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Kwok YT, Mah AP. Qualitative study on experience of healthcare staff who have undergone a hybrid root cause analysis training programme. BMJ Open Qual 2023; 12:bmjoq-2022-002153. [PMID: 37003599 PMCID: PMC10083879 DOI: 10.1136/bmjoq-2022-002153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/05/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Root cause analysis (RCA) is a structured investigation methodology aimed at identifying systems factors to prevent recurrence of incidents. To enhance staff's knowledge and skills, a hybrid RCA training course was conducted in February 2021. Overseas instructors conducted training online and local participants attended the training together physically with onsite facilitator support. This study aimed at understanding the experiences of trainees who have undergone the training, evaluated its effectiveness and identified opportunities to enhance RCA training quality in the future. METHODS A qualitative study using virtual synchronous focus group interviews was conducted. Purposive sampling was adopted to invite all trainees from the RCA training course to join. A semistructured interview was used to guide the study participants to share their experiences. All groups were audio-recorded, transcribed verbatim and anonymised for data analysis. RESULTS Overall, 6 focus groups with 19 participants were held between July and November 2021. Five key themes were identified including: (1) training contents, (2) perceptions of RCA, (3) challenges in RCA, (4) hybrid training and (5) future perspectives. Participants felt the RCA training was useful and broadened their understanding in incident investigation. More in-depth training in interviewing skills, report writing with practical sessions could further enhance their competencies in RCA. Participants accepted the use of hybrid online-offline training well. Most participants would welcome an independent organisation to conduct RCA as findings would be more objective and recommendations more effective. CONCLUSIONS This study provided an evaluation on the effectiveness of a hybrid RCA training course. Healthcare and training organisations can consider this training mode as it could reduce the cost of training and enhance flexibility in course arrangement while preserving quality and effectiveness. Virtual focus groups to interview participants were found to be convenient as it minimised travelling time and onsite arrangement while maintaining the quality of discussion.
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Affiliation(s)
- Yick-Ting Kwok
- Root Cause Analysis Review Workgroup, Hospital Authority, Hong Kong, Hong Kong
- Quality and Safety Division, New Territories West Cluster, Hospital Authority, Hong Kong, Hong Kong
| | - Alastair P Mah
- Root Cause Analysis Review Workgroup, Hospital Authority, Hong Kong, Hong Kong
- Medical Affairs, United Family Healthcare, Beijing, China
- Faculty of Health, School of Medicine, Deakin University, Geelong, Victoria, Australia
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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2
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Bandansin J, Jamjuree D, Boonprakob M, Chaleoykitti S. Development of a clinical learning model to enhance patient safety awareness competency among Thai nursing students. BELITUNG NURSING JOURNAL 2022; 8:153-160. [PMID: 37521895 PMCID: PMC10386801 DOI: 10.33546/bnj.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/06/2022] [Accepted: 03/08/2022] [Indexed: 08/01/2023] Open
Abstract
Background Enhancing patient safety awareness competency in nursing students is a necessity as they will be the next generation of professional nurses to take care of patients. One of the strategies is to create an innovative learning model using questioning as part of the metacognitive thinking concept. Objective This study aimed to develop a clinical learning model to enhance patient safety awareness competency among Thai nursing students and determine its effectiveness. Methods The study used a research and development design with two phases: (1) the development of a clinical learning model to enhance patient safety awareness competency among nursing students, and (2) the evaluation of the effectiveness of the developed clinical learning model. The evaluation was done quantitatively and qualitatively. In the quantitative strand, a quasi-experimental method using repeated measures design was used in 24 students. While in the qualitative strand, a qualitative descriptive design was employed in 24 students and three teachers. Results In the first phase, the DUIR clinical learning model was developed, consisting of four processes: 1) Doubt (D), 2) Understanding (U), 3) Insight (I), and 4) Reflected value (R). The patient safety awareness competency included two components: managing patient safety and solving problems related to unsafe patient care. In the second phase, the model was evaluated by the students and the teachers. It revealed that nursing students' patient safety awareness competency was very high, and the competency was statistically different before and after the learning model. Conclusion The developed DUIR learning model using a questioning strategy is considered effective to encourage students to reflect critically on their own clinical experiences in order to achieve quality and safe care outcomes, thereby enhancing patient safety awareness for nursing students in a sustainable way. This model serves as an input for Thai nursing education and beyond.
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Coulthard MG, Osborne JM, McCaffery K, McAuley SA, McEniery JA. Multi-incident analysis of reviews of serious adverse clinical events in children with serious bacterial infection and/or sepsis in Queensland, Australia between 2012 and 2017. J Paediatr Child Health 2022; 58:497-503. [PMID: 34553810 DOI: 10.1111/jpc.15759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 11/27/2022]
Abstract
AIM To report on findings from a multi-incident analysis of reviews of serious paediatric adverse clinical events related to serious bacterial infection and/or sepsis (hereafter referred to as sepsis for brevity) in Queensland, Australia, between 2012 and 2017. METHODS The Queensland Paediatric Quality Council reviewed documentation from reviews of serious adverse events occurring in children (<18 years) with a diagnosis of sepsis at Queensland public hospitals between 2012 and 2017, including clinical details, coronial reports, autopsy reports and root cause analysis documents. A multi-incident tool was designed and used by an expert panel to identify patient and facility demographics, contributing factors, and human and system factors associated with paediatric serious adverse events. RESULTS There were 28 serious adverse clinical events reported related to paediatric sepsis, characterised by a high proportion of deaths (23) and a predominance of children aged under 4 years. Approximately half of all facilities were classified as rural and remote health services. Contributing factors included difficulty in recognising and responding to the deteriorating patient, inadequate management/treatment, diagnostic error (mainly diagnostic delay) and escalation delay/failure. Major system factors included communication issues, incorrect use of the early warning tool, inadequate coordination of care planning, policy/protocol/guideline failures and workforce problems. CONCLUSION Multi-incident analysis is a useful tool for identifying themes that recur in similar events and presents opportunities for system-wide improvement. Common themes and contributing factors were identified which may provide possibilities for earlier identification and intervention in childhood serious bacterial infection and/or sepsis.
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Affiliation(s)
- Mark G Coulthard
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Jodie M Osborne
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia
| | - Kevin McCaffery
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Sharon A McAuley
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Julie A McEniery
- Queensland Paediatric Quality Council, Queensland Health, Brisbane, Queensland, Australia.,Mayne Academy of Paediatrics, School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Queensland Children's Hospital, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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4
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Baartmans MC, Van Schoten SM, Wagner C. Generic analysis method to learn from serious adverse events in Dutch hospitals: a human factors perspective. BMJ Open Qual 2022; 11:e001637. [PMID: 35105550 PMCID: PMC8808443 DOI: 10.1136/bmjoq-2021-001637] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/15/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospitals in various countries such as the Netherlands investigate and analyse serious adverse events (SAEs) to learn from previous events and attempt to prevent recurrence. However, current methods for SAE analysis do not address the complexity of healthcare and investigations typically focus on single events on the hospital level. This hampers hospitals in their ambition to learn from SAEs. Integrating human factors thinking and using a holistic and more consistent method could improve learning from SAEs. AIM This study aims to develop a novel generic analysis method (GAM) to: (1) facilitate a holistic event analysis using a human factors perspective and (2) ease aggregate analysis of events across hospitals. METHODS Multiple steps of carefully evaluating, testing and continuously refining prototypes of the method were performed. Various Dutch stakeholders in the field of patient safety were involved in each step. Theoretical experts were consulted, and the prototype was pretested using information-rich SAE reports from Dutch hospitals. Expert panels, engaging quality and safety experts and medical specialists from various hospitals were consulted for face and content validity evaluation. User test sessions concluded the development of the method. RESULTS The final version of the GAM consists of a framework and affiliated questionnaire. GAM combines elements of three methods for SAE analysis currently practised by Dutch hospitals. It is structured according to the Systems Engineering Initiative for Patient Safety model, which incorporates a human factors perspective into the analysis. These eases aggregated analysis of SAEs across hospitals and helps to consider the complexity of healthcare work systems. CONCLUSION The GAM is a valuable new tool for hospitals to learn from SAEs. The method can facilitate a holistic aggregate analysis of SAEs across hospitals using a human factors perspective, and is now ready for further extensive testing.
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Affiliation(s)
- Mees Casper Baartmans
- Department of Organisation and Quality of Care, Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands
| | - Steffie Marijke Van Schoten
- Department of Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, The Netherlands
| | - Cordula Wagner
- Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands
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5
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Johansen LT, Braut GS, Acharya G, Andresen JF, Øian P. Adverse events reporting by obstetric units in Norway as part of their quality assurance and patient safety work: an analysis of practice. BMC Health Serv Res 2021; 21:931. [PMID: 34493278 PMCID: PMC8424984 DOI: 10.1186/s12913-021-06956-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Norwegian Board of Health Supervision aims to contribute to the improvement of quality and patient safety in the healthcare services. Planned audits were performed to investigate how 12 selected Norwegian obstetric units reported and analyzed adverse events as the part of their quality assurance and patient safety work. METHODS Serious adverse events coded as birth asphyxia, shoulder dystocia and severe postpartum hemorrhage that occurred during 2014 (the most recent year for which the quality assured data were available) were obtained from the Medical Birth Registry of Norway. The obstetric units were asked to submit medical records, internal adverse events reports, and their internal guidelines outlining which events should be reported to the quality assurance system. We identified the adverse events at each obstetric unit that were reported internally and/or to the central authorities. Two obstetricians carried out an evaluation of each event reported. RESULTS Five hundred fifty-three serious adverse events were registered among 17,323 births that took place at the selected units. Twenty-one events were excluded because of incorrect coding or missing information. Eight events were registered in more than one category, and these were distributed to the category directly related to injury or adverse outcome. Nine of twelve (75 %) obstetric units had written guidelines describing which events should be reported. The obstetric units reported 49 of 524 (9.3 %) serious adverse events in their internal quality assurance system and 39 (7.4 %) to central authorities. Of the very serious adverse events, 29 of 149 (19.4 %) were reported. Twenty-three of 49 (47 %) reports did not contain relevant assessments or proposals for improving quality and patient safety. CONCLUSIONS This study showed that adverse event reporting and analyses by Norwegian obstetric units, as a part of quality assurance and patient safety work, are suboptimal. The reporting culture and compliance with guidelines need to be improved substantially for better safety in patient care, risk mitigation and clinical quality assurance.
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Affiliation(s)
- Lars T Johansen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.
| | - Geir Sverre Braut
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway.,Stavanger University Hospital, Stavanger, Norway.,Western Norway University of Applied Sciences, Sogndal, Norway
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway.,Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway.,Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institute and Center for Fetal Medicine, Department of Women's Health, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Fredrik Andresen
- Department for Specialized Health Services, Norwegian Board of Health Supervision, PO Box 231 Skøyen, 0213, Oslo, Norway
| | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
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Hibbert PD, Clay-Williams R, Westbrook J, Reed RL, Georgiou A, Wiles LK, Molloy CJ, Braithwaite J. Reducing preventable harm to residents in aged care: A systems approach. Australas J Ageing 2020; 40:72-76. [PMID: 33006429 DOI: 10.1111/ajag.12861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/30/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Abstract
Residents in Australian aged care facilities can suffer serious preventable harm from incidents ('adverse events' (AEs)). An inadequate response to AEs by aged care facilities can compound distress to residents and their families/carers. Facilities have an obligation to respond to and investigate AEs involving residents, learn from them, and take action to reduce the chance of them reoccurring . Residential aged care facilities have a duty to create a culture where staff, residents and families/carers feel comfortable reporting AEs or complaints; there is adequate time and resources to manage AEs and complaints; and feedback is provided to staff, residents and their families/carers on the results of investigations into AEs/complaints. The Aged Care Quality and Safety Commission's role should encompass additional governance functions such as sharing results and lessons learnt from AEs, complaints and investigations across Australia, assuring the quality of investigations conducted by facilities, and undertaking national system-wide investigations.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Richard L Reed
- Flinders University General Practice and Primary Health Care, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Andrew Georgiou
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Louise K Wiles
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Charlotte J Molloy
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Roos Af Hjelmsäter E, Ros A, Gäre BA, Westrin Å. Deficiencies in healthcare prior to suicide and actions to deal with them: a retrospective study of investigations after suicide in Swedish healthcare. BMJ Open 2019; 9:e032290. [PMID: 31831542 PMCID: PMC6924838 DOI: 10.1136/bmjopen-2019-032290] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES The overall aim of this study was to aggregate the conclusions of all investigations conducted after suicides reported to the supervisory authority in Sweden in 2015, and to identify deficiencies in healthcare found in these investigations; the actions proposed to deal with the deficiencies; the level of the organisational hierarchy (micro-meso-macro) in which the deficiencies and actions were situated; and outcomes of the supervisory authority's decisions. DESIGN AND SETTING This is a retrospective study of all reports from Swedish primary and secondary healthcare after suicide to the regulatory authority in Sweden in 2015. RESULTS In 55% (n=240) of cases, healthcare providers reported healthcare deficiencies that contributed to suicide; these deficiencies were primarily in 'suicide risk assessment' and 'treatment'. Actions aimed at preventing new suicides were proposed in 80% of cases (n=347). By far, the most frequent actions were 'education and competence', present in 52% of cases (n=227) and did not much correspond with identified deficiencies. Sixty-five per cent of the deficiencies and actions were at microlevel, while the remainders were at mesolevel. In 65% (n=284) of cases, the supervisory authority approved the investigation without further requirements. CONCLUSIONS The most common identified deficiencies were related to care in the immediate interface between patient and staff. Actions proposed to prevent new suicides were centred on single educational interventions without distinctive sustainable effects in the organisations and usually did not correspond with the identified deficiencies. Future research should examine if application of a framework based on knowledge of the suicide process, suicide prevention strategies and patient safety would enable more sophisticated investigations that could facilitate progress on suicide prevention.
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Affiliation(s)
- Elin Roos Af Hjelmsäter
- Höglandssjukhuset, Region Jönköping, Eksjö, Sweden
- Jönköping Academy for Improvement of Health and Welfare, The School of Health and Welfare Jönköping University, Jönköping University, Jonkoping, Sweden
| | - Axel Ros
- Jönköping Academy for Improvement of Health and Welfare, The School of Health and Welfare Jönköping University, Jönköping University, Jonkoping, Sweden
- Ryhov, Region Jönköping, Jonkoping, Sweden
| | - Boel Andersson Gäre
- The Jönköping Academy for Improvement of Health and Welfare, Hogskolan i Jonkoping Halsohogskolan, Jonkoping, Sweden
- Futurum, Landstinget i Jonkopings lan, Jonkoping, Sweden
| | - Åsa Westrin
- Faculty of Medicine, Department of Clinical Sciences, Division of Psychiatry, Lund University, Lund, Sweden
- Office for Psychiatry and Habilitation, Psychiatry Research Skåne, Region Skåne, Lund, Sweden
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Hamilton MJ, McEniery JA, Osborne JM, Coulthard MG. Implementation and strength of root cause analysis recommendations following serious adverse events involving paediatric patients in the Queensland public health system between 2012 and 2014. J Paediatr Child Health 2019; 55:1070-1076. [PMID: 30582234 DOI: 10.1111/jpc.14344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/31/2018] [Accepted: 11/18/2018] [Indexed: 11/28/2022]
Abstract
AIM This study evaluates the implementation rate and strength of the recommendations developed in all root cause analyses (RCAs) performed following serious clinical incidents involving children that have resulted in permanent harm or death in Queensland public hospitals over a 3-year period. METHODS Severity assessment classification 1 events were identified from a Queensland Paediatric Quality Council database of paediatric clinical incidents that occurred in Queensland between 1 January 2012 and 31 December 2014. There were 150 recommendations extracted from RCAs pertaining to the 42 serious adverse events involving paediatric patients. RESULTS Of the recommendations, 82% were implemented; 33% of recommendations were classified as stronger, 33% as intermediate and 34% weaker in terms of their potential to improve patient safety. CONCLUSIONS This study describes the implementation of recommendations and classifies them in terms of potential to prevent patient harm and save lives. Future research is needed to determine if the RCA process does indeed prevent harm.
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Affiliation(s)
- Monique J Hamilton
- Academic Discipline of Paediatrics and Child Health, University of Queensland, Brisbane, Queensland, Australia
| | - Julie A McEniery
- Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Jodie M Osborne
- Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
| | - Mark G Coulthard
- Academic Discipline of Paediatrics and Child Health, University of Queensland, Brisbane, Queensland, Australia.,Queensland Paediatric Quality Council, Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
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Vincent C, Carthey J, Macrae C, Amalberti R. Safety analysis over time: seven major changes to adverse event investigation. Implement Sci 2017; 12:151. [PMID: 29282080 PMCID: PMC5745912 DOI: 10.1186/s13012-017-0695-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 12/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. MAIN TEXT The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects. We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations. CONCLUSIONS Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.
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Affiliation(s)
- Charles Vincent
- Department of Experimental Psychology, University of Oxford, 15 Parks Road, Oxford, OX1 3PW, UK.
| | | | - Carl Macrae
- Department of Experimental Psychology, University of Oxford, 15 Parks Road, Oxford, OX1 3PW, UK
| | - Rene Amalberti
- Haute Autorité de Santé, Paris, 5 Avenue du Stade de France, Saint-Denis, 93210, Paris, France
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Improving Apparent Cause Analysis Reliability: A Quality Improvement Initiative. Pediatr Qual Saf 2017; 2:e025. [PMID: 30229162 PMCID: PMC6132456 DOI: 10.1097/pq9.0000000000000025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/17/2017] [Indexed: 11/26/2022] Open
Abstract
Introduction Apparent cause analysis (ACA) is a process in quality improvement used to examine events. A baseline assessment of completed ACAs at a tertiary care free-standing pediatric academic hospital revealed they were ineffective due to low-quality analysis, unreliable action plans, and poor spread, leading to error recurrence. The goal of this project was to increase ACA action plan reliability scores while maintaining or decreasing turnaround time. Methods The Model for Improvement served as the framework for this quality improvement initiative. We developed a key driver diagram, established measures, tested interventions using plan- do-study-act cycles, and implemented the effective interventions. To measure reliability, we created a high reliability toolkit that links each action item/intervention to a level of reliability and scored each ACA action plan to determine overall reliability score. Action plans scored as low level of reliability required revision before implementation. Results Average ACA action plan reliability scores increased from 86.4% to 96.1%. ACA turnaround time decreased from a baseline of 13 days to 8.6 days. Stakeholders reported a subjective increase in satisfaction with the revamped ACA process. Conclusions Incorporating high reliability principles into ACA action plan development increased the effectiveness of ACA while decreasing turnaround time. The high reliability toolkit was instrumental in providing an organizational resource for approaching this subset of cause analyses. The toolkit provides a way for safety/quality leaders to connect with stakeholders to design highly reliable solutions that improve safety for patients, families, and staff.
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Card AJ, Ward JR, Clarkson PJ. Rebalancing risk management--part 1: The Process for Active Risk Control (PARC). J Healthc Risk Manag 2016; 34:21-30. [PMID: 25319465 DOI: 10.1002/jhrm.21155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Risk assessment, by itself, does nothing to reduce risk or improve safety. It can only change outcomes by informing the design and management of effective risk control interventions. But current practice in healthcare risk management suffers from an almost complete lack of support for risk control. This first installment of a 2-part series on rebalancing risk management describes a new framework to guide risk control practice: The Process for Active Risk Control.
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Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf 2016; 26:417-422. [PMID: 27340202 PMCID: PMC5530340 DOI: 10.1136/bmjqs-2016-005511] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 11/24/2022]
Affiliation(s)
| | - Susan Carr
- John Walls Renal Unit, University Hospitals of Leicester, Leicester, UK
| | - Justin Waring
- CHILL, Nottingham University Business School, University of Nottingham, Nottingham, UK
| | - Mary Dixon-Woods
- SAPPHIRE, Department of Health Sciences, University of Leicester, Leicester, UK
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13
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Abdi Z, Ravaghi H. Implementing root cause analysis in Iranian hospitals: challenges and benefits. Int J Health Plann Manage 2016; 32:147-162. [DOI: 10.1002/hpm.2335] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 10/09/2015] [Accepted: 12/07/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Zhaleh Abdi
- National Institute of Health Research (NIHR); Tehran University of Medical Sciences; Tehran Iran
| | - Hamid Ravaghi
- School of Health Management and Information Sciences; Iran University of Medical Sciences; Tehran Iran
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14
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Card AJ. The Active Risk Control (ARC) toolkit: a new approach to designing risk control interventions. J Healthc Risk Manag 2015; 33:5-14. [PMID: 24756824 DOI: 10.1002/jhrm.21137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Current practice in healthcare risk management is supported by many tools for risk assessment (understanding problems), but none for risk control (solving problems). THE RESULTS a failure to improve safety, and a waste of the investment made in risk assessment. The Active Risk Control (ARC) Toolkit, available for free, fills this void with a systematic, structured approach to risk control.
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van der Starre C, van Dijk M, van den Bos A, Tibboel D. Paediatric critical incident analysis: lessons learnt on analysis, recommendations and implementation. Eur J Pediatr 2014; 173:1449-57. [PMID: 24878871 DOI: 10.1007/s00431-014-2341-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 05/14/2014] [Accepted: 05/19/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED The objectives of this study were to identify causal and contributing factors of serious patient safety incidents in a paediatric university hospital, to report on ensuing recommendations and to assess the extent of implementation of the recommendations. The possible causal and contributing factors identified in 17 incidents were classified by a system devised by Vincent et al. Proposed recommendations were classified by the same system, and degrees of implementation were established. A median of 5 causal and contributing factors per incident were identified. Twenty-two percent of all factors were related to teamwork and 22 % to task factors. A median of 5 recommendations per analysis were formulated. Most recommendations were related to task factors (36 %). The time load of each analysis was a mean of 27 h. One third of the recommendations have been acted upon, mostly those related to task and team factors. CONCLUSION Incident analysis is time-consuming but yields indispensable information on causal and contributing factors, presenting numerous opportunities for quality improvement. The value of these analyses could be improved by appointing responsibilities and setting up time frames for implementation. A bottom-up approach with managerial support appears to be a key to turning incident analysis and quality improvement into an ongoing process.
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Affiliation(s)
- Cynthia van der Starre
- Intensive Care Unit, Erasmus MC Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands,
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Abou-El-Enein M, Römhild A, Kaiser D, Beier C, Bauer G, Volk HD, Reinke P. Good Manufacturing Practices (GMP) manufacturing of advanced therapy medicinal products: a novel tailored model for optimizing performance and estimating costs. Cytotherapy 2013; 15:362-83. [PMID: 23579061 DOI: 10.1016/j.jcyt.2012.09.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 07/27/2012] [Accepted: 09/03/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND AIMS Advanced therapy medicinal products (ATMP) have gained considerable attention in academia due to their therapeutic potential. Good Manufacturing Practice (GMP) principles ensure the quality and sterility of manufacturing these products. We developed a model for estimating the manufacturing costs of cell therapy products and optimizing the performance of academic GMP-facilities. METHODS The "Clean-Room Technology Assessment Technique" (CTAT) was tested prospectively in the GMP facility of BCRT, Berlin, Germany, then retrospectively in the GMP facility of the University of California-Davis, California, USA. CTAT is a two-level model: level one identifies operational (core) processes and measures their fixed costs; level two identifies production (supporting) processes and measures their variable costs. The model comprises several tools to measure and optimize performance of these processes. Manufacturing costs were itemized using adjusted micro-costing system. RESULTS CTAT identified GMP activities with strong correlation to the manufacturing process of cell-based products. Building best practice standards allowed for performance improvement and elimination of human errors. The model also demonstrated the unidirectional dependencies that may exist among the core GMP activities. When compared to traditional business models, the CTAT assessment resulted in a more accurate allocation of annual expenses. The estimated expenses were used to set a fee structure for both GMP facilities. A mathematical equation was also developed to provide the final product cost. CONCLUSIONS CTAT can be a useful tool in estimating accurate costs for the ATMPs manufactured in an optimized GMP process. These estimates are useful when analyzing the cost-effectiveness of these novel interventions.
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Affiliation(s)
- Mohamed Abou-El-Enein
- Berlin-Brandenburg Center for Regenerative Therapies, Charité University Medicine, Campus Virchow, Berlin, Germany.
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Schmidt RL, Messinger BL, Layfield LJ. Internal Labeling Errors in a Surgical Pathology Department: A Root Cause Analysis. Lab Med 2013. [DOI: 10.1309/lmienkgrn0ae39ng] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Serv Res 2013; 13:50. [PMID: 23391260 PMCID: PMC3574857 DOI: 10.1186/1472-6963-13-50] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 01/28/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Root cause analysis (RCA) originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning. Despite the limitations of the RCA evidence base, healthcare authorities and decision makers in NHS Scotland - similar to those internationally - have invested heavily in developing training programmes to build local capacity and capability, and this is a cornerstone of many organizational policies for investigating safety-critical issues. However, to our knowledge there has been no systematic attempt to follow-up and evaluate post-training experiences of RCA-trained staff in Scotland. Given the significant investment in people, time and funding we aimed to capture and learn from the reported experiences, benefits and attitudes of RCA-trained staff and the perceived impact on healthcare systems and safety. METHODS We adapted a questionnaire used in a published Australian research study to undertake a cross sectional online survey of health care professionals (e.g. nursing & midwifery, medical doctors and pharmacists) formally trained in RCA by a single territorial health board region in NHS Scotland. RESULTS A total of 228/469 of invited staff completed the survey (48%). A majority of respondents had yet to participate in a post-training RCA investigation (n=127, 55.7%). Of RCA-experience staff, 71 had assumed a lead investigator role (70.3%) on one or more occasions. A clear majority indicated that their improvement recommendations were generally or partly implemented (82%). The top three barriers to RCA success were cited as: lack of time (54.6%), unwilling colleagues (34%) and inter-professional differences (31%). Differences in agreement levels between RCA-experienced and inexperienced respondents were noted on whether a follow-up session would be beneficial after conducting RCA (65.3% v 39.4%) and if peer feedback on RCA reports would be of educational value (83.2% v 37.0%). Comparisons with the previous research highlighted significant differences such as less reported difficulties within RCA teams (P<0.001) and a greater proportion of respondents taking on RCA leadership roles in this study (P<0.001). CONCLUSION This study adds to our knowledge and understanding of the need to improve the effectiveness of RCA training and frontline practices in healthcare settings. The overall evidence points to a potential organisational learning need to provide RCA-trained staff with continuous development opportunities and performance feedback. Healthcare authorities may wish to look more critically at whom they train in RCA, and how this is delivered and supported educationally to maximize cost-benefits, organizational learning and safer patient care.
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Affiliation(s)
- Paul Bowie
- Postgraduate General Practice Education, NHS Education for Scotland, 2 Central Quay, Glasgow, Scotland, G3 8BW, United Kingdom.
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Cassin BR, Barach PR. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin North Am 2012; 92:101-15. [PMID: 22269264 DOI: 10.1016/j.suc.2011.12.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article discusses the limitations of root cause analysis (RCA) for surgical adverse events. Making sense of adverse events involves an appreciation of the unique features in a problematic situation, which resist generalization to other contexts. The top priority of adverse event investigations must be to inform the design of systems that help clinicians to adapt and respond effectively in real time to undesirable combinations of design, performance, and circumstance. RCAs can create opportunities in the clinical workplace for clinicians to reflect on local barriers and identify enablers of safe and reliable outcomes.
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Affiliation(s)
- Bryce R Cassin
- University of Western Sydney, School of Nursing and Midwifery, Locked Bag 1797, Penrith South DC, New South Wales 1797, Australia.
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Card AJ, Ward J, Clarkson PJ. Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis. J Healthc Risk Manag 2012; 31:6-12. [PMID: 22359258 DOI: 10.1002/jhrm.20090] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to successful risk control? Are there categories of risk control that are more likely to be effective? And do healthcare risk managers have the tools they need to support the risk control process? This systematic review examines how the healthcare sector translates risk analysis to risk control action plans and examines how to do better. It suggests that the hierarchy of risk controls should inform risk control action planning and that new tools should be developed to improve the risk control process.
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Affiliation(s)
- Alan J Card
- University of Cambridge Engineering Design Centre
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