Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges

Generative artificial intelligence, patient safety and healthcare quality: a review

The capabilities of artificial intelligence (AI) have accelerated over the past year, and they are beginning to impact healthcare in a significant way. Could this new technology help address issues that have been difficult and recalcitrant problems for quality and safety for decades? While we are early in the journey, it is clear that we are in the midst of a fundamental shift in AI capabilities. It is also clear these capabilities have direct applicability to healthcare and to improving quality and patient safety, even as they introduce new complexities and risks. Previously, AI focused on one task at a time: for example, telling whether a picture was of a cat or a dog, or whether a retinal photograph showed diabetic retinopathy or not. Foundation models (and their close relatives, generative AI and large language models) represent an important change: they are able to handle many different kinds of problems without additional datasets or training. This review serves as a primer on foundation models' underpinnings, upsides, risks and unknowns-and how these new capabilities may help improve healthcare quality and patient safety.

Applying an equity lens to hospital safety monitoring: a critical interpretive synthesis protocol

INTRODUCTION

Hospital safety monitoring systems are foundational to how adverse events are identified and addressed. They are well positioned to bring equity-related safety issues to the forefront for action. However, there is uncertainty about how they have been, and can be, used to achieve this goal. We will undertake a critical interpretive synthesis (CIS) to examine how equity is integrated into hospital safety monitoring systems.

METHODS AND ANALYSIS

This review will follow CIS principles. Our initial compass question is: How is equity integrated into safety monitoring systems? We will begin with a structured search strategy of hospital safety monitoring systems in CINAHL, EMBASE, MEDLINE and PsycINFO for up to May 2023 to identify papers on safety monitoring systems generally and those linked to equity (eg, racism, social determinants of health). We will also review reference lists of selected papers, contact experts and draw on team expertise. For subsequent literature searching stages, we will use team expertise and expert contacts to purposively search the social science, humanities and health services research literature to support the development of a theoretical understanding of our topic. Following data extraction, we will use interpretive processes to develop themes and a critique of the literature. The above processes of question formulation, article search and selection, data extraction, and critique and synthesis will be iterative and interactive with the goal to develop a theoretical understanding of equity in hospital monitoring systems that will have practice-based implications.

ETHICS AND DISSEMINATION

This review does not require ethical approval because we are reviewing published literature. We aim to publish findings in a peer-reviewed journal and present at conferences.

Developing a Framework and Electronic Tool for Communicating Diagnostic Uncertainty in Primary Care: A Qualitative Study

IMPORTANCE

Communication of information has emerged as a critical component of diagnostic quality. Communication of diagnostic uncertainty represents a key but inadequately examined element of diagnosis.

OBJECTIVE

To identify key elements facilitating understanding and managing diagnostic uncertainty, examine optimal ways to convey uncertainty to patients, and develop and test a novel tool to communicate diagnostic uncertainty in actual clinical encounters.

DESIGN, SETTING, AND PARTICIPANTS

A 5-stage qualitative study was performed between July 2018 and April 2020, at an academic primary care clinic in Boston, Massachusetts, with a convenience sample of 24 primary care physicians (PCPs), 40 patients, and 5 informatics and quality/safety experts. First, a literature review and panel discussion with PCPs were conducted and 4 clinical vignettes of typical diagnostic uncertainty scenarios were developed. Second, these scenarios were tested during think-aloud simulated encounters with expert PCPs to iteratively draft a patient leaflet and a clinician guide. Third, the leaflet content was evaluated with 3 patient focus groups. Fourth, additional feedback was obtained from PCPs and informatics experts to iteratively redesign the leaflet content and workflow. Fifth, the refined leaflet was integrated into an electronic health record voice-enabled dictation template that was tested by 2 PCPs during 15 patient encounters for new diagnostic problems. Data were thematically analyzed using qualitative analysis software.

MAIN OUTCOMES AND MEASURES

Perceptions and testing of content, feasibility, usability, and satisfaction with a prototype tool for communicating diagnostic uncertainty to patients.

RESULTS

Overall, 69 participants were interviewed. A clinician guide and a diagnostic uncertainty communication tool were developed based on the PCP interviews and patient feedback. The optimal tool requirements included 6 key domains: most likely diagnosis, follow-up plan, test limitations, expected improvement, contact information, and space for patient input. Patient feedback on the leaflet was iteratively incorporated into 4 successive versions, culminating in a successfully piloted prototype tool as an end-of-visit voice recognition dictation template with high levels of patient satisfaction for 15 patients with whom the tool was tested.

CONCLUSIONS AND RELEVANCE

In this qualitative study, a diagnostic uncertainty communication tool was successfully designed and implemented during clinical encounters. The tool demonstrated good workflow integration and patient satisfaction.

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020

INTRODUCTION

The imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched in the National Health Service (NHS) in England. NHS Secondary Care Trusts (NSCTs) are legally required to publish quantitative and qualitative information relating to deaths due to problems in care within their organisation, including any learning derived from these deaths.

METHOD

All LfDs report from 2017 to 2020 were reviewed and evaluated, quantitatively and qualitatively using sequential content and reflexive thematic analysis, through a critical realist lens to understand what we can learn from LfDs reporting and the mechanisms enabling or preventing engagement with the LfDs programme.

RESULTS

The majority of NSCTs have identified learning, actions and, to a lesser degree, assessed the impact of these actions. The most frequent learning relates to missed/delayed/uncoordinated care and communication/cultural issues. System issues and lack of resources feature infrequently. There is significant variation among NSCTs as to what 'learning' in this context actually means and a lack of oversight combining patient safety initiatives.

DISCUSSION

Engagement of NSCTs with the LfDs programme varies significantly. Learning as a result of the LfDs programme is occurring. The ability, significance or value of this learning in preventing future patient deaths remains unclear. Consensus about what constitutes effective learning with regard to patient safety needs to be defined and agreed on.

Research as care: practice-based knowledge translation as transformative learning through video-reflexive ethnography

Collaborative approaches to knowledge translation seek to make research useful and applicable, by centring the perspectives and concerns of healthcare actors (rather than researchers) in problem formulation and solving. Such research thus involves multiple actors, in interaction with pre-existing ecologies of knowledge and expertise. Although collaboration is emphasised, conflict, dissonance, and other tensions, may arise from the multiplicity of perspectives and power dynamics involved. Our article examines knowledge translation in this space, as both empirical focus and research methodology. Drawing from practice theory and critical pedagogy, we describe knowledge translation as a situated and social process of transformative learning, enabled by reflexive dialogue about practice, and supported by care. With examples from five studies across two countries, we show that practice-based knowledge translation can be mediated by researchers, using video-reflexive ethnography. We describe the importance (and features) of practices of care in these studies, that created psychological safety for transformative learning. We argue that attempts to transform and improve healthcare must account for sustained and reciprocal care, both for, and between, those made vulnerable in the process, and that knowledge translation can, and should, be a process of capacity strengthening, with care as a core principle and practice.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative

BACKGROUND

The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact.

OBJECTIVE

We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada.

METHODS

The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents.

RESULTS

Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes.

CONCLUSION

The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Patient safety as a global health priority

Patient safety is a discipline that has arisen in response to the increasing complexity of health care delivery and the associated increase in patient harm. Adverse health care events are a serious problem, causing significant harm to the patient and increasing health care costs. The World Health Organization has identified patient safety as one of the key priorities for world health. The current review presents the historical background that led to the formation of the discipline of patient safety, the determinants of adverse events in medical practice, and the main tools for dealing with them.