In 2009, a National Confidential Enquiry into Patient Outcome and Death report detailed significant shortcomings in recognition and management of patients with acute kidney injury (AKI). As part of a national collaborative to reduce harm from AKI, the Scottish Patient Safety Programme developed two care bundles to improve response (‘SHOUT’) and review (‘BUMP’) of AKI.Baseline data from eight patients with AKI on the acute medical unit (AMU) in Ninewells Hospital showed 62% compliance with SHOUT. However, most patients were transferred from AMU within 24 hours so BUMP could not be assessed. Our aim was to achieve >95% compliance with SHOUT on AMU within 2 months. The content of the SHOUT bundle was condensed onto a sticker for the case notes, which was implemented using Plan-Do-Study-Act cycles. Compliance was assessed weekly and feedback obtained from stakeholders concerning their opinion of the sticker, SHOUT bundle and care bundles in general.Use of the sticker was 27% in week 1 but fell to 5% by week 4. Compliance with the bundle varied from 45% to 60% and was only slightly improved by use of the sticker (OR 1.58, 95% CI 0.39 to 6.42). Staff found the sticker burdensome and did not agree that all elements of SHOUT were equally important. This opinion was supported by finding that their compliance with sepsis and hypovolaemia recommendations was 91%–100% throughout, whereas urinalysis was documented in only 55%–63% of patients. Several staff mentioned ‘bundle fatigue’ and on one day we identified 22 other care bundles or structured improvement forms in AMU.We concluded that the AMU staff had legitimate concerns about the SHOUT care bundle and that our intervention was demotivating. Overcoming bundle fatigue will not be a simple task. We plan to work with staff on integrating AKI into patient safety huddles and on using modelling and recognition of good practice to improve motivation.

BackgroundThere is evidence that medical students have the potential to actively initiate, lead and bring about change through quality improvement within healthcare organisations. For effective change to occur, it is important that students are introduced to, and exposed to the value and necessity of quality improvement early in their careers. The aim of this study was to explore the perspectives and experiences of medical students and their mentors after undertaking quality improvement projects within the healthcare setting, and if such practice-based experiences were an effective way of building improvement capacity and changing practice.MethodsA qualitative interpretive description methodology, using focus groups with medical students and semi-structured interviews with academic and clinical mentors following completion of students’ 4-week quality improvement projects was adopted.ResultsThe findings indicate that there are a range of facilitators and barriers to undertaking and completing quality improvement projects in the clinical setting, such as time-scales, differing perspectives, roles and responsibilities between students and multidisciplinary healthcare professionals.ConclusionsThis study has demonstrated that quality improvement experiential learning can develop knowledge and skills among medical students and transform attitudes towards quality improvement. Furthermore, it can also have a positive impact on clinical staff and healthcare organisations. Despite inherent challenges, undertaking quality improvement projects in clinical practice enhances knowledge, understanding and skills, and allows medical students to see themselves as important influencers of change as future doctors.

Our aim was to test the feasibility of interprofessional, workplace-based learning about improvement through a 4-week placement for one medical and two pharmacy final year students in an Acute Surgical Receiving Unit (ASRU). The target was insulin because this is a common, high-risk medicine in this ASRU and the intervention was medicines reconciliation. Baseline data were collected from 10 patients and used to construct a cause and effect diagram and a process map through feedback and discussions with staff. Hypoglycaemia occurred in four patients but hyperglycaemia occurred in eight patients, of whom six were placed on intravenous insulin infusion (IVII). We estimated that £2454 could be saved by preventing one patient from going on IVII. The students designed and tested a sticker to improve medicines reconciliation for insulin patients. An online form was created to capture clinician feedback on the layout and usability of the sticker. The intervention was associated with improvements in the reliability of medicines reconciliation. The students’ work contributed to a larger project to reduce the risk of hypoglycaemia in the ASRU. This proved beneficial in enabling the students to engage with the clinical team. Nonetheless, it was challenging for students from two Universities to get a shared understanding of improvement methods and work effectively with the clinical team. The students said that they learnt more about quality improvement in a working healthcare environment than they would ever learn in a classroom and they valued the opportunity to work with students from other healthcare backgrounds in practice. Despite the additional staff time required to support students from two Universities, both have supported continuation of this work.

Making referrals to other hospital specialties is one of the key duties of the foundation doctor, which can be difficult and time consuming. In Ninewells hospital, Scotland, in our experience the effectiveness of referrals is limited by contact details not being readily accessible and foundation doctors not knowing what information is relevant to each specialty.We surveyed foundation doctors on their experience of the existing referral process to identify where we needed to focus to improve the process. The doctors reported significant delays in obtaining contact details from the operator, and found they did not know the specific information needed in each referral.To increase the information available to foundation doctors, we set up a page on the staff intranet called 'Referral Finder'. This page includes contact details, guidelines for referral, and links to relevant protocols for each specialty. By making this information readily accessible our objective was to increase the speed and quality of referrals.When surveyed two months after the web page was established, foundation doctors reported a reduction in calls to operator from baseline and reported achieving more effective referrals. When asked to comment, many doctors asked if the page could include details for other hospitals in our health board and provide more specialty specific information.This feedback prompted us to extend the scope of the page to include the district general hospital in our region, and update many of the existing details. Doctors were then surveyed after the updates, 100% agreed that the website saved time and there was a 49.3% reduction in doctors who reported not knowing the specific information needed for a referral.Having adequate information improved referrals and resulted in time saved. This would allow more time for patient care. The quality improvement project was praised among doctors as a useful, innovative and replicable project. ProblemIn Ninewells hospital, Dundee, Scotland, foundation doctors spent considerable time accessing referral contact details via the operator. This resulted in significant delays which impacted on other ward jobs and patient care. After obtaining the contact details from the operator, more time was spent accumulating patient information by the doctor to make the referral. Despite this, referrals were often lacking specific information resulting in inadequate referrals.Ninewells is a large teaching hospital with 26 specialties where the referral process, and the specific information required for referral, varies between each specialty. Existing paper records of referral contact details in the wards were incomplete and were not kept updated. In addition, there was no guidance on what to include in the referral for any specialty. As two foundation doctors, we had encountered frustration at wasted time, incomplete referrals, and patient safety issues caused by the lack of available referral information. We felt a simple online page where referral information was kept would mean the informat...