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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
Published on: February 16, 2011
Understanding limited effectiveness of a set of interventions implemented under continuous quality improvement
Kelly Estrada-Orozco1,2,3, Steffany Villate-Soto3, Giancarlo Buitrago3
1Fundación Universitaria Sanitas, Bogotá, Colombia.
Introduction:
Medication errors remain a major contributor to adverse events (AEs) in surgical services, particularly in low-middle income countries (LMICs), where structural and organizational constraints may limit the effectiveness of quality improvement strategies. Continuous quality improvement (CQI) methods are widely implemented to reduce preventable harm; however, evidence regarding their real-world effectiveness and the mechanisms underlying success or failure in LMIC contexts is limited. This study aimed not only to evaluate the impact of a set of interventions under CQI methodology targeting medication prescribing and administration processes, but also to explain the absence of expected effects through a process-informed assessment.
Methods:
A prospective cohort study using an interrupted time series design without a control group was conducted in a high-complexity teaching hospital in Bogotá, Colombia. The intervention targeted prescribing and administration of antibiotics, anticoagulants, and opioids, and included protocol reinforcement, a mobile application (PROA UNAL), standardized pain assessment, and three Plan-Do-Study-Act cycles. Process and outcome indicators were measured biweekly across baseline, implementation, and sustainability phases. Segmented regression and multivariable logistic regression assessed intervention effects, while a structured process assessment examined fidelity, mechanisms of impact, and contextual factors.
Results:
A total of 713 patients were distributed across the three phases of the study (194 baseline; 366 implementation; 153 sustainability). The three structured PDSA cycles were conducted, starting from protocol development to the adherence monitoring for each intervention. Implementation fidelity varied across components (100% for prophylactic antibiotic timing, 80% for PROA UNAL application use, and 40% for standardized postoperative pain scale implementation). No significant improvements were observed in process indicators, medication-related AEs, or clinical incidents (CIs). Adjusted models confirmed the absence of intervention effects. Process evaluation identified key contextual barriers-high staff turnover, fragmented governance, limited frontline engagement, and lack of real-time feedback-that hindered implementation.
Discussion:
The absence of measurable effects appears attributable to limited fidelity and contextual misalignment rather than intrinsic ineffectiveness of the interventions under the CQI methodology. Future initiatives in LMICs surgical settings should incorporate readiness assessments, governance alignment, real-time feedback, and sustained frontline.
Insights
Continuous quality improvement (CQI) methods did not reduce medication errors in a Colombian surgical setting. Limited implementation fidelity and contextual barriers hindered the intervention
Area of Science:
- Surgical Safety
- Medication Management
- Healthcare Quality Improvement
Background:
- Medication errors are a significant cause of adverse events in surgery, especially in low-middle income countries (LMICs).
- Continuous quality improvement (CQI) is used to reduce harm, but its effectiveness and underlying mechanisms in LMICs are not well understood.
- This study evaluated CQI interventions targeting medication prescribing and administration in a surgical setting.
Purpose of the Study:
- To assess the impact of CQI interventions on medication errors in surgical services.
- To identify factors contributing to the success or failure of these interventions in a LMIC context.
- To provide insights for future quality improvement initiatives in similar settings.
Main Methods:
- A prospective cohort study with an interrupted time series design was conducted in a Colombian teaching hospital.
- Interventions included protocol reinforcement, a mobile application (PROA UNAL), standardized pain assessment, and Plan-Do-Study-Act (PDSA) cycles.
- Process and outcome indicators were measured, alongside a structured process assessment of fidelity, mechanisms, and context.
Main Results:
- No significant improvements were observed in process indicators, medication-related adverse events, or clinical incidents.
- Implementation fidelity varied, with only 40% adherence for standardized postoperative pain scale implementation.
- Contextual barriers such as high staff turnover and fragmented governance hindered implementation.
Conclusions:
- The lack of measurable effects was attributed to limited implementation fidelity and contextual misalignment, not the CQI methodology itself.
- Future initiatives in LMICs require readiness assessments, governance alignment, real-time feedback, and sustained frontline engagement.
- Addressing contextual factors is crucial for successful quality improvement in surgical settings.
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