Intra and Interorganizational Learning Networks and the Implementation of Quality Improvement Initiatives: The Case of a Portuguese Teaching Hospital

Learning has an important position in the development of employees and their expertise. This article focuses on the role and utilization of intra and interorganizational formal and informal learning within different types of learning networks. Specifically, we investigate different types of networks (inter- or intraorganizational) and different types of learning (formal or informal) that can occur within such networks. Our qualitative case study is based on 46 expert interviews involving 49 interviewees, through which we explore how formal and informal learning was used in the development and implementation of quality improvement initiatives at a large public teaching hospital in Portugal. Our analysis suggests that formal and informal learning can take place within different types of learning networks that draw on internal resources as well as on the collaboration with external entities. The article argues that it is important for HRD managers, seeking to support organizational learning, to understand how different types of learning take place, and which features of learning networks support these processes.

Nutritional Status of older patients attending Cork University Dental School and Hospital

Objectives: This study aimed to gather data on the nutritional status of older patients attending Cork University Dental School and Hospital for treatment in the Restorative Department. Information was also collected about the medical status of the patients including the prevalence of self-reported xerostomia.
Methods: Data was collected by a self-completion questionnaire followed by a brief clinical examination. Nutritional Status was measured using the short version of the Mini Nutritional Assessment (MNA) which recorded patients’ Body Mass Index (BMI). The MNA consists of 6 parameters (including questions relating to patients’ history and anthropometric data) with a maximum total of 14 points. Scores of 12-14 indicate “normal nutritional status” whilst those between 8 and 11 indicate a patient “at risk of malnutrition”. Scores lower than 8 are an indication a patient who is “malnourished”. All patients attending Cork University Dental School and Hospital aged 65 years and older were invited to participate in the study.

Results: A total of 22 subjects participated in this study. Twelve patients were partially dentate with 10 edentulous. The results from the MNA indicate that 11 patients were of “normal nutritional status” with 11 patients identified as being “at risk of malnutrition”. None of the subjects were “malnourished”. Edentate patients generally recorded lower MNA scores than partially dentate patients. In total, 9 patients reported experiencing xerostomia with 8 indicating that they needed to sip liquids to aid swallowing but only 3 had difficulty swallowing food.

Conclusion: This small study indicates that a number of the older patients attending Cork University Dental School and Hospital for dental care may be “at risk of malnutrition”. These findings suggest that nutritional advice and dental care should both be included in an overall package of care for older patients.

An audit of antimicrobial treatment of lower respiratory and urinary tract infections in a hospital setting

Objectives: To audit the quality of treatment of lower respiratory tract infections (LRTIs) and urinary tract infections (UTIs) and to identify targets for antibiotic stewardship. Methods: The audit involved collecting data on admitted patients, who were diagnosed with LRTIs or UTIs and subsequently received antibiotic treatment (January 2009-April 2009). Key findings: The percentage adherence rate for hospital antibiotic policy was 68.6% (24/35). Documentation of the CURB-65 score was found in 80% (16/20) of the patients' clinical notes, for which 46.2% (6/13) of patients were treated according to their CURB- 65 score. The percentages of delayed and missed doses for all antibiotics were 21.7% (254/1171) and 8.6% (101/1171), respectively. The percentage of patients switched from intravenous to oral antibiotics in accordance with the policy was 58.5% (31/53). The mean length of stay for patients switched in line with the guidelines was 6.9 days (range: 2-18 days) compared with 13.2 days (range: 4-28 days) for patients treated with intravenous antibiotics >24 h after the intravenous to oral switch criteria were fulfilled; this equates to on average an extra 6.3 days of hospitalisation (p=0.01). Conclusions: The study identified a number of targets for quality improvement including adherence to antibiotic policy, documentation of the CURB-65 score in patients' notes and treating patients accordingly, addressing the issue of missed and delayed doses, and maintaining adherence to the hospital intravenous-to-oral antibiotic switch policy. The findings suggest that the quality of antibiotic prescribing could be improved by measuring and addressing such performance indicators.

The Coxian phase-type distribution as a contribution to the multilevel model of in-hospital mortality

This paper presents multilevel models that utilize the Coxian phase-type distribution in order to be able to include a survival component in the model. The approach is demonstrated by modeling patient length of stay and in-hospital mortality in geriatric wards in Italy. The multilevel model is used to provide a means of controlling for the existence of possible intra-ward correlations, which may make patients within a hospital more alike in terms of experienced outcome than patients coming from different hospitals, everything else being equal. Within this multilevel model we introduce the use of the Coxian phase-type distribution to create a covariate that represents patient length of stay or stage (of hospital care). Results demonstrate that the use of the multilevel model for representing the in-patient mortality is successful and further enhanced by the inclusion of the Coxian phase-type distribution variable (stage covariate).

A Conditional Approach for Modelling Patient Re-admissions in Hospital using a mixture of Coxian phase-type distributions incorporating Bayes Theorem

The number of elderly patients requiring hospitalisation in Europe is rising. With a greater proportion of elderly people in the population comes a greater demand for health services and, in particular, hospital care. Thus, with a growing number of elderly patients requiring hospitalisation competing with non-elderly patients for a fixed (and in some cases, decreasing) number of hospital beds, this results in much longer waiting times for patients, often with a less satisfactory hospital experience. However, if a better understanding of the recurring nature of elderly patient movements between the community and hospital can be developed, then it may be possible for alternative provisions of care in the community to be put in place and thus prevent readmission to hospital. The research in this paper aims to model the multiple patient transitions between hospital and community by utilising a mixture of conditional Coxian phase-type distributions that incorporates Bayes' theorem. For the purpose of demonstration, the results of a simulation study are presented and the model is applied to hospital readmission data from the Lombardy region of Italy.

Medication Reconciliation at Discharge from Hospital: A Systematic Review of the Quantitative Literature

Medicines reconciliation is a way to identify and act on discrepancies in patients’ medical histories and it is found to play a key role in patient safety. This review focuses on discrepancies and medical errors that occurred at point of discharge from hospital. Studies were identified through the following electronic databases: PubMed, Sciences Direct, EMBASE, Google Scholar, Cochrane Reviews and CINAHL. Each of the six databases was screened from inception to end of January 2014. To determine eligibility of the studies; the title, abstract and full manuscript were screened to find 15 articles that meet the inclusion criteria. The median number of discrepancies across the articles was found to be 60%. In average patient had between 1.2–5.3 discrepancies when leaving the hospital. More studies also found a relation between the numbers of drugs a patient was on and the number of discrepancies. The variation in the number of discrepancies found in the 15 studies could be due to the fact that some studies excluded patient taking more than 5 drugs at admission. Medication reconciliation would be a way to avoid the high number of discrepancies that was found in this literature review and thereby increase patient safety.

Prevalence, Nature, Severity and Risk Factors for Prescribing Errors in Hospital Inpatients: Prospective Study in 20 UK Hospitals

Introduction: It has been suggested that doctors in their first year of post-graduate training make a disproportionate number of prescribing errors.

Obkective: This study aimed to compare the prevalence of prescribing errors made by first-year post-graduate doctors with that of errors by senior doctors and non-medical prescribers and to investigate the predictors of potentially serious prescribing errors.

Methods: Pharmacists in 20 hospitals over 7 prospectively selected days collected data on the number of medication orders checked, the grade of prescriber and details of any prescribing errors. Logistic regression models (adjusted for clustering by hospital) identified factors predicting the likelihood of prescribing erroneously and the severity of prescribing errors.

Results: Pharmacists reviewed 26,019 patients and 124,260 medication orders; 11,235 prescribing errors were detected in 10,986 orders. The mean error rate was 8.8 % (95 % confidence interval [CI] 8.6-9.1) errors per 100 medication orders. Rates of errors for all doctors in training were significantly higher than rates for medical consultants. Doctors who were 1 year (odds ratio [OR] 2.13; 95 % CI 1.80-2.52) or 2 years in training (OR 2.23; 95 % CI 1.89-2.65) were more than twice as likely to prescribe erroneously. Prescribing errors were 70 % (OR 1.70; 95 % CI 1.61-1.80) more likely to occur at the time of hospital admission than when medication orders were issued during the hospital stay. No significant differences in severity of error were observed between grades of prescriber. Potentially serious errors were more likely to be associated with prescriptions for parenteral administration, especially for cardiovascular or endocrine disorders.

Conclusions: The problem of prescribing errors in hospitals is substantial and not solely a problem of the most junior medical prescribers, particularly for those errors most likely to cause significant patient harm. Interventions are needed to target these high-risk errors by all grades of staff and hence improve patient safety.