Redressing balance saves around £5000 for each year of healthy life gained
But not if temporary agency staff are used

Employing too few permanent nurses on hospital wards is linked to longer inpatient stays, readmissions, patient deaths, and ultimately costs more in lives and money, finds a long term study published online in the journal BMJ Quality & Safety.

Redressing the balance is cost-effective, saving an estimated £4728 for each year of healthy life gained per patient, but not if  temporary agency staff are used to plug the gaps, the findings indicate.

Inadvertent understaffing–through unfilled vacancies–or deliberate–through cost cutting measures–of ward nurses risks harming hospital patients, and is a key contributor to nursing recruitment and retention issues, say the researchers.

Much of the existing research on the impact of the nursing staff:patient ratio is cross- sectional and so of limited use in determining causal factors, they add.

To find out if investing in higher nurse staffing levels to offset understaffing would be cost-effective, they set out to estimate the associations between registered nurse and healthcare assistant staffing levels and risk of patient deaths, readmissions, and length of stay in acute adult inpatient wards.

They drew on data provided by four NHS hospital trusts with diverse nurse staffing levels, sizes, teaching status, serving diverse local populations in England. Three of the trusts provided acute inpatient services predominantly from single hospital sites, and the fourth provided inpatient services across four sites within one city.

The data were derived from electronic healthcare records and staffing rosters and spanned the period April 2015 to March 2020 for a total of 626,313 patients in 185 different acute care wards.

Two main nursing team roles were included in the study: registered nurses (RNs) who have completed university degree level training and are registered with the profession’s regulator; and nursing support staff (such as healthcare assistants) who don’t have this level of training and who are largely unregulated.

The incremental cost effectiveness of eliminating the understaffing of these two roles was estimated from the costs and consequences of moving from the observed staffing shortfall averaged over the study period to the planned staffing level.

Patients spent an average of 8 days on the ward. Over the first 5 days of their inpatient stay, patients were provided with a daily average of just over 5 hours of care from RNs and just under 3 hours of care from nursing support staff.

The calculations showed that patients on wards understaffed by RNs were more likely to die (5% vs 4% for those with adequate RN staffing levels), to be readmitted (15% vs 14%), and to stay in hospital longer (8 days vs 5 days), with similar figures for inadequate numbers of nursing support staff.

Patients who experienced understaffing received an average care shortfall of 1 hour 9 minutes/day in the first 5 days, while those who didn’t experience understaffing, received an average of 3 hours 22 minutes of care above the ward average.

During the study period, 31,885 patients died. Each day a patient experienced RN understaffing (staffing below the ward average) during the first 5 days of their stay, the risks of death and readmission within 30 days increased by 8% and 1%, respectively. When all 5 days after admission were understaffed, length of stay increased by 69%.

Days of nursing support understaffing were also associated with similar increases in the risks of death and length of stay within 30 days: 7% and 61%, respectively. But the risk of readmission within 30 days fell by 0.6%.

The estimated total cost of providing care for the 626,313 adults included in the study amounted to  £2,613,385,125, or £4173 per admission.

The researchers calculated that eliminating understaffing of both nursing roles would cost an additional £197 per patient admission, avoiding 6527 of the 31,885 deaths during the study period and gaining 44,483 years of life in good health.

This equates to an additional staff cost of £2778 per healthy year of life, and £2685 if reduced sick leave and averted readmissions are taken into account. But accounting for reduced length of stay amounts to savings of £4728 per additional year of healthy life gained—an overall cost saving from increasing staffing levels.

If agency staff are used to eliminate understaffing instead, staff costs for each additional healthy year of life gained were higher, ranging from £7320 to £14,639.

“The findings give no indication that it makes rational economic sense to target efforts to rectify low staffing only on the most acute patients. Not only is this logistically difficult for patients whose acuity is emergent (occurring while on a general ward), it also gives much less benefit at a considerably higher cost per unit improvement in outcome,” explain the researchers.

“Steps to address low staffing for the general (lower acuity) population are likely to benefit high-acuity patients as well, in so far as they are in the same units, whereas the opposite is unlikely to occur if interventions are targeted on high-acuity patients in high-acuity units,” they add.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that the data came exclusively from hospitals in the English NHS, so may not be more widely applicable. Understaffing was also judged relative to ward norms rather than a validated assessment of staffing need.

But the researchers conclude: “When considering alternative policy strategies, this study indicates the importance of prioritising investment in RNs employed on wards over support staff, as well as showing there are no shortcuts to employing enough RNs, as using temporary staff is more costly and less effective.”

30 April 2025

Research: Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation Doi: 10.1136//bmjqs-2024- 018138
Journal: BMJ Quality & Safety

External funding: National Institute for Health and Research (NIHR)

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Too few ward nurses linked to longer hospital stay, readmission, and risk of death first appeared on BMJ Group.

In almost two-thirds of cases, treatment or care received was responsible, and in more than a third harm was due to lack of access to care

Almost one in ten people in Great Britain experienced healthcare-related harm due to care or treatment they received from the National Health Service (NHS) or difficulties accessing care in the last three years, show the findings of a large population survey published in the journal BMJ Quality & Safety.

In more than eight out of ten cases, the harm had a moderate or severe impact on the respondent. Disadvantaged groups, including people with disabilities, long term conditions and those in lower socioeconomic groups, were more likely to experience NHS-related harm, and when they did the consequences were likely to be more severe.

The survey used a specially designed questionnaire to collect data from patients on the incidence and consequences of a range of NHS-related adverse events – not only medical or physical consequences of treatment or care, but also psychological harm and harm due to lack of access to care.

Ipsos administered the survey and used quota sampling to ensure participants and therefore results reflected the sociodemographic profile of Great Britain. Between November 2021 and May 2022, 10,064 people in England, Scotland and Wales completed the survey.

A total of 9.7% of participants reported experiencing NHS-related harm in the previous three years: in 6.2% of cases the harm was caused by treatment or care received and in 3.5% of cases it was due to lack of access to care. In most cases hospitals were responsible for the provision of that care. Incidents of harm were higher in women and lower in people aged over 65 years.

In 44.8% of cases the respondent said that the harm experienced had a severe impact and in 37.6% of cases a moderate impact. People with long-term illness or disability, or in lower socioeconomic or other disadvantaged groups reported higher rates and more severe impact of harm.

Around two-thirds of people who experienced harm shared their experience and sought support from family and friends, and almost 60% sought advice and support from professional sources. Around a third sought support from their GP surgery (34.7%), a similar number sought support from the health provider which caused the harm (31.6%), and 11.6% contacted the Patient Advice and Liaison Service (PALS) which is intended to provide an alternative to official NHS grievance processes in England.

Few people who experienced harm took any formal action, 17% made a formal complaint to the NHS and only 2.1% made a legal claim for compensation.

One in five survey respondents (21.6%) said they would not want to make a financial claim against the NHS for harm, which the authors say reflects patient “loyalty to the NHS.”

Rather than compensation, what many patients who had experienced harm wanted was treatment or care to redress the harm by addressing physical or psychological needs (44.4%), an explanation of what had happened (34.8%) and access to treatment previously refused (29.7%).

Two-thirds of people who made a formal complaint felt it was not handled well and only around half were satisfied with their experience of PALS.

“When people cannot get validation of their experiences and adequate help with recovery through these routes, they may be forced to consider taking legal action,” the authors write.

The authors highlight a number of limitations to their study, including that it was conducted during the covid-19 pandemic which may have led to higher rate of harm than usual and potential issues of representation and bias despite the use of quota sampling.

Nevertheless, the authors conclude, “This study found higher rates of NHS-related harm than previous surveys and showed the impact is likely to have significant consequences for individual patients, families and carers, health services and the economy.”

The study is one of the first to explicitly assess actions after harm due to lack of access to care, they add. “An important finding of this study is that people harmed through a lack of access to care also require support, and the responses they desire differ from people who were harmed through treatment of care received. Having their situation recognised and being signposted towards appropriate support via a local healthcare provider may be vital in reducing harm in this group.”

The findings also highlight significant inequities in rates and impact of harm, as well as in responses in the aftermath of harm. Taken together, the differences point towards socially disadvantaged people being more likely to be harmed, experiencing higher impact and being less able to advocate for themselves in the aftermath of harm, the authors say.

02/04/2025

Notes for editors
Research: Patient-reported harm from NHS treatment or care, or the lack of access to care: a cross-sectional survey of general population prevalence, impact and responses doi: 10.1136/bmjqs-2024-017213
Journal: BMJ Quality & Safety

Funding: National Institute for Health Research Policy Research Programme

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Survey
Subjects: People

The post Almost one in ten people surveyed report having been harmed by the NHS in the last three years first appeared on BMJ Group.

And complexity of answers might make them hard to understand without college degree

Patients shouldn’t rely on AI powered search engines and chatbots to always give them  accurate and safe information on drugs, conclude researchers in the journal BMJ Quality & Safety, after finding a considerable number of answers were wrong or potentially harmful.

What’s more, the complexity of the answers provided might make it difficult for patients to fully understand them without a degree level education, add the researchers.

In February 2023, search engines underwent a significant shift thanks to the introduction of AI-powered chatbots, offering the promise of enhanced search results, comprehensive answers, and a new type of interactive experience, explain the researchers.

While these chatbots can be trained on extensive datasets from the entire internet, enabling them to converse on any topic, including healthcare-related queries, they are also capable of generating disinformation and nonsensical or harmful content, they add.

Previous studies looking at the implications of these chatbots have primarily focused on the perspective of healthcare professionals rather than that of patients.  To address this, the researchers explored the readability, completeness, and accuracy of chatbot answers for queries on the top 50 most frequently prescribed drugs in the US in 2020, using Bing copilot, a search engine with AI-powered chatbot features.

To simulate patients consulting chatbots for drug information, the researchers reviewed research databases and consulted with a clinical pharmacist and doctors with expertise in pharmacology to identify the medication questions that patients most frequently ask their healthcare professionals.

The chatbot was asked 10 questions for each of the 50 drugs, generating 500 answers in total. The questions covered what the drug was used for, how it worked, instructions for use, common side effects, and contraindications.

Readability of the answers provided by the chatbot was assessed by calculating the Flesch Reading Ease Score which estimates the educational level required to understand a particular text.

Text that scores between 0 and 30 is considered very difficult to read, necessitating degree level education. At the other end of the scale, a score of 91–100 means the text is very easy to read and appropriate for 11 year-olds.

To assess the completeness and accuracy of chatbot answers,responses were compared with the drug information provided by a peer-reviewed and up-to-date drug information website for both healthcare professionals and patients (drugs.com)

Current scientific consensus, and likelihood and extent of possible harm if the patient followed the chatbot’s recommendations, were assessed by seven experts in medication safety, using a subset of 20 chatbot answers displaying low accuracy or completeness, or a potential risk to patient safety.

The Agency for Healthcare Research and Quality (AHRQ) harm scales were used to rate patient safety events and the likelihood of possible harm was estimated by the experts in accordance with a validated framework.

The overall  average Flesch Reading Ease Score was just over 37, indicating that degree level education would be required of the reader. Even the highest readability of chatbot answers still required an educational level of high (secondary) school.

Overall, the highest average completeness of chatbot answers was 100%, with an average of 77%. Five of the 10 questions were answered with the highest completeness, while question 3 (What do I have to consider when taking the drug?) was answered with the lowest average completeness of only 23%.

Chatbot statements didn’t match the reference data in 126 of 484 (26%) answers, and were fully inconsistent in 16 of 484 (just over 3%).

Evaluation of the subset of 20 answers revealed that only 54% were rated as aligning with scientific consensus. And 39% contradicted the scientific consensus, while there was no established scientific consensus for the remaining 6%.

Possible harm resulting from a patient following the chatbot’s advice was rated as highly likely in 3% and moderately likely in 29% of these answers. And a third (34%) were judged as either unlikely or not at all likely to result in harm, if followed.

But irrespective of the likelihood of possible harm, 42% of these chatbot answers were considered to lead to moderate or mild harm, and 22% to death or severe harm. Around a third (36%) were considered to lead to no harm.

The researchers acknowledge that their study didn’t draw on real patient experiences and that prompts in different languages or from different countries may affect the quality of chatbot answers.

“In this cross-sectional study, we observed that search engines with an AI-powered chatbot produced overall complete and accurate answers to patient questions,” they write.

“However, chatbot answers were largely difficult to read and answers repeatedly lacked information or showed inaccuracies, possibly threatening patient and medication safety,” they add.

A major drawback was the chatbot’s inability to understand the underlying intent of a patient question, they suggest.

“Despite their potential, it is still crucial for patients to consult their healthcare professionals, as chatbots may not always generate error-free information. Caution is advised in recommending AI-powered search engines until citation engines with higher accuracy rates are available,” they conclude.

11/10/2024

Notes for editors
Research: Artificial intelligence-powered chatbots in search engines: a cross sectional study on the quality and risks of drug information for patients Doi: 10.1136/bmjqs-2024-017476
Journal: BMJ Quality & Safety

External funding: Bundesministerium für Bildung und Forschung

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Don’t rely on AI chatbots for accurate, safe drug information, patients warned first appeared on BMJ Group.

Most preventable, underscoring need for new approaches to surveillance, say researchers

Harmful diagnostic errors may be occurring in as many as 1 in every 14 (7%) hospital patients—at least those receiving general medical care—suggest the findings of a single centre study in the US, published online in the journal BMJ Quality & Safety.

Most (85%) of these errors are likely preventable and underscore the need for new approaches to improving surveillance to avoid these mistakes from happening in the first place, say the researchers.

Previously published reports suggest that current trigger tools for picking up medical mistakes aren’t good enough to detect harmful diagnostic errors, including those with less severe outcomes, suggest the researchers.

They therefore developed and validated a structured case review process to enable clinicians to interrogate the electronic health record (EHR) to evaluate the diagnostic process for hospital patients, assess the likelihood of a diagnostic error, and characterise the impact and severity of harm.

They used the process to estimate retrospectively the prevalence of harmful diagnostic errors in a randomly selected sample of 675 hospital patients out of a total of 9147 in receipt of general medical care between July 2019 and September 2021, excluding the height of the COVID-19 pandemic (April-December 2020).

Cases deemed to be at high risk of diagnostic error were categorised as: transfer to intensive care 24 or more hours after admission (130; 100%); death within 90 days of admission either in hospital or after discharge (141; 38.5%); complex clinical issues, but no transfer to intensive care or death within 90 days of admission (298; 7%).

Complex clinical issues included clinical deterioration; treatment by several different medical teams; unexpected events, such as cancelled surgery; unclear or discrepant diagnostic information recorded in the medical notes.

Cases deemed to be at low risk were those fulfilling none of the high risk criteria (106; 2.5%).

Each case was reviewed by two adjudicators trained to judge the likelihood of diagnostic error and identify associated process failures using the Diagnostic Error Evaluation and Research Taxonomy modified for acute care.

Harm was classified as minor, moderate, severe, and fatal, and whether the diagnostic error contributed to the harm and whether it was preventable were also assessed.

Cases with discrepancies or uncertainty about the diagnostic error or its impact were further reviewed by an expert panel.

Among all the cases reviewed, diagnostic errors were found in 160 cases (154 patients). These comprised: intensive care transfer (54); death within 90 days (34); complex clinical issues (52); low risk patients (20).

Harmful diagnostic errors were assessed to have occurred in 84 cases (82 patients), of which 37 (28.5%) occurred among intensive care transfers; 18 (13%) among those who died within 90 days; 23 (8%) among those with complex clinical issues; and 6 (6%) in low risk cases.

Harm severity was characterised as minor in 5 (6%), moderate in 36 (43%), major in 25 (30%) and fatal in 18 (21.5%).

In all, an estimated 85% of harmful diagnostic errors were preventable, with older, White, non-Hispanic, non-privately insured and high-risk patients most at risk.

Weighted to take account of the population, the researchers estimated the proportion of harmful, preventable, and severely harmful diagnostic errors in general medical hospital patients to be just over 7%, 6%, and 1%, respectively.

Process failures were significantly associated with diagnostic errors, particularly uncertainty in initial assessments and complex diagnostic testing and interpretation (4 times the risk), suboptimal subspecialty consultation (3 times the risk), concerns reported by patients (3 times the risk) and history taking (2.5 times the risk).

Forty (48%) diagnostic errors were related to the primary diagnosis at admission or discharge and 44 (52.5%) to a secondary diagnosis. Fifty two (62%) were characterised as delays. Errors associated with major or fatal harm were frequent in the high risk group (55%, 43/78) and rare in the low risk group (0/6).

The most frequent diagnoses associated with diagnostic errors included heart failure, acute kidney failure, sepsis, pneumonia, respiratory failure, altered mental state, abdominal pain and hypoxaemia (low blood oxygen levels).

Careful analysis of the errors and integrating AI tools into the workflow should help to minimise their prevalence, by improving monitoring and triggering timely interventions, suggest the researchers.

This is an observational study, based on estimates, drawn from data on patients receiving general medical care at one single centre, and should be interpreted in that context, caution the researchers.

They also acknowledge that the sample was restricted to patients with a length of hospital stay under 21 days, and that the study relied on information captured in the electronic health record, which is prone to inaccurate recording of deaths within 90 days.

Nevertheless, they conclude: “We estimate that a harmful [diagnostic error] occurred in 1 of every 14 patients hospitalised on general medicine, the majority of which were preventable. Our findings underscore the need for novel approaches for adverse [diagnostic error] surveillance.”

02/10/2024

Notes for editors
Research: Adverse diagnostic events in hospitalised patients: a single- centre, retrospective cohort study Doi 10.1136/bmjqs-2024-017183
Journal: BMJ Quality & Safety

External funding: Agency for Healthcare Research and Quality (AHRQ)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Harmful diagnostic errors may occur in 1 in every 14 general medical hospital patients first appeared on BMJ Group.

Outpacing 45% increase in world’s population during the same period (1990-2019)
Older people worldwide bear the brunt, with steepest rise among 65-69 year olds 

The proportion of patient harms associated with medical procedures, treatment, and contact with healthcare systems rose by 59%, from 11 million to 18 million globally between 1990 and 2019, finds a data analysis published online in the journal BMJ Quality & Safety.

They outpaced the increase in the world’s population of 45% over the same period. And older people bore the brunt of these incidents, with the steepest rise among 65-69 year olds, the findings show.

In developed nations, over 50% of inpatient harms are deemed preventable, rising to 83% in developing nations, note the researchers. These harms undermine health and the quality of life, are costly, and erode public trust, while squandering valuable resources, they add.

But current estimates of the ‘adverse effects of medical treatment’ rely heavily on medical record reviews and voluntary reporting systems. And the lack of a systematic, consistent global approach, makes it difficult to accurately quantify the numbers and inform health policy priorities, say the researchers.

In a bid to address this, they drew on data from the Global Burden of Disease (GBD) study for 204 countries for the period 1990-2019. The GBD includes information from a range of sources, including surveillance systems, government records, health facility reports, and surveys.

The researchers looked at the overall and age standardised number of new incidents globally and nationally. They then looked at time trends, stratified by age and sex and the Sociodemographic Index (SDI), a composite of income, education, and fertility rate of individual countries that represents their social and economic development.

Between 1990 and 2019, the global population increased by 45%. But over the same period, reported cases of patient harm arising from medical treatment rose faster—by 59% from around 11 million to 18 million.

The overall incidence rate was 232.5 per 100,000 of the global population in 2019, representing a 10% increase since 1990. And the age standardised incidence rate was just over 233/100,000, representing an increase of 4.5%.

Regionally, the overall incidence rate for all age groups in the high SDI region increased from 515/100,000 in 1990 to almost 823/100,000 in 2019, representing an increase of 60%. And the age standardised incidence rate rose from 502 to 648/100,000, an increase of 29%.

France was the only country in the high SDI region to buck this trend for all age groups, with the steepest decline in cases among 50 to 70 year olds, possibly because of a string of patient safety policies and measures implemented nationwide, suggest the researchers.

The sharpest fall in overall incidence rate was observed in low SDI regions, falling by 14% from 155 to 141/100,000; the age-standardised incidence rate in these regions fell by around 10% from 147 to 139/100,000.

Globally, the incidence remained largely unchanged across age bands up to the 45–49 year old age bracket. But incidence rates increased among 50–94 year olds, with the steepest increase among 65-69 year olds, at around 2% a year.

 Cases among those aged under 1, 1–4, 5–9, and 10–24 fell. But in 2019, cases among those aged 0–4 still accounted for over 17.5% of all cases.

Between 1990 and 2019, all five SDI regions closely matched the global trends, with decreasing proportions of cases among the under 24s and increases among the over 50s.

There are several possible reasons for the disparate trends between high and low SDI regions, suggest the researchers. These include the extent of healthcare provision, which is higher in wealthier and more developed countries. For example, the incidence of patient harm in the USA was about 50 times higher at all ages than it was in Indonesia.

Higher incidence in the high SDI region may also reflect better monitoring systems and greater and more equitable population access to healthcare, not just poor quality or overtreatment, they suggest. And people are more likely to live longer in wealthier countries.

As to the higher rates of patient harms among older people, the researchers suggest that drugs are likely to explain most of these as a result of age-related physiological factors affecting drug metabolism and clearance, polypharmacy, co-existing health conditions, and declines in cognitive and functional capacity reducing medication adherence.

“This confluence of factors renders appropriate medication management exponentially more challenging in advanced-age populations with complex comorbidities,” they write.

The researchers acknowledge various limitations to their findings, including that many lower SDI countries lacked reliable original data, for which predictive estimates had to be substituted. And the GBD study only evaluated the overall numbers of patient harms without any analysis of the types or severity of incident.

But the researchers conclude: “As population age and medical services expand with socio-economic development, addressing [adverse effects of medical treatment] incidents becomes a universal imperative to safeguard patient wellbeing and ensure equitable access to quality healthcare.”

12/07/2024

Notes for editors
Research: Global, regional and national time trends in incidence of adverse effects of medical treatment, 1990–2019: an age–period–cohort analysis from the Global Burden of Disease 2019 study Doi: 10.1136/bmjqs-2023-016971
Journal: BMJ Quality & Safety

External funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post Rise in global number of patient harms from 11 million to 18 million (59%) in 30 years first appeared on BMJ Group.

Outpacing 45% increase in world’s population during the same period (1990-2019)
Older people worldwide bear the brunt, with steepest rise among 65-69 year olds 

The proportion of patient harms associated with medical procedures, treatment, and contact with healthcare systems rose by 59%, from 11 million to 18 million globally between 1990 and 2019, finds a data analysis published online in the journal BMJ Quality & Safety.

They outpaced the increase in the world’s population of 45% over the same period. And older people bore the brunt of these incidents, with the steepest rise among 65-69 year olds, the findings show.

In developed nations, over 50% of inpatient harms are deemed preventable, rising to 83% in developing nations, note the researchers. These harms undermine health and the quality of life, are costly, and erode public trust, while squandering valuable resources, they add.

But current estimates of the ‘adverse effects of medical treatment’ rely heavily on medical record reviews and voluntary reporting systems. And the lack of a systematic, consistent global approach, makes it difficult to accurately quantify the numbers and inform health policy priorities, say the researchers.

In a bid to address this, they drew on data from the Global Burden of Disease (GBD) study for 204 countries for the period 1990-2019. The GBD includes information from a range of sources, including surveillance systems, government records, health facility reports, and surveys.

The researchers looked at the overall and age standardised number of new incidents globally and nationally. They then looked at time trends, stratified by age and sex and the Sociodemographic Index (SDI), a composite of income, education, and fertility rate of individual countries that represents their social and economic development.

Between 1990 and 2019, the global population increased by 45%. But over the same period, reported cases of patient harm arising from medical treatment rose faster—by 59% from around 11 million to 18 million.

The overall incidence rate was 232.5 per 100,000 of the global population in 2019, representing a 10% increase since 1990. And the age standardised incidence rate was just over 233/100,000, representing an increase of 4.5%.

Regionally, the overall incidence rate for all age groups in the high SDI region increased from 515/100,000 in 1990 to almost 823/100,000 in 2019, representing an increase of 60%. And the age standardised incidence rate rose from 502 to 648/100,000, an increase of 29%.

France was the only country in the high SDI region to buck this trend for all age groups, with the steepest decline in cases among 50 to 70 year olds, possibly because of a string of patient safety policies and measures implemented nationwide, suggest the researchers.

The sharpest fall in overall incidence rate was observed in low SDI regions, falling by 14% from 155 to 141/100,000; the age-standardised incidence rate in these regions fell by around 10% from 147 to 139/100,000.

Globally, the incidence remained largely unchanged across age bands up to the 45–49 year old age bracket. But incidence rates increased among 50–94 year olds, with the steepest increase among 65-69 year olds, at around 2% a year.

 Cases among those aged under 1, 1–4, 5–9, and 10–24 fell. But in 2019, cases among those aged 0–4 still accounted for over 17.5% of all cases.

Between 1990 and 2019, all five SDI regions closely matched the global trends, with decreasing proportions of cases among the under 24s and increases among the over 50s.

There are several possible reasons for the disparate trends between high and low SDI regions, suggest the researchers. These include the extent of healthcare provision, which is higher in wealthier and more developed countries. For example, the incidence of patient harm in the USA was about 50 times higher at all ages than it was in Indonesia.

Higher incidence in the high SDI region may also reflect better monitoring systems and greater and more equitable population access to healthcare, not just poor quality or overtreatment, they suggest. And people are more likely to live longer in wealthier countries.

As to the higher rates of patient harms among older people, the researchers suggest that drugs are likely to explain most of these as a result of age-related physiological factors affecting drug metabolism and clearance, polypharmacy, co-existing health conditions, and declines in cognitive and functional capacity reducing medication adherence.

“This confluence of factors renders appropriate medication management exponentially more challenging in advanced-age populations with complex comorbidities,” they write.

The researchers acknowledge various limitations to their findings, including that many lower SDI countries lacked reliable original data, for which predictive estimates had to be substituted. And the GBD study only evaluated the overall numbers of patient harms without any analysis of the types or severity of incident.

But the researchers conclude: “As population age and medical services expand with socio-economic development, addressing [adverse effects of medical treatment] incidents becomes a universal imperative to safeguard patient wellbeing and ensure equitable access to quality healthcare.”

11/06/2024

Notes for editors
Research: Global, regional and national time trends in incidence of adverse effects of medical treatment, 1990–2019: an age–period–cohort analysis from the Global Burden of Disease 2019 study Doi: 10.1136/bmjqs-2023-016971
Journal: BMJ Quality & Safety

External funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post Rise in global number of patient harms from 11 million to 18 million (59%) in 30 years first appeared on BMJ Group.

Avoiding 16,000 patient harms and saving 20+ lives and £millions for services in England

Implementing a single shared digital prescribing record across the NHS in England could avoid nearly 1 million drug errors every year, stopping up to 16,000 fewer patients from being harmed, and saving up to 22 lives every year, suggests a modelling study, published online in BMJ Quality & Safety.

The figures, which are based on the assumption that such a system could reduce medication errors by at least 10%, and by as much as 50%, could also save £millions for the NHS, say the researchers.

Previously published research suggests that drug errors cost the NHS £98 million every year, consuming over 180,000 bed days, and contributing to around 1700 deaths.

A major nationwide initiative is currently under way across NHS health and social care to enable different information systems to share data digitally, often referred to as system interoperability, explain the researchers.

But as yet, there’s no evidence to show what impact this would have on patient safety, so, at the behest of NHS England, the researchers set out to estimate the current extent and consequences of drug errors associated with information transfer within the NHS in England, and how effective system interoperability might be in reducing them.

In the absence of routinely collected data on drug errors in the NHS, the researchers drew on published evidence and third party expertise to estimate the annual prevalence, associated patient harm, and NHS costs of undetected drug errors as patients transition through care.

The researchers focused on errors that are most likely to occur when someone has to manually transfer prescription information: omitted medicines; extra and duplicated medicines; wrong dose, frequency, timing, or formulation; and medicines intended for immediate/short term use but prescribed for long term use instead.

The care transition points studied were: hospital admission from primary care; hospital discharge into primary care; transfer from one hospital to another for inpatient or outpatient care; and transfers between departments/clinics within the same hospital.

Associated hospital admission and inpatient treatment, length of hospital stay, and death were used to reflect patient harms, as these were the only objective measures of harm that could be estimated from the available data.

National data sources for England were used to estimate costs, which were reported for the cost year 2020-21.

The total annual number of undetected drug errors was estimated to affect around 1.8 million prescription items at transitions of care in hospitals in England.

Of these, over half (52%) happened when patients were admitted to hospital, and 44% when they were discharged; 3% occurred during transfers from one hospital to another; and 1% occurred during transfers within the same hospital.

These errors were estimated to affect around 380,000 episodes of patient care, resulting in avoidable harms to 31,500 patients, 36,500 additional bed days at a cost of around £17.8 million to the NHS, and more than 40 deaths.

Based on these figures, the researchers estimated that for every 10% reduction in the number of drug errors during transitions of care, there would be at least 3000 fewer episodes of associated patient harm and at least 3500 fewer bed days needed, saving the NHS nearly £1.8 million, and 4 lives every year.

And if the implementation of a single shared digital prescription record halved the number of these errors, there could be around 1 million fewer drug errors during transitions of care, up to 16,000 fewer people experiencing associated harms, and more than 20 lives saved every year, estimate the researchers.

The researchers acknowledge that they had to make various assumptions in their calculations, given that there’s little data on drug errors and their consequences, and couldn’t include key care transitions, such as to and from care homes and mental health facilities.

But given this, their figures are likely to be underestimates, they suggest, and conclude that “an interoperable prescription information system has the potential to substantially reduce transition medication error prevalence, associated harm, and healthcare costs.”

There are likely to be other benefits too, including healthcare professional time saved, improved patient experience and care quality, quicker discharge, and enhanced medicines optimisation across organisations, they say.

“The widespread adoption and active use of interoperable systems across the NHS will be pivotal to realising the benefits of interoperability and a key step towards the ultimate aim of having one patient-centred consolidated medication record, to which there will be fully interoperable access,” they add.

27/03/2024

Notes for editors

Research: Estimating the impact on patient safety of enabling the digital transfer of patients’ prescription information in the English NHS doi: 10.1136/bmjqs-2023-016675

Journal: BMJ Quality & Safety

External funding: NHS England

Link to Academy of Medical Sciences Press releases labelling system

http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes

Evidence type: Modelling study

Subjects: People

The post Shared digital NHS prescribing record could avoid nearly 1 million annual drug errors first appeared on BMJ Group.

Activity focused on meeting minimum requirement, after which it tails off

There’s strong evidence of a ‘threshold effect’ in English hospitals’ efforts to comply with the 18-week referral to treatment standard, concludes a long term data analysis of performance against the target, published online in the journal BMJ Quality & Safety.

The target focused activity on meeting the threshold requirement for patients on the waiting list after which it tailed off—the so-called threshold effect–rather than instigating pervasive improvement in practice, the analysis indicates. Clinical need may be a secondary consideration for meeting the target, suggest the researchers.

In 2012, an 18-week referral to treatment standard was introduced in England. This stipulated that at any point at least 92% of patients requiring hospital treatment should have been waiting for less than 18 weeks.

But how this target affects hospitals that are close to meeting it rather than those that have already met it or fall far short of doing so isn’t clear.

To try and find out, the researchers retrospectively scrutinised publicly available monthly data on treatment waiting times for all 144 non-specialist acute NHS hospital trusts in England between January 2016 and September 2021.

Treatment covers admission to hospital; surgery; starting a course of drugs; fitting a medical device; agreeing to monitor the condition to see if further treatment is warranted; or receiving advice from a clinician on how to manage a condition.

They analysed waiting times for all patients and then repeated this for 13 specific treatment groups: cardiology; cardiothoracic; dermatology; ear, nose and throat; gastroenterology; general surgery; gynaecology; neurosurgery; ophthalmology; oral surgery; plastic surgery; trauma and orthopaedics; and urology.

A threshold effect shows up as a spike in the data, known as discontinuity, which appears around the target threshold, explain the researchers.

Their analysis showed that the proportion of NHS hospital trusts meeting the target worsened over time, falling from 92% in 2015-16 to 64% in 2021-22.

Similarly, the percentage of trusts where patients waited less than 18 weeks fell gradually after the removal in 2016-17 of the financial sanction for breaching the standard. It then fell sharply during the early phase of COVID-19 in 2020-21 before gradually recovering.

There was strong evidence of a threshold effect up to 2019-20, despite the fall in the number of hospital trusts meeting the target.

The data repeatedly showed a large spike in the number of trusts exactly meeting the 92% target threshold for the 18-week standard, followed by a sharp drop after the target had been reached. This suggests that some trusts treat the minimum number of patients waiting under 18 weeks to comply with the standard, say the researchers.

The threshold effect only disappeared in the financial years 2020-21 and 2021-22, when the COVID-19 pandemic made it virtually impossible for most hospitals to meet the target.

Hospitals near the target likely act to clear it, while those further away from meeting it don’t bother, on the grounds that it would be futile to do so, suggest the researchers.

They acknowledge that the study wasn’t designed to investigate the behavioural triggers and motivations that might explain the threshold effect.

Nevertheless, they conclude: “Our findings suggest that hospital trusts may choose whom to treat based on the target instead of clinical need, as the target provides no encouragement to treat patients who have only been waiting for a short time or who have already passed the 18-week wait.”

Performance targets are common in the NHS, they add. But they caution: “Policymakers should be circumspect in their use of targets. Second, if targets are used, then policymakers should examine for threshold effects routinely. Third, targets should be carefully designed to mitigate threshold effects.”

In a linked editorial, Nigel Edwards, chief executive of the health think tank, the Nuffield Trust, London, says that while targets can be effective and are helpful for public accountability, the study “joins a long litany of examples of the unintended impact of targets.”

He explains: “The most sustainable approach to meeting a target is to redesign processes and realign resources to ensure that the targets are met as a by-product of a well designed system.

“However, if there are insufficient resources—for example, in the case of waiting lists where demand exceeds capacity, or the organisation lacks the skills and resources to undertake a major review of processes and ways of working—less desirable approaches may be taken.”

These include demanding unsustainable levels of work from staff to meet the target, to the exclusion of almost everything else; and ‘gaming’ the targets, which can lead to an arms race of increasingly complex rules designed to eliminate the practice, he suggests.

The NHS has often focused on input targets rather than outcomes and on promoting ‘achieving the numbers’ over developing a better understanding of the problem, and often without involving those responsible for delivery, he adds.

“The experience of the use of targets in the English NHS, as evidenced by [the study authors] and many other researchers, suggests that over-reliance on a small number of high-profile measures is risky. A richer picture of how the system being measured works and how its staff and managers behave and are motivated is needed for sustainable long-term change,” he writes.

“Effective performance improvement systems cannot be built solely on targets but need a great deal of managerial judgement. The improvement system and the local teams delivering improvement both need the management capacity to make good judgements to avoid the issues of gaming, overpromising, and other perverse ways of pursuing the metric while missing the point,” he concludes.

05/09/2023

Notes for editors
Research: Unintended consequences of the 18- week referral to treatment standard in NHS England: a threshold analysis doi 10.1136/bmjqs-2023-015949
Editorial: Targets: unintended and unanticipated  effects doi 10.1136/bmjqs-2023-016247
Journal: BMJ Quality & Safety

Funding: (Research) National Institute of Health Research Applied Research Collaboration West Midlands

Link to Academy of Medical Sciences press release labelling system http://press.psprings.co.uk/AMSlabels.pdf

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Observational (data analysis); Opinion
Subjects: People

The post Strong evidence of ‘threshold effect’ for NHS 18-week waiting list target first appeared on BMJ Group.

Avoidable consequences cost NHS upwards of £98 million and 1700+ lives every year

More than 237 million medication errors are made every year in England, the avoidable consequences of which cost the NHS upwards of £98 million and more than 1700 lives every year, indicate national estimates, published online in the journal BMJ Quality & Safety.

The harms caused by medication errors have been recognised as a global issue, amid increasingly complex healthcare needs and the introduction of many new medicines. 

And the World Health Organization (WHO) aims to halve the level of severe avoidable harm associated with medication error at any point in the process—prescribing, dispensing, administration, and monitoring–between 2017 and 2022.

To obtain up to date estimates of the number of medication errors, and their potential financial and human impact on the NHS in England, the researchers pooled prevalence estimates from the available evidence and studies measuring the harms caused, published up to October 2018.

And they calculated the number of opportunities for medication error by stage and setting–primary care; care homes; hospitals and at the point of discharge (transition)–using published statistics on the annual number of medicines dispensed and used, bed occupancy data, and numbers of care home residents, for the whole of England for one calendar year.

Based on all this information, they estimated that more than 237 million medication errors are made every year in England.

Errors are made at every stage of the process, with over half (54%) made at the point of administration and around 1 in 5 made during prescribing (21%). Dispensing accounts for 16% of the total.

Error rates are lowest in primary care, but because of the sector’s size, these account for nearly 4 out of every 10 (38%). Error rates are highest in care homes (42%), despite covering fewer patients than the other sectors. Around 1 in 5 medication errors are made in hospitals.

The researchers estimated that nearly 3 out of 4 medication errors (72%) are minor, while around 1 in 4 (just under 26%) have the potential to cause moderate harm; just 2% could potentially result in serious harm.

Around a third (34%) of potentially harmful medication errors are made during prescribing in primary care.

The researchers calculated that “definitely avoidable” medication errors cost the NHS nearly £98.5 million every year and 1708 lives.

For the worst case scenario, which assumes a hospital stay of 14 days for each incident and the need for a broad range of NHS services, the estimates come in at £1.6 billion and 22,303 lives, respectively, each year.

The researchers point out that there were simply no UK medication error data available for certain stages of the medication process or for any stage of the process in care homes.

And their calculations didn’t include medication errors made by patients or their caregivers, and relied on certain assumptions about the extent of direct harms caused. 

But the estimated error rates are similar to those reported for the USA and European Union countries. And their findings have informed the Department of Health and Social Care’s decision to commission a new system to monitor and prevent medication errors.

The available evidence shows that the medicines most often implicated in hospital admissions attributable to medication errors are non-steroidal anti-inflammatories (NSAIDs); clot busters (anti-platelet drugs); drugs to treat epilepsy and low blood glucose; water tablets (diuretics); inhaled corticosteroids; and certain types of heart drugs (cardiac glycosides and beta blockers), say the researchers.

Most (80%) of the resulting deaths are caused by gastrointestinal bleeds from NSAIDs, aspirin, or the blood thinner warfarin.

“Ubiquitous medicines use in health care leads, unsurprisingly, to high numbers of medication errors, although most are not clinically important,” they write. 

“Effective targeting of finite healthcare resources to reduce medication errors requires understanding of where errors cause the most burden. Data linkage between errors and patient outcomes is essential to progress understanding in this area,” they conclude.

[Ends]

11/06/2020

Notes for editors
Research: Economic analysis of the prevalence and clinical and economic burden of medication error in England  doi 10.1136/bmjqs-2019-010206
Journal: BMJ Quality & Safety

Funding: National Institute for Health Research (NIHR)

Disclaimer: The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care

Academy of Medical Sciences Labelling System
http://press.psprings.co.uk/AMSlabels.pdf

Peer reviewed? Yes
Evidence type: Analysis of published data
Subjects: Medicines and people

Embargoed link to research
https://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs-2019-010206

The post 237+ million medication errors made every year in England first appeared on BMJ Group.