPs’ communication of advice to facilitate patients’ self-care and prompt follow-up when the diagnosis is uncertain: a realist review of ‘safety-netting’ in primary care by C Friedemann Smith (@cfrieders) et al. BMJ Quality & Safety 2022;31:541-554.

Safety-netting, when performed well as a strategy for dealing with diagnostic uncertainty, combines anticipatory guidance for patients on appropriate self-care and when they should return for further consultation. Friedemann Smith and colleagues performed a realist review of 95 documents to create an evidence-based theory of and recommendations for achieving effective communication of safety-netting advice. Ultimately, the team described 22 context, mechanism and outcome configurations informing their programme theory across four domains: 1) advice content, 2) agreeing to the plan, 3) documentation, and 4) additional considerations. Across these domains, the authors offer 15 recommendations to reach shared understanding between the clinician and the patient, which they mapped to three popular primary care consultation models. While many of these recommendations would be easily recognizable in an ideal consultation, time constraints and the frequent presence of multiple patient concerns and comorbidities means additional research is needed on practical implementation and follow-up of safety-netting advice plans.

Joel Boggan

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