The 2015 Garrod Lecture: Why is improvement difficult?

Journal of Antimicrobial Chemotherapy

Volumn 70, Issue 11, 2015, Pages 2931-2944

  Davey, Peter ^a  

^a UNIVERSITY OF DUNDEE   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANTIBIOTIC AGENT; ANTIINFECTIVE AGENT;

ANTIBIOTIC PROPHYLAXIS; ANTIBIOTIC THERAPY; ARTICLE; BEHAVIOR CHANGE; CATHETER INFECTION; CLINICAL DECISION MAKING; CULTURAL ANTHROPOLOGY; DECISION SUPPORT SYSTEM; EMPOWERMENT; ERGONOMICS; HEALTH CARE POLICY; HUMAN; LEADERSHIP; MEDICAL EDUCATION; PATIENT EDUCATION; POSTOPERATIVE PERIOD; PRESCRIPTION; PROFESSIONAL KNOWLEDGE; DRUG UTILIZATION; HEALTH PERSONNEL ATTITUDE; PROCEDURES; STANDARDS;

ANTI-BACTERIAL AGENTS; ATTITUDE OF HEALTH PERSONNEL; DRUG PRESCRIPTIONS; DRUG UTILIZATION; EDUCATION, MEDICAL; HUMANS;

EID: 84949033581     PISSN: 03057453     EISSN: 14602091     Source Type: Journal    
DOI: 10.1093/jac/dkv214     Document Type: Article

References (74)

1. Department of Health 2013. UK Five Year Antimicrobial Resistance Strategy 2013 to 2018. https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018.
2. Cronshaw HL, Daniels R, Bleetman A et al. Impact of the Surviving Sepsis Campaign on the recognition and management of severe sepsis in the emergency department: are we failing? Emerg Med J 2010; 28: 670-5.
3. Daniels R, Nutbeam T, McNamara G et al. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emerg Med J 2010; 28: 507-12.
4. Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-96.
5. Davey P, Sneddon J, Nathwani D. Overview of strategies for overcoming the challenge of antimicrobial resistance. Expert Rev Clin Pharmacol 2010; 3: 667-86.
6. Kunin CM, Tupasi T, Craig WA. Use of antibiotics a brief exposition of the problem and some tentative solutions. Ann Intern Med 1973; 79: 555-60.
7. Kunin CM. Problem of antibiotic usage: definitions, causes, and proposed solutions. Ann Intern Med 1978; 89: 802-5.
8. Cooke D, Salter AJ, Phillips I. Antimicrobial misuse, antibiotic policies and information resources. J Antimicrob Chemother 1980; 6: 435-43.
9. UK Department of Health. 2000. UK Antimicrobial Resistance Strategy and Action Plan. http://antibiotic-action.com/wp-content/uploads/2011/07/DH-UK-antimicrobial-resistance-strategy-and-action-plan.pdf.
10. European Union Conference 1998. The Copenhagen Recommendations. Report from the Invitational EU Conference on the Microbial Threat. Edited by Rosdahl VK, Pedersen KB. http://www.reactgroup.org/uploads/react/resources/430/The%20Copenhagen%20Recommendations.en.504.pdf.
11. UK House of Lords Select Committee on Science and Technology. Resistance to Antibiotics and Other Antimicrobial Agents. London: Stationery Office, 1998; 1-108.
12. Shlaes DM, Gerding DN, John JF et al. Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Clin Infect Dis 1997; 25: 584-99.
13. World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance. http://www.who.int/drugresistance/WHO_Global_Strategy.htm/en/.
14. Gawande A. Reith Lectures 2014: The Future of Medicine. http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atulgawande-2014-reith-lectures.
15. Davey P, Brown E, Charani E et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013; issue 4: CD003543.
16. Davey P, Peden C, Brown E et al. Interventions to improve antibiotic prescribing practices for hospital inpatients (updated protocol). Cochrane Database Syst Rev 2014; issue 8: CD011236.
17. Davey P, Peden C, Charani E et al. Time for action-improving the design and reporting of behaviour change interventions for antimicrobial stewardship in hospitals: early findings from a systematic review. Int J Antimicrob Agents 2015; 45: 203-12.
18. Holden RJ, Carayon P, Gurses AP et al. SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients. Ergonomics 2013; 56: 1669-86.
19. Fenwick T, Edwards R, Sawchuk P. Emerging Approaches to Educational Research: Tracing the Sociomaterial. Abingdon: Routledge, 2011.
20. Gardner B, Whittington C, McAteer J et al. Using theory to synthesise evidence from behaviour change interventions: the example of audit and feedback. Soc Sci Med 2010; 70: 1618-25.
21. Ivers N, Jamtvedt G, Flottorp S et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; issue 6: CD000259.
22. Lloyd RC. Quality Health Care: A Guide to Developing and Using Indicators. Sudbury, MA: Jones and Barrett, 2004.
23. The Health Foundation. Overcoming Challenges to Improving Quality. 2012. http://www.health.org.uk/publication/overcoming-challengesimproving-quality.
24. Michie S, Richardson M, Johnston M et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013; 46: 81-95.
25. Hoffmann TC, Glasziou PP, Boutron I et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 2014; 348: g1687.
26. Michie S, Fixsen D, GrimshawJM et al. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implement Sci 2009; 4: 40.
27. Weinberg M, Fuentes JM, Ruiz AI et al. Reducing infections among women undergoing cesarean section in Colombia by means of continuous quality improvement methods. Arch Intern Med 2001; 161: 2357-65.
28. Crombie IK, Davies HTO. Missing link in the audit cycle. Qual Health Care 1993; 2: 47-8.
29. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 2011; 6: 42.
30. BMJ Group. BMJ Quality. http://quality.bmj.com/.
31. Institute for Healthcare Improvement. IHI Open School Quality Improvement Practicum. http://www.ihi.org/offerings/IHIOpenSchool/Courses/Pages/Practicum.aspx.
32. Prior M, Elouafkaoui P, Elders A et al. Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol. Implement Sci 2014; 9: 50.
33. Scottish Dental Clinical Effectiveness Programme. Drug Prescribing for Dentistry. http://www.sdcep.org.uk/published-guidance/drug-prescribing.
34. Patel SJ, Oshodi A, Prasad P et al. Antibiotic use in neonatal intensive care units and adherence with Centers for Disease Control and Prevention 12 Step Campaign to Prevent Antimicrobial Resistance. Pediatr Infect Dis J 2009; 28: 1047-51.
35. Patel S, Landers T, Larson E et al. Clinical vignettes provide an understanding of antibiotic prescribing practices in neonatal intensive care units. Infect Control Hosp Epidemiol 2011; 32: 597-602.
36. Patel SJ, Saiman L, Duchon JM et al. Development of an antimicrobial stewardship intervention using a model of actionable feedback. Interdiscip Perspect Infect Dis 2012; 2012: 150367.
37. Charani E, Castro-Sanchez E, Sevdalis N et al. Understanding the determinants of antimicrobial prescribing within hospitals: the role of 'prescribing etiquette'. Clin Infect Dis 2013; 57: 188-96.
38. Marwick C, Guthrie B, Pringle J et al. A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series. BMJ Qual Saf 2013; doi:10.1136/bmjqs-2013-002176.
39. Scottish Antimicrobial Prescribing Group and Scottish Patient Safety Programme. Sepsis Collaborative Measurement Plan. http://www.knowledge.scot.nhs.uk/sepsisvte/sepsis.aspx.
40. Benn J, Koutantji M, Wallace L et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009; 18: 11-21.
41. Nelson EC, Splaine ME, Batalden PB et al. Building measurement and data collection into medical practice. Ann Intern Med 1998; 128: 460-6.
42. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-32.
43. Dixon-Woods M, Bosk CL, Aveling EL et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011; 89: 167-205.
44. Dixon-Woods M, Leslie M, Tarrant C et al. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8: 70.
45. Dixon-Woods M, Leslie M, Bion J et al. What counts? An ethnographic study of infection data reported to a patient safety program. Milbank Q 2012; 90: 548-91.
46. The Health Foundation. Lining Up: How is Harm Measured? 2013. http://www.health.org.uk/publication/lining-how-harm-measured.
47. Bion J, Richardson A, Hibbert P et al. 'Matching Michigan': a 2-year stepped interventional programme to minimise central venous catheterblood stream infections in intensive care units in England. BMJ Qual Saf 2013; 22: 110-23.
48. Kritchevsky SB, Braun BI, Bush AJ et al. The effect of a quality improvement collaborative to improve antimicrobial prophylaxis in surgical patients: a randomized trial. Ann Intern Med 2008; 149: 472-80, W89-93.
49. Sun TB, Chao SF, Chang BS et al. Quality improvements of antimicrobial prophylaxis in coronary artery bypass grafting. J Surgical Res 2011; 167: 329-35.
50. Bate P. Context is Everything: Perspectives on Context. London: Health Foundation, 2014; 1-30. http://www.health.org.uk/publication/perspectivescontext.
51. Dixon-Woods M. The Problem of Context in Quality Improvement: Perspectives on Context. London: Health Foundation, 2014; 87-101. http://www.health.org.uk/publication/perspectives-context.
52. Feynman R. Cargo cult science: some remarks on science, pseudoscience and learning how not to fool yourself. In: Robbins J, ed. The Pleasure of Finding Things Out. London: Penguin Books, 2007; 205-16.
53. Bate P, Robert G, Fulop N et al. Perspectives on Context. The Health Foundation. 2014. http://www.health.org.uk/publication/perspectives-context.
54. Mattick K, Kelly N, Rees C. A window into the lives of junior doctors: narrative interviews exploring antimicrobial prescribing experiences. J Antimicrob Chemother 2014; 69: 2274-83.
55. Damschroder LJ, Aron DC, Keith RE et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50.
56. Clinical Human Factors Group. Towards a Working Definition of Human Factors in Healthcare. http://www.chfg.org/news-blog/towards-a-working-definition-of-human-factors-in-healthcare.
57. Russ AL, Fairbanks RJ, Karsh BTet al. The science of human factors: separating fact from fiction. BMJ Qual Saf 2013; 22: 802-8.
58. Hignett S, Jones EL, Miller D et al. Human factors and ergonomics and quality improvement science: integrating approaches for safety in healthcare. BMJ Qual Saf 2015; 24: 250-4.
59. Carayon P, Schoofs Hundt A, Karsh BT et al. Work system design for patient safety: the SEIPSmodel. Qual Saf Health Care 2006; 15 Suppl 1: i50-8.
60. Karsh BT, Waterson P, Holden RJ. Crossing levels in systems ergonomics: a framework to support 'mesoergonomic' inquiry. Appl Ergon 2014; 45: 45-54.
61. Bleakley A. Blunting Occam's razor: aligning medical education with studies of complexity. J Eval Clin Pract 2010; 16: 849-55.
62. Martimianakis MA, Albert M. Confronting complexity: medical education, social theory and the 'fate of our times'. Med Educ 2013; 47: 3-5.
63. Fenwick T, Dahlgren MA. Towards socio-material approaches in simulation-based education: lessons from complexity theory. Med Educ 2015; 49: 359-67.
64. Fenwick T. Sociomateriality in medical practice and learning: attuning to what matters. Med Educ 2014; 48: 44-52.
65. Mennin S. Self-organisation, integration and curriculum in the complex world of medical education. Med Educ 2010; 44: 20-30.
66. Lucas B, Hanson J, Claxton G. Thinking like an Engineer: Implications for the Education System. London: Royal Academy of Engineering, 2014. http://www.raeng.org.uk/publications/reports/thinking-like-an-engineerimplications-full-report.
67. Lucas B, Nacer H. Habits of Improvers: Thinking about Education for Improvement in Health. London: Health Foundation, 2015 in press.
68. Davey P, Tully V, Grant A et al. Learning from errors: what is the return on investment from training medical students in incident review? Clin Risk 2013; 19: 1-5.
69. Trotter N, Doherty C, Tully V et al. Improving the recognition of post-operative acute kidney injury. BMJ Qual Improv Rep 2014; 3: doi:10.1136/bmjquality.u205219.w2164.
70. Bell S, Davey P, Nathwani D et al. Risk of acute kidney injury with gentamicin as surgical prophylaxis. JASN J Am Soc Nephrol 2014; 25: 2625-32.
71. NHS Tayside. NHS Tayside Patient Safety Network - Developing a Systematic Approach. 2014. http://www.nhstaysidecdn.scot.nhs.uk/NHSTaysideWeb/idcplg?IdcService=GET_SECURE_FILE&dDocName=PROD_202894&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1.
72. Academic Health Science Partnership in Tayside. AHSP Workstreams. http://www.ahspartnership.org.uk/ahsp/ahsp-workstreams.
73. Scottish Improvement Science Collaborating Centre. 2015. Capability and Capacity Building. http://siscc.dundee.ac.uk/capability-and-capacitybuilding.
74. Vandenbroucke JP. Observational research, randomised trials, and two views of medical science. PLoS Med 2008; 5: e67.