Top 10 articles of 2023, #6-10

In this post, we’re offering summaries and comments on articles from BMJ Quality & Safety’s Top 10 Articles of 2023. For the full list of our 23 finalists, click here, and to read more about the annual Top Article selection process, please click here. To briefly summarize, the editors 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 this Top 10. These articles demonstrate the wonderful breadth of valuable articles published in BMJ Quality & Safety every year.

  1. Systematic review of clinical debriefing tools: attributes and evidence for use by EC Phillips et al. BMJ Quality & Safety 2024;33:187-198. Accompanying blog post available here.

Clinical debriefing occurs in many different contexts in healthcare, including after unexpected clinical deterioration, recognized safety events, and patient incivility. Several reasons exist for inconsistent implementation of debriefs after such events, including clinical needs of other patients, discomfort or inadequate training for facilitating such discussions, and lack of systemwide standardization. Phillips and colleagues performed a systematic review of tools for debriefing after unplanned clinical events in hospital settings. The authors found 21 tools that met their inclusion criteria, with most being used in specific settings (such as the Emergency Department) or specific clinical scenarios (such as cardiac arrest). Only one identified tool (‘TALK’) was specifically designed for multiple event types across a diversity of clinical settings, but many recommended similar components: debriefing soon after the event, a duration generally of less than 10 minutes, use of a private space away from the event and ongoing clinical care, using a ‘blame free’ opening to create a psychologically safe environment, open discussion of emotions and reactions, engagement on what went well and what could be improved, identifying possible changes to be made, and a strategy for follow-up of participant well-being. Ultimately, having a shared structural framework for flexible debriefings across clinical settings would allow institutional leaders to promote debriefing and normalize such conduct.

  1. How to co-design a prototype of a clinical practice tool: a framework with practical guidance and a case study by M Woodward et al. BMJ Quality & Safety 2024;33:258-70. Accompanying editorial available here.

Clinical tools are ubiquitous in health care, yet many tools have not gone through rigorous design processes prior to deployment. In this article, Woodward and colleagues describe their five-step FRESCO (FRamework for co-dESign of Clinical practice tOols) process to combine user-centred methods and co-design principles in creating clinical tools, applying it to develop a prototype track-and-trigger chart for fetal deterioration during labour intended for national use. Their five steps are as follows: 1) establish a multidisciplinary advisory group; 2) develop initial drafts of the prototype; 3) conduct think-aloud usability evaluations; 4) test the prototype in clinical situations; and 5) generate a final prototype informed by workshops. These steps correlate with a co-design framework moving from the pre-design phase in steps 1 and 2, a generative phase in step 3 and an evaluative phase in steps 4 and 5, before moving to implementation and post-design phases for ongoing analysis of practical implementation to inform later modifications. While following this framework would be likely to require significant resources in terms of time and personnel, the costs of implementing poorly-designed tools can also be high, whether measured in risks to patient safety, rework for tool improvement, or in failure to achieve optimal clinical outcomes.

  1. Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis by C Feather (@calandrafeather) et al. BMJ Quality & Safety 2023;32:357-368. Accompanying editorial available here.

Including the indication for medication prescriptions is increasingly seen as a strategy for improving medication safety and ordering efficiency. Adoption of this practice, however, often has lagged behind such recommendations. Feather and colleagues systematically reviewed interventions aimed to increase indication-based prescribing alongside identification of barriers and facilitators. They identified 21 articles across a mix of clinical environments targeted at multiple different practitioners, including physicians, advanced practice providers, nurses, pharmacists, and patients. The interventions generally fell into two categories: those encouraging documentation via selection of the indication from a list or free-text entry, and those requiring medication ordering to be via pre-defined indication-based ordering processes. Approximately half of studies focused on antimicrobial selection, most often assessing (and most successfully improving) the appropriateness of chosen therapies. Other outcomes included indication documentation accuracy, rates of usage, and prescribing errors, as well as workflow and clinical outcomes. The majority of studies reported a positive outcome. Several potential facilitators were identified that should promote uptake, including improved ability to identify and correct prescribing errors and improved team communication. However, workflow considerations were frequently noted barriers, including those related to time and lack of perceived benefits. Continuing to address such workflow concerns through efforts such as redesign will hopefully overcome provider reluctance and simplify safer prescribing for all.

  1. Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis by R Payne et al. BMJ Quality & Safety Published Online First: 28 November 2023. Accompanying editorial available here.

During the COVID-19 pandemic, remote clinical encounters increased substantially in many health systems. The persistent use of these technologies may alleviate some pressures on primary care but also increases the potential risks of rare patient safety events. Payne and colleagues therefore executed a combined Safety I review of 95 rare, documented safety incidents for remote primary care encounters from 2015-2023 and performed Safety II qualitative examination via interviews, workshops, and field observations in 12 general practices in the United Kingdom over two years to explore actions that prevented such incidents. Many of the safety incidents exhibited multiple contributing themes. For example, errors in assessment may be compounded using remote modalities with patients with difficulty communicating with issues such as cognitive impairment or extremes of age. Other contributing themes included inflexible application of triage rules, patient complexity, organisational issues, and inadequate training. Strategies noted to compensate for these vulnerabilities included timely clinician review of lists of patients with complaints of uncertain urgency, customised anticipatory safety-netting guidance, conversion to in-person or home visits when deemed helpful or necessary by the triage team, and informal communication directly to clinicians by triage staff. Hopefully, guidance from such safety event analyses can inform strategies that mitigate the risks inherent in these remote encounters and allow delivery to be safe, equitable, and patient-centred.

  1. Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis by JN Chu (@janetnchu) et al. BMJ Quality & Safety Published Online First: 30 December 2023. Accompanying editorial available here.

Language discordant clinical care, where the clinician and the patient speak different languages, is theorized to have several quality and safety implications. However, studies measuring unplanned health care re-utilization have had mixed results, and it is unclear the degree to which interpreter services might affect any outcomes disparities. Chu and colleagues therefore undertook a systematic review and meta-analysis of language discordance and unplanned hospital readmissions or emergency department (ED) revisits and the impact of interpreter services. Forty-nine studies met their inclusion criteria, with 13 including pediatric populations and 33 having a ‘good’ quality rating. Roughly one-third of the 31 studies examining hospital readmissions in adults showed a significant increase in the odds of readmission in those with language discordance, which was confirmed on meta-analysis. Two of these studies explicitly provided or verified interpreter use, showing no significant difference in hospital readmission. Fewer studies (13) examined ED revisits in adults, but roughly half found a significant difference, which was again confirmed in meta-analysis. Only three studies measured pediatric readmissions, finding no significant difference, while five studied pediatric ED revisits, showing significant increases in the odds of ED revisits at 3 and 7 days. More standardized approaches to identify language-discordant healthcare interactions and provision of high-quality interpreter services would benefit both health systems and patients globally.

Joel Boggan

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