We have seen some truly excellent articles published in the BMJ Quality and Safety in 2024. The articles discussed in this blog represent the best of these, and have been selected based on engagement metrics and scores assigned by the editorial board. Further information about the process used to select these papers can be found in a past blog. This post will discuss the articles ranked sixth to tenth.
We would like to express our thanks to the authors of these excellent papers and to all of the BMJ Quality and Safety team who helped during the selection process – this was not an easy task!
Societal demographic structures are changing across the world – societies are ageing, and chronic disease and multimorbidity are becoming increasingly common. Community health care services such as primary and ambulatory care are responsible for the management of most chronic disease. However, health services are under pressure and satisfaction with services in some countries is at an all-time low. To shift the dial in a positive direction we must understand what aspects of health and health care delivery matter most to patients, and use these to measure and drive change.
This study described the development of a conceptual framework on which the International Survey of People Living with Chronic Conditions Patient-Reported Indicator Surveys (PaRIS) survey was based. The survey was developed by the Organisation for Economic Co-operation and Development and aimed to collect data related to patient reported experiences and patient reported outcomes in primary and ambulatory care. The conceptual framework was developed iteratively based on pre-existing conceptual frameworks, and engagement with experts and patients internationally. The key domains within the developed conceptual framework included patient reported outcomes and experience of care, and also other factors that can directly or indirectly influence these, including factors related to the health care system and wider determinants of health. A strength of this study was its conscious effort to engage with patients and experts internationally.
The survey has since been completed by more than 100,000 patients in over 1,800 primary care practices across 19 countries 1. It has shone an important light on the experiences and outcomes of patients living with chronic disease across the world. The report highlights that “people are living longer but not necessarily better”. These findings should represent the start of a conscious and collaborative effort to listen to the patient voice and use patient experiences as a catalyst for change.
- OECD (2025), Does Healthcare Deliver?: Results from the Patient-Reported Indicator Surveys (PaRIS), OECD Publishing, Paris, https://doi.org/10.1787/c8af05a5-en.
Medication errors can occur at any stage from prescribing to administration, sometimes with serious consequence. As the last step in this process – and consequentially the final opportunity for prevention – medicines administration is a key point where errors could be intercepted. Barcode medication administration (BCMA) technology attempts to ensure that the right medication, at the right dose, in the right formulation is given to the right patient. It requires that medication packaging and patient identification are scanned, with potential errors flagged to the healthcare professional prior to administration. BCMA has previously been shown to reduce medication errors, but as with all technological innovations, it relies upon utilisation by end-users. In some settings, BCMA is under-utilised.
In this study, a feedback intervention that aimed to increase the rate of BCMA utilisation was developed and tested in a central London hospital. The intervention was co-designed with frontline staff, based upon prior qualitative research, and informed by behavioural science. The feedback intervention was based on a positively framed motivational nudge to frontline staff. Senior nursing staff on the wards allocated to the intervention arm praised nursing staff that utilised BCMA, gave target utilisation rates for the ward, and highlighted benefits of BCMA at morning and evening handovers. The intervention was implemented on 5 non-randomly selected wards and compared to 14 other wards in the same hospital. Prior to implementation, control wards had a weekly median medication scan rate of 18%, and intervention wards 15%. Following implementation, control wards had a weekly median medication scan rate of 27%, and intervention wards 41%.
This study demonstrates the value of engaging frontline staff to fully understand the barriers that surround the implementation of safety-promoting technology, and provides a compelling example of the potential benefit of low-cost feedback interventions. Long-term sustainability and scalability are key challenges of feedback interventions. In this study, the intervention period was approximately 18 weeks, and there was an indication that its impact was starting to wane towards the end. It is essential that such interventions are embedded as part of a process of continuous and sustained evaluation and improvement. Effort must also be made to ensure that only the most pertinent and preventable safety messages are highlighted, to prevent fatigue and maximise their effectiveness.
8 – Adverse diagnostic events in hospitalised patients: a single-centre, retrospective cohort study Accompanying editorial available here
Diagnosis is central to medical practice and embodies both the art and science of medicine. It is dependent upon the gathering and interpretation of information, usually in the form of patient histories, physical examination, or diagnostic investigation. Rarely does a single piece of information provide a definitive diagnosis – all of this information is considered together and in context. Even when done well, diagnoses are often uncertain. Given the complexity, it is unsurprising that diagnoses are not always correct. However, as treatments are started and stopped on the basis of diagnoses, diagnostic errors can cause significant patient harm, and improving diagnostic accuracy can improve patient care.
This study sought to estimate the prevalence of adverse diagnostic events in hospitalised patients and explore associated harm. Diagnostic error was defined as the failure to establish an accurate and timely explanation of a patient’s health problem, or a failure to communicate that health problem to the patient. The authors conducted rigorous retrospective case reviews based on the ‘Safer Dx framework’ from a sample of patients. These patients were all treated under general medicine as inpatients in a single hospital in Boston. Population estimates were derived from the sample and it was estimated that harmful diagnostic errors occur in 7.2% of patients, and severely harmful diagnostic errors in 1.1%. Notably, it was estimated that 84.7% of harmful diagnostic errors were preventable. Several process failures were associated with harmful diagnostic errors including assessment failures and failures in diagnostic test ordering, amongst others.
This study provides valuable insights into the realities of diagnostic error, including their frequency and consequence. Whilst this study clearly underlines the problem, the ultimate goal is to prevent diagnostic error and subsequent patient harm. Future work is needed to explore the potential for techniques to identify diagnostic errors to ensure they are acted upon appropriately.
7 – Do healthcare professionals work around safety standards and should we be worried? A scoping review
As a healthcare professional I am confident that answer to the question posed in the title of this paper is yes, and yes (at least sometimes). Healthcare professionals deliver care in a fast-paced environment under significant time and resource constraint. This is coupled with an ever-expanding list of safety standards and checklists implemented in an attempt to improve patient safety. Inevitably, when staff are faced with multiple competing demands and limited time, pragmatic decisions are made. Sometimes these pragmatic decisions involve ‘workarounds’, which can have positive or negative effects on patient care. This scoping review sought to understand the circumstances and perceived implications of working around safety standards.
Of the 27 included studies, most were conducted in acute hospital settings but others were also conducted across other settings. Over half of the safety standard workarounds were related to medicines safety and a wide range of causes were identified. Organisational workarounds such as those caused by workload and resources were the most common cause identified, reported in over 90% of papers. The use of workarounds was also strongly influenced by context with some occurring in emergency and exceptional circumstances. Notably, there were often good reasons for workarounds and they usually represented an attempt to deliver more efficient or person-centred care. For example, several examples were provided where staff omitted certain tasks in an attempt to deliver care in a timely fashion. Others did not adhere to electronic health record policies in an attempt to be more present with patients. The authors noted that safety standard workarounds could have positive, negative or mixed implications for patients, staff, and organisations.
Given the complexity of clinical practice, it is impossible to develop safety standards that are relevant to all circumstances. Therefore, if the ultimate goal is to optimise patient safety, we should not aim to eliminate workarounds completely. Staff need to be empowered to make pragmatic decisions grounded in evidence with the patient at the centre. Having said that, it seems that the present balance is not optimised, and organisational pressures are such that staff are routinely left with no choice but to work around safety standards.
6 – Role of knowledge and reasoning processes as predictors of resident physicians’ susceptibility to anchoring bias in diagnostic reasoning: a randomised controlled experiment Accompanying editorial available here
As highlighted in the study featuring at number 8 in this blog, diagnostic error is common. Harmful diagnostic errors are estimated to occur in just over 7% of general medical patients. The vast majority of diagnostic errors are deemed preventable, and therefore there is a need to understand why they occur. This study examines the role of cognitive bias. Diagnostic reasoning requires clinicians to extract salient information from a patient history. However, this salient information is often hidden amongst other information, including salient distracting features. Salient distracting features are pieces of information that are not relevant to the current problem, but are notable because of their association with another plausible disease, and they can result in anchoring bias. Anchoring bias occurs when clinicians diagnose a disease associated with these salient distracting features, even in the presence of contradictory evidence.
This study sought to explore the relationship between clinician knowledge levels and susceptibility to this form of bias. They started by evaluating disease knowledge of residents in the Netherlands, with a focus on discriminating features of disease. One week later they presented several case vignettes, and residents (with an average of just under 3 years in clinical practice) were asked to give a diagnosis, and their confidence in the diagnosis. These case vignettes were designed such that salient distracting features were either present, or not present. Interestingly, residents with less knowledge of discriminating features were more likely to provide incorrect diagnoses induced by anchoring bias. Whilst this did not translate in to significant differences in diagnostic accuracy scores, it does highlight an important interaction between medical knowledge and susceptibility to cognitive bias. A logical inference from these results is that education about diagnostic reasoning and bias may reduce susceptibility to such biases. However, logic does not always marry with reality and the authors highlight mixed results from such educational efforts. Educational strategies that underline the importance of discriminating features of disease may be a valuable strategy to reduce anchoring bias.