A culture of safety or coping? Ritualistic behaviours in the operating theatre

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

Implications of resource constraints and high workload on speaking up about threats to patient safety: a qualitative study of surgical teams in Ghana

Background

Although under-resourcing of healthcare facilities and high workload is known to undermine patient safety, there is a dearth of evidence about how these factors affect employee voice and silence about unsafe care. We address this gap in the literature by exploring how resource constraints and high workload influence the willingness of staff to speak up about threats to patient safety in surgical departments in Ghana.

Method

Semistructured interviews with a purposeful sample of 91 multidisciplinary professionals drawn from a range of specialities, ranks and surgical teams in two teaching hospitals in Ghana. Conservation of Resources theory was used as a theoretical frame for the study. Data were processed and analysed thematically with the aid of NVivo 12.

Results

Endemic resource constraints and excessive workload generate stress that undermines employee willingness to speak up about unsafe care. The preoccupation with managing scarce resources predisposes managers in surgical units to ignore or downplay concerns raised and not to instigate appropriate remedial actions. Resource constraints lead to rationing and improvising in order to work around problems with inadequate infrastructure and malfunctioning equipment, which in turn creates unsupportive environments for staff to air legitimate concerns. Faced with high workloads, silence was used as a coping strategy by staff to preserve energy and avoid having to take on the burden of additional work.

Conclusion

Under-resourcing and high workload contribute significantly towards undermining employee voice about unsafe care. We highlight the central role that adequate funding and resourcing play in creating safe environments and that supporting ‘hearer’ courage may be as important as supporting speaking up in the first place.

Organizational learning in hospitals: A realist review

AIM

To establish a middle-range theory of organizational learning in hospitals.

DESIGN

A realist review of the literature, conducted according to established standards for realist and meta-narrative evidence syntheses. Middle-range theory development was performed according to Smith and Liehr's recommendations.

DATA SOURCES

Two comprehensive scientific databases and six discipline-focused databases spanning health care, life sciences, business, sociology, and psychology were searched from inception to 12 May 2016.

REVIEW METHODS

Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms, and outcomes associated with organizational learning.

RESULTS

The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes.

CONCLUSION

This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals, and provides a middle-range theory of organizational learning in hospitals.

IMPACT

This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle-range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning.

Getting in the Flo: My year as a scholar

In November 2016, I was awarded an Emerging Leaders Scholarship from the Florence Nightingale Foundation to help me positively impact patient care and also improve how I lead change within my organisation. This article highlights some of the learning experiences over the last year and the impact that the Scholarship has had.

"We Won't Retire Without Skeletons in the Closet": Healthcare-Related Regrets Among Physicians and Nurses in German-Speaking Swiss Hospitals

Physicians and nurses are expected to systematically provide high-quality healthcare in a context marked by complexity, time pressure, heavy workload, and the influence of nonclinical factors on clinical decisions. Therefore, healthcare professionals must eventually deal with unfortunate events to which regret is a typical emotional reaction. Using semistructured interviews, 11 physicians and 13 nurses working in two different hospitals in the German-speaking part of Switzerland reported a total of 48 healthcare-related regret experiences. Intense feelings of healthcare-related regrets had far-reaching repercussions on participants' health, work-life balance, and medical practice. Besides active compensation strategies, social capital was the most important coping resource. Receiving superiors' support was crucial for reaffirming professional identity and helped prevent healthcare professionals from quitting their job. Findings suggest that training targeting emotional coping could be beneficial for quality of life and may ultimately lead to lower job turnover among healthcare professionals.

Understanding the occupational and organizational boundaries to safe hospital discharge

OBJECTIVE

Safe hospital discharge relies upon communication and coordination across multiple occupational and organizational boundaries. Our aim was to understand how these boundaries can exacerbate health system complexity and represent latent sociocultural threats to safe discharge.

METHODS

An ethnographic study was conducted in two local health and social care systems (health economies) in England, focusing on two clinical areas: stroke and hip fracture patients. Data collection involved 345 hours of observations and 220 semi-structured interviews with health and social care professionals, patients and their lay carers.

RESULTS

Hospital discharge involves a dynamic network of interactions between heterogeneous health and social care actors, each characterized by divergent ways of organizing discharge activities; cultures of collaboration and interaction and understanding of what discharge involves and how it contributes to patient recovery. These interrelated dimensions elaborate the occupational and organisational boundaries that can influence communication and coordination in hospital discharge.

CONCLUSIONS

Hospital discharge relies upon the coordination of multiple actors working across occupational and organizational boundaries. Attention to the sociocultural boundaries that influence communication and coordination can help inform interventions that might support enhanced discharge safety.

Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study

Background

Hospital settings have an important impact on children harmed by parents and carers. Concern arises from the capacity of these settings to respond effectively to individual needs despite increased NHS policy awareness and actions on safeguarding. Patient safety initiatives have rarely modelled in detail the social and cultural dynamics of child health settings and children’s safeguarding. This study is focused on supporting and evaluating clinician-led service design in an acute trust. A suite of initiatives and artefacts has been designed, based on sociotechnical principles, on the premise that only a thorough understanding of human, social and organisational challenges will afford effective solutions.

Objectives

The study addresses the following primary question: ‘Can a safeguarding culture be designed within the hospital environment that will provide the conditions for the detection of children at risk of abuse and support protective actions before discharge, including collaboration with external agencies?’ Objectives include the development of a sociologically rich understanding of why diagnostic failures and communication breakdowns occur; the design of a suite of integrated interventions for promoting a positive safety culture, following a user-centred approach; and the evaluation of the effectiveness of this package, including its generalisability across sites.

Design

The study took place in two sites: the primary site where the initiatives were developed and a further site with the original intention of transferring developments. The investigation follows a broaddesign scienceapproach. The evaluation of a design intervention relies on a rigorous understanding of the realities of everyday practice, and the study thus draws on mixed methods to examine the impact of service redesign on cultures and practices.

Findings

The data suggest that safeguarding children can become mainstream patient safety business. Board support is vital. In our primary site, there has been a steady integration of learning from serious case reviews and other child protection-related processes with ‘patient safety’-related incidents, with growing recognition that similar systemic issues impact on both domains. Making use of a familiar vocabulary to redescribesafeguardingas asafetyissue, and thus as something fundamental to the functions of an acute hospital, has been part of the success. The data suggest that persistence, resilience and vigilance from the safeguarding leadership and executive teams are crucial. Current policy includes the development of the Child Protection Information Sharing project, which is intended to improve information flow between the NHS, particularly hospitals and children’s social care. The findings from this study suggest the importance of good design, piloting, incrementalism and a thorough empirical engagement with everyday practices during implementation of this and any future information systems based reform.

Conclusions

Safeguarding takes place in a complex system and even minor changes within any part of that system can impact on the rest in unpredictable ways. It is important that managers adopt a ‘design attitude’ and seek to mitigate unintended consequences through careful experimentation. The findings suggest the need for the design of systems to enhance communication and not simply to ‘share information’. Technological solutions impact on everyday decision-making and can have unintended consequences. Attention to forces of change and stasis in health settings, the factors affecting technology transfer and the impact of the configuration of local authority services are suggested as a key priorities for future research.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Alcohol and drug testing of health professionals following preventable adverse events: a bad idea

Various kinds of alcohol and drug testing, such as preemployment, routine, and for-cause testing, are commonly performed by employers. While healthcare organizations usually require preemployment drug testing, they vary on whether personnel will be subjected to further testing. Recently, a call has gone out for postincident testing among physicians who are involved in serious, preventable events, especially ones leading to a patient's death. This article will offer a number of counterarguments to that proposal and discuss an alternate approach: that health institutions can better improve patient safety and employees' well-being by implementing an organizational policy of "speaking up" when system operators notice work behaviors or environmental factors that threaten harm or peril. The article will conclude with a description of various strategies that facilitate speaking up, and why the practice constitutes a superior alternative to mandatory alcohol and drug testing in the wake of serious, harm-causing medical error.

Investigating the safety of medication administration in adult critical care settings

BACKGROUND

Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings.

PURPOSE

This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant.

CONCLUSION

The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.

Review article: new directions in medical education related to anesthesiology and perioperative medicine

PURPOSE

We aim to provide a broad overview of current key issues in anesthesiology education to encourage both "clinician teachers" and "clinician educators" in academic health centres to consider how medical educational theory can inform their own practice.

PRINCIPAL FINDINGS

Evolving contextual issues, such as work-hour reform and the patient safety movement, necessitate innovative approaches to anesthesiology education. There is a substantial amount of relevant literature from other disciplines, such as sociology, psychology, and human factors research, using methodologies that are often unfamiliar to most clinicians. Recurring themes include the increasing use of simulation-based education, the importance of faculty development, challenges in teaching and assessing the non-medical expert roles, and the promise of team training and interprofessional education. Interdisciplinary collaborations are likely key to answering pressing questions in anesthesiology education, and a greater understanding of qualitative and mixed methods research will allow a broader range of questions to be answered. Simulation offers the opportunity to learn from failures without exposing patients to risk and brings the challenge of integrating innovations into existing curricula. Interprofessional education allows learning in the teams that will work together; even so, it needs to be prioritized to overcome logistical barriers. The challenges of introducing a competency-based curriculum have resulted in hybrid systems where elements of competency-based medical education have been combined with traditional apprenticeship curricula. The value of faculty development to encourage even simple measures, such as establishing learning objectives and discussing these with trainees, cannot be over-emphasized. Key issues in assessment include the need to evaluate multiple levels of performance in a cohesive system of assessment and the need to identify the unintended consequences of assessment.

CONCLUSIONS

We have identified a number of key themes and challenges for anesthesiology education. This discussion will continue in greater depth in individual articles in this issue so as to promote further interest in a growing body of literature that is relevant to anesthesiology education.

The challenges of undertaking root cause analysis in health care: A qualitative study

Objectives

Root cause analysis (RCA) is a framework for structured investigations of safety incidents. Our aim was to identify the barriers to successful learning in health care and to make recommendations for service development.

Methods

A qualitative study that ‘tracked’ the investigation procedures and practices of ten patient safety incidents in two National Health Service (NHS) hospitals. Non-participant observations of the complete investigation process in various managerial and administrative settings, together with semi-structured qualitative interviews with those involved in the process, and following the completion of the final report.

Results

There are several challenges to undertaking root cause analysis in health care. These are associated with forming and leading the investigation team; gathering and analysing supporting evidence; and formulating and implementing service improvements. Undertaking root cause analysis remains a complex non-linear task which entails balancing a multiplicity of concerns and expectations. Supporting enhanced incident investigation requires keeping in focus the instrumental aim of triggering sustainable service improvement and not for the investigation to become an end in itself.

Conclusions

Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management.

Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety

CONTEXT

Many safety initiatives have been transferred successfully from commercial aviation to health care. This article develops a typology of aviation safety initiatives, applies this to health care, and proposes safety measures that might be adopted more widely. It then presents an economic framework for determining the likely costs and benefits of different patient safety initiatives.

METHODS

This article describes fifteen examples of error countermeasures that are used in public transport aviation, many of which are not routinely used in health care at present. Examples are the sterile cockpit rule, flight envelope protection, the first-names-only rule, and incentivized no-fault reporting. It develops a conceptual schema that is then used to argue why analogous initiatives might be usefully applied to health care and why physicians may resist them. Each example is measured against a set of economic criteria adopted from the taxation literature.

FINDINGS

The initiatives considered in the article fall into three themes: safety concepts that seek to downplay the role of heroic individuals and instead emphasize the importance of teams and whole organizations; concepts that seek to increase and apply group knowledge of safety information and values; and concepts that promote safety by design. The salient costs to be considered by organizations wishing to adopt these suggestions are the compliance costs to clinicians, the administration costs to the organization, and the costs of behavioral distortions.

CONCLUSIONS

This article concludes that there is a range of safety initiatives used in commercial aviation that could have a positive impact on patient safety, and that adopting such initiatives may alter the safety culture of health care teams. The desirability of implementing each initiative, however, depends on the projected costs and benefits, which must be assessed for each situation.