Informing understanding of coordination of care for patients with heart failure with preserved ejection fraction: a secondary qualitative analysis.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) are a complex and underserved group. They are commonly older patients with multiple comorbidities, who rely on multiple healthcare services. Regional variation in services and resourcing has been highlighted as a problem in heart failure care, with few teams bridging the interface between the community and secondary care.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

Why Is The Area Important?: A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable.

User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment.

Background: Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context.

Development and application of 'systems thinking' principles for quality improvement.

Introduction: 'Systems thinking' is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a 'Safety-II systems approach' to promote understanding of how safety may be achieved in complex work systems.

Using Always Events to derive patient-centred quality improvement priorities in a specialist primary care service providing care to a homeless population.

Background: 'Always Events' (AE) is a validated quality improvement (QI) method where patients, and/or carers, are asked what is so important that it should 'always' happen when they interact with healthcare services. Answers that meet defined criteria can be used to direct patient-centred QI activities. This method has never, to our knowledge, been applied in the care of a UK homeless population.

Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method.

Background: Ensuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge.

Background: Pharmacists' completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.

Methods: This is a systematic literature review and meta-analysis of extracted data.

Effects of Patent Foramen Ovale Closure on Obstructive Sleep Apnea Syndrome: PCOSA Study.

Background: Previous studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS.

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved.

Understanding and responding when things go wrong: key principles for primary care educators.

Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a 'systems approach' could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care.

Human factors in general practice - early thoughts on the educational focus for specialty training and beyond.

In the third article in the series, we describe the outputs from a series of roundtable discussions by Human Factors experts and General Practice (GP) Educational Supervisors tasked with examining the GP (family medicine) training and work environments through the lens of the systems and designed-centred discipline of Human Factors and Ergonomics (HFE). A prominent issue agreed upon proposes that the GP setting should be viewed as a complex sociotechnical system from a care service and specialty training perspective. Additionally, while the existing GP specialty training curriculum in the United Kingdom (UK) touches on some important HFE concepts, we argue that there are also significant educational gaps that could be addressed (e.

The past, present and future of patient safety education and research in primary care.

In the first series of related articles, we describe how assurance of patient safety in primary care was traditionally viewed by the medical profession hierarchy as being wholly dependent at the individual level upon a combination of education and training, knowledge, skill, experience and commitment to professional development. As well as summarising the evidence underpinning what we know about patient safety in primary care, we outline how contemporary thinking has evolved to recognise that the safety issue is complex, problematic and systemic, and that it is now beginning to attract the attention of national policymakers, educators and research funders in some countries. We also describe a range of recently developed educational safety concepts and methods that have been implemented as part of current national programme initiatives in the United Kingdom and internationally.

Developing a ward round checklist to improve patient safety.

Checklists have been shown to improve care and reduce morbidity and mortality in the healthcare setting.[1] Their application in safety-critical industries outside of medicine continues to offer a strong argument for their application to medicine.[2] The daily in-patient medical ward round is a complex process and includes multiple potential risks to patient safety.

Improving management of gout in primary care using a customised electronic records template.

It is known that the management of chronic gout in relation to serum uric acid (SUA) monitoring, allopurinol dosing, and lifestyle advice is often sub-optimal in primary care.[1] A quality improvement project in the form of a criterion based audit was carried out in an urban general practice to improve the care of patients being treated for gout. Baseline searching of EMIS confirmed that management of patients with gout who were taking allopurinol was not in line with current guidance.

Quality improvement project using a care bundle approach on the management of the immediate discharge document (IDD) within a single general practice.

The Scottish Patient Safety Programme in Primary Care (SPSP-PC) aims to improve the medicines reconciliation process in primary care to help reduce the number of adverse events causing avoidable harm. [1] The aim of this project is to improve the process for handling Immediate Discharge Documents (IDDs) in a single practice and develop a protocol using the care bundle approach. The care bundle consisted of: 1.

Quality improvement training for core medical and general practice trainees: a pilot study of project participation, completion and journal publication.

Background And Objectives: Small-scale quality improvement projects are expected to make a significant contribution towards improving the quality of healthcare. Enabling doctors-in-training to design and lead quality improvement projects is important preparation for independent practice. Participation is mandatory in speciality training curricula.

A before and after study of warfarin monitoring in a single region as part of the Scottish patient safety programme in primary care.

Introduction: Warfarin is an effective drug for patients at risk of thromboembolic events, but sub-optimal pharmacological management may cause significant harm. As part of the Scottish patient safety programme in primary care, one health board region aimed to determine if the international normalised ratio control for patients taking warfarin in general practice improved over the first 12 months of participation.

Methods: A before and after study of a multi-intervention improvement strategy was employed that combined financial incentivisation, a regional learning collaborative, clinical care bundle implementation, audit and feedback and clinical 'safety champions'.

Quality improvement and person-centredness: a participatory mixed methods study to develop the 'always event' concept for primary care.

Objectives: (1) To ascertain from patients what really matters to them on a personal level of such high importance that it should 'always happen' when they interact with healthcare professionals and staff groups. (2) To critically review existing criteria for selecting 'always events' (AEs) and generate a candidate list of AE examples based on the patient feedback data.

Design: Mixed methods study informed by participatory design principles.

Participatory design of a preliminary safety checklist for general practice.

Background: The use of checklists to minimise errors is well established in high reliability, safety-critical industries. In health care there is growing interest in checklists to standardise checking processes and ensure task completion, and so provide further systemic defences against error and patient harm. However, in UK general practice there is limited experience of safety checklist use.

Quality and safety issues highlighted by patients in the handling of laboratory test results by general practices--a qualitative study.

Background: In general practice internationally, many care teams handle large numbers of laboratory test results relating to patients in their care. Related research about safety issues is limited with most of the focus on this workload from secondary care and in North American settings. Little has been published in relation to primary health care in the UK and wider Europe.

Identification of coronary plaque sub-types using virtual histology intravascular ultrasound is affected by inter-observer variability and differences in plaque definitions.

Background: Recent studies show that virtual histology intravascular ultrasound (VH-IVUS) can identify plaques at high risk of rupture, such as thin-capped fibroatheromata, raising the possibility of immediate targeted intervention. However, plaque classification entails border recognition and subjective assessment of plaque architecture, introducing inter-observer variability without confirmation by core-labs. Furthermore, the accuracy of local versus core-laboratory VH-IVUS plaque classification and effects of different plaque definitions have not been examined.

Association between IVUS findings and adverse outcomes in patients with coronary artery disease: the VIVA (VH-IVUS in Vulnerable Atherosclerosis) Study.

Objectives: The purpose of this study was to determine whether thin-capped fibroatheromata (TCFA) identified by virtual histology intravascular ultrasound (VH-IVUS) are associated with major adverse cardiac events (MACE) on individual plaque or whole patient analysis.

Background: Post-mortem studies have identified TCFA as the substrate for most myocardial infarctions. However, little is known about the natural history of individual TCFA and their link with MACE.