title: Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.
abstract: BACKGROUND
  Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these.
  
  
  METHODS
  We used a mixed methods, controlled before and after design. At baseline, wards were audited on medication safety indicators; during the 'feedback' phase scorecard results were presented to intervention wards on a weekly basis over 7 weeks. We interviewed 49 staff, including clinicians and managers, about scorecard implementation.
  
  
  RESULTS
  At baseline, 18.7% of patients (total n=630) had incomplete allergy documentation; 53.4% of patients (n=574) experienced a drug omission in the preceding 24 h; 22.5% of omitted doses were classified as 'critical'; 22.1% of patients (n=482) either had ID wristbands not reflecting their allergy status or no ID wristband; and 45.3% of patients (n=237) had drugs that were either unlabelled or labelled for another patient in their drug lockers. The quantitative analysis found no significant improvement in intervention wards following scorecard feedback. Interviews suggested staff were interested in scorecard feedback and described process and culture changes. Factors influencing scorecard implementation included 'normalisation' of errors, study duration, ward leadership, capacity to engage and learning preferences.
  
  
  CONCLUSIONS
  Presenting evidence-based performance indicators may potentially influence staff behaviour. Several practical and cultural factors may limit feedback effectiveness and should be considered when developing improvement interventions. Quality scorecards should be designed with care, attending to evidence of indicators' effectiveness and how indicators and overall scorecard composition fit the intended audience.
authors.affiliation: Department of Applied Health Research, University College London, , London, UK.
authors.forename: Angus I G
authors.initials: AI
authors.lastname: Ramsay
authors.forename: Simon
authors.initials: S
authors.lastname: Turner
authors.forename: Gillian
authors.initials: G
authors.lastname: Cavell
authors.forename: C Alice
authors.initials: CA
authors.lastname: Oborne
authors.forename: Rebecca E
authors.initials: RE
authors.lastname: Thomas
authors.forename: Graham
authors.initials: G
authors.lastname: Cookson
authors.forename: Naomi J
authors.initials: NJ
authors.lastname: Fulop
mesh_terms: D019985:Benchmarking / Q000379:methods*; D003430:Cross-Sectional Studies; D004739:England; D006757:Hospital Units; D006801:Humans; D007407:Interviews as Topic; D008505:Medical Staff, Hospital / Q000523:psychology / Q000706:statistics & numerical data; D015279:Organizational Culture; D061214:Patient Safety / Q000592:standards*; D010865:Pilot Projects; D036301:Qualitative Research; D013222:State Medicine; D011795:Surveys and Questionnaires
keywords: Audit and Feedback; Governance; Medication Safety; Patient Safety; Quality Improvement
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