Methods for studying medication safety following electronic health record implementation in acute care: a scoping review

OBJECTIVES

The objective of this scoping review is to map methods used to study medication safety following electronic health record (EHR) implementation. Patterns and methodological gaps can provide insight for future research design.

MATERIALS AND METHODS

We used the Joanna Briggs Institute scoping review methodology and a custom data extraction table to summarize the following data: (1) study demographics (year, country, setting); (2) study design, study period, data sources, and measures; (3) analysis strategy; (4) identified limitations or recommendations; (5) quality appraisal; and (6) if a Safety-I or Safety-II perspective was employed.

RESULTS

We screened 5879 articles. One hundred and fifteen articles met our inclusion criteria and were assessed for eligibility by full-text review. Twenty-seven articles were eligible for extraction.

DISCUSSION AND CONCLUSION

We found little consistency in how medication safety following EHR implementation was studied. Three study designs, 7 study settings, and 10 data sources were used across 27 articles. None of the articles shared the same combination of design, data sources, study periods, and research settings. Outcome measures were neither defined nor measured consistently. It may be difficult for researchers to aggregate and synthesize medication safety findings following EHR implementation research. All studies but one used a Safety-I perspective to study medication safety. We offer a conceptual model to support a more consistent approach to studying medication safety following EHR implementation.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study

BACKGROUND

The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context.

METHODS

We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript.

RESULTS

We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose.

CONCLUSIONS

We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Mapping Processes in the Emergency Department Using the Functional Resonance Analysis Method

Emergency departments (EDs) are dynamic, complex, and demanding environments. Introducing changes that lead to improvements in EDs can be challenging owing to the high staff turnover and mix, high patient volume with different needs, and being the front door to the hospital for the sickest patients. Quality improvement is a methodology applied routinely in EDs to instigate change to improve several outcomes such as waiting times, time to definitive treatment, and patient safety. Introducing the changes needed to transform the system in this way is seldom straightforward with the risk of "not seeing the forest for the trees" when attempting to change the system. In this article, we demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem ("the forest") and to support quality improvement planning, identifying priorities and patient safety risks.

A qualitative study of organisational resilience in care homes in Scotland

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

A systems analysis of the COVID-19 pandemic response in the United Kingdom - Part 1 - The overall context

The most common reaction to suggesting that we could learn valuable lessons from the way the current pandemic has been/ is being handled, is to discourage the attempt; as it is suggested that it can all be done more accurately and authoritatively after the inevitable Public Inquiry (Slater, 2019). On the other hand, a more constructive approach, is to capture and understand the work that was actually done.This would include normal activities, as well as positive adaptations to challenges and failures that may have occurred. Such an approach aimed at improving what worked, rather than blaming people for what went wrong, has the potential to contribute more successfully to controlling the consequences of the current crisis. Such an approach should thus be aimed at detecting and feeding back lessons from emerging and probably unexpected behaviours and helping to design the system to adapt better to counter the effects. The science and discipline of Human Factors (HF) promotes system resilience. This can be defined as an organisation's ability to adjust its functioning before, during or after significant disturbances (such as a pandemic), enabling adaptation and operation under both anticipated and unanticipated circumstances. A "functional" approach methodology enables the identification of where the system and its various interdependent functions (an activity or set of activities that are required to give a certain output), could be improved and strengthened; if not immediately, at least for the future. Along these lines, suggestions for adding key resilience functions are additionally identified and outlined. The application and insights gained from this functional approach to the 2015 MERS-Cov pandemic in South Korea has been seen as contributing substantially to the effective response to the current crisis in that country (Min, submitted for publication). In this paper, we present an overarching framework for a series of projects that are planned to carry out focussed systems-based analysis to generate learning from key aspects of the COVID-19 pandemic response in the United Kingdom.

Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory

OBJECTIVE

To develop mid-range programme theory from perceptions and experiences of out-of-hours community palliative care, accounting for human factors design issues that might be influencing system performance for achieving desirable outcomes through quality improvement.

SETTING

Community providers and users of out-of-hours palliative care.

PARTICIPANTS

17 stakeholders participated in a workshop event.

DESIGN

In the UK, around 30% of people receiving palliative care have contact with out-of-hours services. Interactions between emotions, cognition, tasks, technology and behaviours must be considered to improve safety. After sharing experiences, participants were presented with analyses of 1072 National Reporting and Learning System incident reports. Discussion was orientated to consider priorities for change. Discussions were audio-recorded and transcribed verbatim by the study team. Event artefacts, for example, sticky notes, flip chart lists and participant notes, were retained for analysis. Two researchers independently identified context-mechanism-outcome configurations using realist approaches before studying the inter-relation of configurations to build a mid-range theory. This was critically appraised using an established human factors framework called Systems Engineering Initiative for Patient Safety (SEIPS).

RESULTS

Complex interacting configurations explain relational human-mediated outcomes where cycles of thought and behaviour are refined and replicated according to prior experiences. Five such configurations were identified: (1) prioritisation; (2) emotional labour; (3) complicated/complex systems; (4a) system inadequacies and (4b) differential attention and weighing of risks by organisations; (5) learning. Underpinning all these configurations was a sixth: (6a) trust and access to expertise; and (6b) isolation at night. By developing a mid-range programme theory, we have created a framework with international relevance for guiding quality improvement work in similar modern health systems.

CONCLUSIONS

Meta-cognition, emotional intelligence, and informal learning will either overcome system limitations or overwhelm system safeguards. Integration of human-centred co-design principles and informal learning theory into quality improvement may improve results.

The contribution of human factors and ergonomics to the design and delivery of safe future healthcare

Human factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, we set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. We consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care

Background

The COVID-19 pandemic has resulted in the rapid reorganisation of health and social care services. Patients are already at significant risk of healthcare-associated harm and the wholesale disruption to service delivery during the pandemic stood to heighten those risks.

Objectives

We explored the type and nature of patient safety incidents in French primary care settings during the COVID-19 first wave to make tentative recommendations for improvement.

Methods

A national patient safety incident reporting survey was distributed to General Practitioners (GPs) in France on 28 April 2020. Reports were coded using a classification system aligned to the WHO International Classification for Patient Safety (incident types, contributing factors, incident outcomes and severity of harm). Analysis involved data coding, processing, iterative generation of data summaries using descriptive statistical analysis. Clinicaltrials.gov: NCT04346121.

Results

Of 132 incidents, 58 (44%) related to delayed diagnosis, assessments and referrals. Cancellations of appointments, hospitalisations or procedures was reported in 22 (17%) of these incidents. Home confinement-related incidents accounted for 13 (10%) reports and inappropriate medication stopping for five (4%). Patients delayed attending or did not consult their general practitioner or other healthcare providers due to their fear of contracting COVID-19 infection at an in-person visit in 26 (10%) incidents or fear of burdening their GPs in eight (3%) incidents.

Conclusion

Constraints from the first wave of the COVID-19 pandemic have contributed to patient safety incidents during non-COVID-19 care. Lessons from these incidents pinpoint where primary care services in France can focus resources to design safer systems for patients.

Preliminary case report study of training and support needed to conduct bowtie analysis in healthcare

Background

There is limited engagement in healthcare with the kinds of proactive approaches to risk assessment used in other industries. Bowtie analysis (BTA) has previously been shown to have potential as a straightforward approach to proactively assessing risk in healthcare. The visual nature of BTA diagrams can aid communication of the essential elements of a complex risk management system. The aim of this small case report study was to investigate the training and support likely to be needed for existing healthcare professionals to conduct BTA in compliance with recognised industry best-practice.

Method

Of 17 volunteers who attended training, 3 completed an analysis of significant healthcare risks in the study period: misadministration of gentamicin; unknown development of acute kidney injury and disposal of medical devices containing patient identifiable information (PII). Subjective assessments of the quality of the analyses were made against indicators of BTA best-practice.

Results

Use of the BTA method led to a deeper understanding of the issues and a more thorough understanding of the risks and what was needed to control them than would have been the case if ‘normal practice’ had been followed. Classroom-based training supported by written guidance; however, do not appear adequate to support development of competence to carry out a quality BTA in a healthcare setting.

Conclusions

BTA seems to have potential though further evaluation of its application and utility is necessary. The most cost-effective and productive approach is likely to be to train a small number of people to develop deeper skills and experience in BTA. In addition to training and user guidance, the opportunity to facilitate at least one analysis, with some specialist/trainer support, appears to be essential in developing BTA competence.

Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning

BACKGROUND

In response to the coronavirus disease of 2019 (COVID-19) pandemic, healthcare systems worldwide have stepped up their infection prevention and control efforts in order to reduce the spread of the infection. Behaviours, such as hand hygiene, screening and cohorting of patients, and the appropriate use of antibiotics have long been recommended in surgery, but their implementation has often been patchy.

METHODS

The current crisis presents an opportunity to learn about how to improve infection prevention and control and surveillance (IPCS) behaviours. The improvements made were mainly informal, quick and stemming from the frontline rather than originating from formal organizational structures. The adaptations made and the expertise acquired have the potential for triggering deeper learning and to create enduring improvements in the routine identification and management of infections relating to surgery.

RESULTS

This paper aims to illustrate how adopting a human factors and ergonomics perspective can provide insights into how clinical work systems have been adapted and reconfigured in order to keep patients and staff safe.

CONCLUSION

For achieving sustainable change in IPCS practices in surgery during COVID-19 and beyond we need to enhance organizational learning potentials.

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

WHY IS THE AREA IMPORTANT?

A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable.

WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?

We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II.

FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE

Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Human factors/ergonomics to support the design and testing of rapidly manufactured ventilators in the UK during the COVID-19 pandemic

Background

This paper describes a rapid response project from the Chartered Institute of Ergonomics & Human Factors (CIEHF) to support the design, development, usability testing and operation of new ventilators as part of the UK response during the COVID-19 pandemic.

Method

A five-step approach was taken to (1) assess the COVID-19 situation and decide to formulate a response; (2) mobilise and coordinate Human Factors/Ergonomics (HFE) specialists; (3) ideate, with HFE specialists collaborating to identify, analyse the issues and opportunities, and develop strategies, plans and processes; (4) generate outputs and solutions; and (5) respond to the COVID-19 situation via targeted support and guidance.

Results

The response for the rapidly manufactured ventilator systems (RMVS) has been used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with RMVS manufacturers.

Conclusion

The documents are part of a wider collection of HFE advice which is available on the CIEHF COVID-19 website (https://covid19.ergonomics.org.uk/).

Development and application of 'systems thinking' principles for quality improvement

Introduction

‘Systems thinking’ is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a ‘Safety-II systems approach’ to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting.

Methods

The original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders.

Results

Six interrelated principles for healthcare were agreed. The foundation concept acknowledges that ‘most healthcare problems and solutions belong to the system’. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions—demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.

A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design.

Conclusions

Application of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.

User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment

Background

Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context.

Methods

A multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and ‘experts’ to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented.

Results

A redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%–98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%).

Conclusions

The checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.

Multi-method evaluation of a national clinical fellowship programme to build leadership capacity for quality improvement

Background

This paper reports the results of the evaluation of the Scottish Quality and Safety Fellowship (SQSF)—a 10-month, lead-level international educational programme established in 2008 with the overarching aim of developing clinicians with advanced quality improvement knowledge, technical ability and essential leadership skills. The evaluation explores four levels of educational and practice outcomes associated with (1) the reaction of fellows to SQSF participation, (2) learning gained, (3) subsequent behaviour changes and (4) the overall impact on national and international level capability and capacity building.

Methods

A theory-informed multi-method design was applied using (1) a search and review of the SQSF organisational database to tabulate personal, professional and demographic characteristics; (2) semi-structured telephone interviews with 16 participants using purposive and self-selected sampling; and (3) a cross-sectional online evaluation survey across all 10 cohorts involving 222 fellows

Results

SQSF was positively perceived as a high-quality learning experience containing a well-balanced mix of theory and practice, with a majority of respondents reporting career changing benefits. Most participants reported improved social, behavioural and emotional skills, knowledge and attitudes and, with sustained support of their host organisations, were able to apply and share learning in their workplace. The impact of the SQSF on a wider national and international level capability and capacity was both mediated and moderated by a wide range of interrelated contextual factors.

Conclusions

This multi-method evaluation demonstrates that SQSF has achieved significant positive outcomes for the great majority of participants. Some tentative recommendations are provided with the aim of further enhancing fellowship content, delivery, transfer and future evaluations of wider impacts at regional, national and international health system levels.

Professional values and behaviours of younger and older general practitioners in Scotland: a cross-sectional survey

Aim

Professionalism has been linked with improved patient care and reduced complaints. Our goal was to define what, if any, differences exist in the professional values and behaviours of younger general practitioners (GPs), those aged 34 years and under, compared with their older colleagues, those being aged 55 years and over.

Method

An online cross-sectional questionnaire survey of GPs in Scotland was undertaken during 2018 using a modified version of the Nijmegen Professionalism Scale, which comprises 4 domains: professionalism towards patients, towards colleagues, towards society and towards oneself. Descriptive and inferential data analysis was undertaken between responses from both GP groups.

Results

273 responses were obtained. Of these, 106 respondents were classed as either younger GPs (n=55; 51.9%) or older (n=51; 48.1%). The greatest number of differences were found in the Professional Distance subsection of professionalism towards patients. The greatest single disparity in responses was to distinguish between personal and professional interests in negotiations (p<0.0001). Younger GPs also reported they were less likely to bear the consequences of their own actions (p<0.02) and to be more likely to give others the blame or responsibility (p<0.006). Younger GPs report being less skilled in quality management, being less able to signal suboptimal care (p<0.006) and justify indications for making home visits (p<0.001).

Conclusion

While there were areas of similarity in relation to collaborating with colleagues, reflection on learning and dealing with emotions, differences were identified in relation to the 5 other subsections. Some differences may be explained by lack of exposure and experience, but this may not account for all the differences reported.

Evaluation of a simulation-based Risk Management and Communication Masterclass to reduce the risk of complaints, medicolegal and dentolegal claims

Objectives

To understand clinicians’ experiences, learning and professional impacts following participation in a Risk Management and Communication Masterclass (RMCM) designed and delivered by Medical Protection Society. To identify the course’s strengths and areas for enhancement.

Design

Mixed method study including semistructured telephone interviews. Interviews were conducted between October and December 2017, 6–30 months after course participation. Data were subjected to a thematic analysis. Quantitative analysis of participants’ feedback ratings (n=486) on RMCMs delivered between December 2014 and May 2017 was also undertaken.

Setting

RMCMs were delivered to Doctors and Dentists based in the UK and Ireland and South Africa. Participants: A sample of 12 volunteer doctors (Obstetricians/Gynaecologists, Orthopaedic/Spinal Surgeons, General Surgeons, Paediatricians, General Practitioners) and dentists chosen to represent different clinical specialities accepted the invitation to participate.

Results

Study participants reported examples of person-centred communication skills such as empathy, shared-decision making and managing patient expectations in their workplaces following participation in the RMCM. Many clinicians gave examples describing how they used the communication models they learned when back at work. They also demonstrated a better understanding of the motivations for patients to complain or claim. RMCM course participants’ high feedback ratings provided further evidence that the course was valuable and met learning objectives.

Conclusions

It may prove difficult to demonstrate quantitatively that liability improves as a direct result of risk management and communications training. Our results on other dimensions (reactions, learning, behaviour change and impact) suggest that the RMCM has a positive and durable effect based on participant feedback.

A preliminary ergonomic analysis of the MRI work system environment: Implications and recommendations for safety and design

INTRODUCTION

The MRI work system environment in acute hospitals poses a significant risk of harm to patients, healthcare practitioners and others, but knowledge of hazards and potential design improvements are limited as safety research is lacking. The aim of this exploratory study was to understand how the discipline of Human Factors and Ergonomics (HFE) can support the understanding and improvement of safety and performance of MRI working environments.

METHODS

A multi-method study of two MRI units in Scottish acute hospital settings based on Human Factors and Ergonomics (HFE) principles was undertaken in May 2016. Data collection sources included published literature, local and national safety incident data, site observations and staff interviews which were triangulated and subject to a content analysis.

RESULTS

A diverse range of system-wide hazards were highlighted which impact on the complexity of MRI work, patient and staff safety and system performance (e.g. adequacy of training and procedures, interactions with equipment, organisation of work). Preliminary recommendations were made to improve system design related to national approaches to safety (e.g. equipment procurement; staff training and procedural standards); interaction design and standardisation (e.g. physical design and barriers, staff uniforms, checking processes); and introduction of MRI passports for patients.

CONCLUSIONS

This exploratory study suggests the need for national co-ordination and standardisation of MRI safety management strategies, based on safety science and HFE evidence and approaches to improve system design and reduce risk to patients, staff and others. A series of provisional recommendations are offered for consideration.

Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory

OBJECTIVES

Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting.

DESIGN

Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT).

SETTING

Scottish general practice.

PARTICIPANTS

We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland.

RESULTS

We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants' involvement; (3) the characteristics of the reviewers-implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful.

CONCLUSIONS

This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors.

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of 'never events'

OBJECTIVES

To examine general practitioner (GP) understanding of the never event (NE) concept in general practice, and to identify potential enablers and barriers to implementation in UK general practice.

DESIGN

Qualitative study using focus groups. The data were analysed thematically and were informed by the normalisation process theory.

SETTING

General practice in Northwest England and Southwest Scotland.

PARTICIPANTS

25 GPs took part in five focus groups. 13 GPs were female and 12 male with an age range of 28-60.

RESULTS

The NE approach of avoiding serious preventable adverse outcomes from healthcare fitted with participants expectations of the delivery of care but the implementation of strategies to prevent the specific NE was considered complex and variable. The main themes identified participants' understandings and perceived limitations of the NE concept; the embedded layers of responsibility to implement NE within practices and the work required for implementation within general practices. Participants' accounts highlighted the differential nature of work in general practice and that the implementation of initiatives to address specific NE should be situated within a learning and systems approach to implementation. Some NEs were considered more relevant and amenable to simple solutions than others which could influence implementation.

CONCLUSIONS

The NE concept was considered overall an important approach to help address key primary care patient safety issues. The utility of individual NEs may vary depending on the complexity of the initiatives that would be needed to manage related risks to as low as reasonably practicable.

Hospital Survey on Patient Safety Culture: psychometric evaluation in Kuwaiti public healthcare settings

OBJECTIVE

As healthcare organisations endeavour to improve the quality and safety of their services, there is increasing recognition of the importance of building a culture of safety to promote patient safety and improve the outcomes of patient care. Surveys of safety culture/climate have not knowingly been conducted in Kuwait public hospitals, nor are valid or reliable survey instruments available for this context. This study aims to investigate the psychometric properties of the HSOPSC (Hospital Survey on Patient Safety Culture) tool in Kuwaiti public hospitals in addition to constructing an optimal model to assess the level of safety climate in this setting.

DESIGN

Cross-sectional study.

SETTING

Three public hospitals in Kuwait.

PARTICIPANTS

About 1317 healthcare professionals.

MAIN OUTCOME MEASURE

An adapted and contextualised version of HSOPSC was used to conduct psychometric evaluation including exploratory factor analysis, confirmatory factor analysis reliability and correlation analysis.

RESULTS

1317 questionnaires (87%) were returned. Psychometric evaluation, showed an optimal model of eight factors and 22 safety climate items. All items have strong factor loadings (0.42-0.86) and are theoretically related. Reliability analysis showed satisfactory results (α >0.60).

CONCLUSIONS

This is the first validation study of a standardised safety climate measure in a Kuwaiti healthcare setting. An optimal model for assessing patient safety climate was produced that mirrors other international studies and which can be used for measuring the prevailing safety climate. More importance should be attached to the psychometric fidelity of safety climate questionnaires before extending their use in other healthcare culture and contexts internationally.

Content analysis of 50 clinical negligence claims involving test results management systems in general practice

Background and aims

Laboratory test results management systems are a complex safety issue in primary care settings worldwide. Related failures lead to avoidable patient harm, medicolegal action, patient complaints and additional workload to problem solve identified issues. We aimed to review and learn from 50 clinical negligence cases involving system failures related to the management of test results.

Methods

The Medical Protection Society database was searched and a convenience sample of 50 claims identified from a 3-year period covering 2014–2016. A content analysis of documentation was undertaken to quantify and theme data, aided by a Risk Assessment Matrix and the Yorkshire Contributory Factors Framework. Quantitative data were subjected to simple descriptive statistical analysis.

Results

14/50 cases (28%) involved a delay in diagnosis or treatment of a patient with cancer. 15 cases were judged to be ‘never events’ (30%) and 85 distinct system issues were identified. Just under half of cases involved a failure to notify patients of an abnormal test result (n=24, 48%), while 18 cases (36%) involved a test result not being actioned by a doctor. The most frequently occurring contributory factors (n=30, 60%) were related to local working conditions, for example, unclear professional responsibilities with regards to test result review or follow-up or lack of patient care continuity.

Conclusion

This small study highlights why test result management systems fail and contribute to future litigation, providing new insights in this area. Most claims involved avoidable harm to patients and preventable organisational risks. The findings point to the inadequate design of practice systems and the need for proactive strategies to improve the management of test results in order to reduce patient harm.

Testing of the 'Always Events' approach to improve the patient experience in the emergency department

Maintaining quality of care and meeting patient expectations in the face of rising demand within emergency departments (ED) is a significant challenge for clinicians. This study tested the Always Events (AE) approach as a means to identify AE's relevance to patient care in the ED and act on this to address patient concerns. The project team looked to identify aspects of care patients would like to see improved within the minor injuries stream (MIS). Following triage, patients typically have presentations that do not require admission and require a single interaction with a clinician. Interventions seeking to improve patient experience were created and impact was monitored using patient feedback using a quality improvement (QI) framework. AEs were identified via convenience sampling using a short semistructured survey questionnaire. Patients were asked 'What should always happen in the Emergency Department?' Communication and information provision regarding how the department worked were identified as key themes. Two interventions, an educational poster and a video campaign, were designed and implemented. Improvement was assessed via convenience sampling of patient questionnaires using a 5-point Likert scale and free-text responses. Initial patient satisfaction levels regarding information provision stood at 80%, rising to 88% after our poster intervention and 92% by the end of the video intervention. Understanding of how the ED functions was initially 83% in the baseline sample before rising to 86% following poster and video interventions. Patient questionnaires indicated that information provision directly from staff was variable throughout the study period. Implementing the AE approach in the MIS has improved patient experience. Our poster intervention had the greatest benefit regarding patient understanding of the ED and information provision. This project has also indicated that the AE method can be successfully combined with a QI tool and applied in the ED to address patient needs.

Preliminary codesign and testing of a feedback tool to improve the quality of peer appraiser documentation for medical revalidation

Medical appraisal and associated revalidation are mandatory for doctors in the United Kingdom. However, the quality of appraisal documentation, which informs the revalidation process on a doctor's fitness-to-practise, is known to be variable. This preliminary study aimed to develop and test a formative educational tool that could be used, as part of routine appraiser training in the general practice setting, to review and provide evidence and feedback on the quality of documentation completion. A mixed-methods study was undertaken based on codesign principles, which elicited the views and opinions of medical appraisers, appraisal leads and medical managers on the content of an educational tool designed to reduce variation in appraisal paperwork completion. The study team created a 24-item educational tool covering six domains of the appraisal process. Domains included 'reflection on practice', 'knowledge, skills and performance' and 'quality and safety'. The tool was piloted amongst appraisers and received positive feedback. This study contributes practical knowledge to help reduce variation in appraisal documentation. The tool can be used to streamline the completion of appraisal documentation by appraisers. It may provide a level of quality assurance and contribute to providing fair, objective and measurable grounds for revalidation.

Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method

BACKGROUND

Ensuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.

METHODS

In a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis.

RESULTS

Fourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed.

CONCLUSIONS

Traditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.

Frequency and nature of potentially harmful preventable problems in primary care from the patient's perspective with clinician review: a population-level survey in Great Britain

OBJECTIVES

To estimate the frequency of patient-perceived potentially harmful problems occurring in primary care. To describe the type of problem, patient predictors of perceiving a problem, the primary care service involved, how the problem was discussed and patient suggestions as to how the problem might have been prevented. To describe clinician/public opinions regarding the likelihood that the patient-described scenario is potentially harmful.

DESIGN

Population-level survey.

SETTING

Great Britain.

PARTICIPANTS

A nationally representative sample of 3975 members of the public aged ≥15 years interviewed during April 2016.

MAIN OUTCOME MEASURES

Counts of patient-perceived potentially harmful problems in the last 12 months, descriptions of patient-described scenarios and review by clinicians/members of the public.

RESULTS

3975 of 3996 participants in a nationally representative survey completed the relevant questions (99.5%). 300 (7.6%; 95% CI 6.7% to 8.4%) of respondents reported experiencing a potentially harmful preventable problem in primary care during the past 12 months and 145 (48%) discussed their concerns within primary care. This did not vary with age, gender or type of service used. A substantial minority (30%) of the patient-perceived problems occurred outside general practice, particularly the dental surgery, walk in clinic, out of hours care and pharmacy. Patients perceiving a potentially harmful preventable problem were eight times more likely to have 'no confidence and trust in primary care' compared with 'yes, definitely' (OR 7.9; 95% CI 5.9 to 10.7) but those who discussed their perceived-problem appeared to maintain higher trust and confidence. Generally, clinicians ranked the patient-described scenarios as unlikely to be potentially harmful.

CONCLUSIONS

This study highlights the importance of actively soliciting patient's views about preventable harm in primary care as patients frequently perceive potentially harmful preventable problems and make useful suggestions for their prevention. Such engagement may also help to improve confidence and trust in primary care.

'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice

Background

Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks.

Methods

A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed.

Results

Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment.

Conclusion

The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so.

Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools

BACKGROUND

The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety climate in healthcare organizations; however, the rigour with which safety climate tools were developed and psychometrically tested was shown to be variable. This paper aims to identify and review questionnaire studies designed to measure safety climate in acute hospital settings, in order to assess the adequacy of reported psychometric properties of identified tools.

METHODS

A systematic review of published empirical literature was undertaken to examine sample characteristics and instrument details including safety climate dimensions, origin and theoretical basis, and extent of psychometric evaluation (content validity, criterion validity, construct validity and internal reliability).

RESULTS

Five questionnaire tools, designed for general evaluation of safety climate in acute hospital settings, were included. Detailed inspection revealed ambiguity around concepts of safety culture and climate, safety climate dimensions and the methodological rigour associated with the design of these measures. Standard reporting of the psychometric properties of developed questionnaires was variable, although evidence of an improving trend in the quality of the reported psychometric properties of studies was noted. Evidence of the theoretical underpinnings of climate tools was limited, while a lack of clarity in the relationship between safety culture and patient outcome measures still exists.

CONCLUSIONS

Evidence of the adequacy of the psychometric development of safety climate questionnaire tools is still limited. Research is necessary to resolve the controversies in the definitions and dimensions of safety culture and climate in healthcare and identify related inconsistencies. More importance should be given to the appropriate validation of safety climate questionnaires before extending their usage in healthcare contexts different from those in which they were originally developed. Mixed methods research to understand why psychometric assessment and measurement reporting practices can be inadequate and lacking in a theoretical basis is also necessary.

Qualitative evaluation of an educational intervention to reduce medicolegal risks for medical doctors experiencing significantly more cases than their peers in the UK and Ireland

OBJECTIVES

The Medical Protection Society (MPS) is a leading protection organisation for healthcare professionals worldwide. In the UK and Ireland, a small minority of MPS members experience significantly more medicolegal cases than their peers and are invited to participate in a risk education (RE) remediation process. To understand more about this educational intervention, we sought to explore participating doctors' views of their experiences of this process and identify self-reported performance improvements and what elements of the intervention could be improved.

DESIGN

Qualitative semistructured telephone interviews with a convenience sample of doctors with significantly more medicolegal cases than their peers identified by MPS.

SETTING

UK and Ireland MPS members.

PARTICIPANTS

A convenience sample of 20 general medical practitioners and hospital specialists from a total of 79 who completed the RE process (25.3% response rate), with a particular focus on the Member Risk Review programme, between November 2013 and October 2015.

RESULTS

19 participants were male and 16 were based in general medical (office) practice. Three key themes were generated: personal and professional impacts and actions (eg, member has taken action to reduce clinical workload); comprehension and validity of RE interventions (eg, risks were related to wider patient management); and feedback and proposals (eg, the supportive nature of the educational interventions should be clear from the start). A number of recommendations were made by participants to improve the RE process and enhance the educational experience.

CONCLUSIONS

The RE process was largely valued by participants with many reporting that participation led to some positive professional behaviour changes and improvements in practice processes and personal well-being.

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge

BACKGROUND

Pharmacists' completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.

METHODS

This is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively.

RESULTS

Fourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre-post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload.

CONCLUSIONS

Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.

Twelve tips for embedding human factors and ergonomics principles in healthcare education

Safety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programs will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support evolving curricula and professional development at all levels - and also challenge prevailing "human factors myths and misunderstandings" - we offer professional guidance as "tips" for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.

Development and piloting of a survey to estimate the frequency and nature of potentially harmful preventable problems in primary care from a UK patient's perspective

OBJECTIVES

To design and pilot a survey to be used at the population level to estimate the frequency of patient-perceived potentially harmful preventable problems occurring in UK primary care. To explore the nature of the problems, patient-suggested strategies for prevention and opinions of clinicians and the public regarding the potential for harm.

DESIGN

A survey was codesigned by three members of the public and one researcher and piloted through public and patient involvement and engagement networks.

SETTING

Self-selected sample of the UK population.

PARTICIPANTS

977 members of the public accessed the online survey during October and November 2015.

PRIMARY OUTCOME MEASURES

Respondent feedback about the ease of completion of the survey, quality of responses in terms of review by clinicians and members of the public, preliminary estimates of the frequency and nature of patient-perceived potentially harmful problems occurring in the last 12 months.

RESULTS

638 (65%) members of the public completed the survey and few respondents reported any difficulty in understanding or completing the survey. 132 (21%) respondents reported experiencing a potentially harmful preventable problem during the past 12 months and 108 (82%) of these respondents provided a description that was adequate for at least one clinician to form an opinion about the potentially harmful problem. Respondents were older than the UK generally, more likely to work or volunteer in the healthcare sector and tended to use primary care more frequently but their confidence and trust in their own general practitioner (GP) was similar to that of the UK population as measured by the annual English GP patient survey.

CONCLUSIONS

The survey was acceptable to patients and mostly provided data of sufficient quality for review by clinicians and members of the public. It is now ready to use at a population level to estimate the frequency and nature of potentially harmful preventable problems in primary care from a patient's perspective.

More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England?

What prevents the delivery of effective, high quality and safe health care in the National Health Service (NHS) in England? This paper presents 760 challenges which 330 NHS staff reported as preventing the delivery of effective, high quality and safe care. Some problems have been known for over 25 years (staff shortages, finance and patient complexity) but other challenges raise questions about the commitment of the NHS to patient and staff safety. For example, Organisational Culture leading to 'stifling bureaucracy', 'odds stacked against smooth […] working' and Workload resulting in 'firefighting daily' and 'perpetual crisis mode'. The role of Human Factors/Ergonomics professional input (engagement with safety scientists) is discussed in the context of success stories and examples of Human Factors Integration from other safety critical industries (Defence, Nuclear and Rail). Practitioner Summary: 760 challenges to the quality, effectiveness and safety of health care were identified at Human Factors/Ergonomics taster workshops in England. These are used to challenge health care providers to think about a Human Factors Integration (HFI systems) approach for safety, well-being and performance for all people involved in providing and receiving health care.

Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice

OBJECTIVE

The Scottish Patient Safety Programme - Pharmacy in Primary Care collaborative is a quality improvement initiative adopting the Institute of Healthcare Improvement Breakthrough Series collaborative approach. The programme developed and piloted High Risk Medicine (HRM) Care Bundles (CB), focused on warfarin and non-steroidal anti-inflammatories (NSAIDs), within 27 community pharmacies over 4 NHS Regions. Each CB involves clinical assessment and patient education, although the CB content varies between regions. To support national implementation, this study aims to understand how the pilot pharmacies integrated the HRM CBs into routine practice to inform the development of a generic HRM CB process map.

METHODS

Regional process maps were developed in 4 pharmacies through simulation of the CB process, staff interviews and documentation of resources. Commonalities were collated to develop a process map for each HRM, which were used to explore variation at a national event. A single, generic process map was developed which underwent validation by case study testing.

RESULTS

The findings allowed development of a generic process map applicable to warfarin and NSAID CB implementation. Five steps were identified as required for successful CB delivery: patient identification; clinical assessment; pharmacy CB prompt; CB delivery; and documentation. The generic HRM CB process map encompasses the staff and patients' journey and the CB's integration into routine community pharmacy practice. Pharmacist involvement was required only for clinical assessment, indicating suitability for whole-team involvement.

CONCLUSIONS

Understanding CB integration into routine practice has positive implications for successful implementation. The generic process map can be used to develop targeted resources, and/or be disseminated to facilitate CB delivery and foster whole team involvement. Similar methods could be utilised within other settings, to allow those developing novel services to distil the key processes and consider their integration within routine workflows to effect maximal, efficient implementation and benefit to patient care.

Repeat prescribing of medications: A system-centred risk management model for primary care organisations

RATIONALE, AIMS AND OBJECTIVES

Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care.

METHODS

All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses.

RESULTS

Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0).

CONCLUSIONS

The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally.

Human factors and ergonomics for primary care

In the second paper of this series, we provide a brief overview of the scientific discipline of human factors and ergonomics (HFE). Traditionally the HFE focus in healthcare has been in acute hospital settings which are perceived to exhibit characteristics more similar to other high-risk industries already applying related principles and methods. This paper argues that primary care is an area which could benefit extensively from an HFE approach, specifically in improving the performance and well-being of people and organisations. To this end, we define the purpose of HFE, outline its three specialist sub-domains (physical, cognitive and organisational HFE) and provide examples of guiding HFE principles and practices. Additionally, we describe HFE issues of significance to primary care education, improvement and research and outline early plans for building capacity and capability in this setting.

The role of informal dimensions of safety in high-volume organisational routines: an ethnographic study of test results handling in UK general practice

BACKGROUND

The handling of laboratory, imaging and other test results in UK general practice is a high-volume organisational routine that is both complex and high risk. Previous research in this area has focused on errors and harm, but a complementary approach is to better understand how safety is achieved in everyday practice. This paper ethnographically examines the role of informal dimensions of test results handling routines in the achievement of safety in UK general practice and how these findings can best be developed for wider application by policymakers and practitioners.

METHODS

Non-participant observation was conducted of high-volume organisational routines across eight UK general practices with diverse organisational characteristics. Sixty-two semi-structured interviews were also conducted with the key practice staff alongside the analysis of relevant documents.

RESULTS

While formal results handling routines were described similarly across the eight study practices, the everyday structure of how the routine should be enacted in practice was informally understood. Results handling safety took a range of local forms depending on how different aspects of safety were prioritised, with practices varying in terms of how they balanced thoroughness (i.e. ensuring the high-quality management of results by the most appropriate clinician) and efficiency (i.e. timely management of results) depending on a range of factors (e.g. practice history, team composition). Each approach adopted created its own potential risks, with demands for thoroughness reducing productivity and demands for efficiency reducing handling quality. Irrespective of the practice-level approach adopted, staff also regularly varied what they did for individual patients depending on the specific context (e.g. type of result, patient circumstances).

CONCLUSIONS

General practices variably prioritised a legitimate range of results handling safety processes and outcomes, each with differing strengths and trade-offs. Future safety improvement interventions should focus on how to maximise practice-level knowledge and understanding of the range of context-specific approaches available and the safeties and risks inherent in each within the context of wider complex system conditions and interactions. This in turn has the potential to inform new kinds of proactive, contextually appropriate approaches to intervention development and implementation focusing on the enhanced deliberation of the safety of existing high-volume routines.

Blood sampling - Two sides to the story

This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the system's resilience in future safety management strategies.

An enhanced induction programme for general practice specialty training: a qualitative study of trainee perceptions and experience

BACKGROUND

Following a Judicial review brought by the British Association of Physicians of Indian Origin, greater expectation is now being placed upon Health Education England Local Offices and Deaneries across Scotland, Wales and Northern Ireland to identify doctors who may go on to experience difficulties in general practice specialty training - and who may benefit from educational support at an early stage. NHS Education for Scotland West region has offered an enhanced induction programme for trainees who were identified as being at risk of difficulty in training.

AIMS

To capture the experience of an enhanced induction programme; exploring insight towards potential difficulties in training; and the feelings relating to being identified as a trainee at risk of difficulty.

METHOD

Interviews with trainees who attended the enhanced induction programme. Transcripts were analysed by a basic thematic analysis approach.

RESULTS

All non-UK Doctors completed 17 interviews. The term 'at risk' was accepted and the intervention was well received. Participants showed insight into the common areas of difficulty in trainees. The workshops helped to develop understanding of cultural differences, use of the ePortfolio, and gave participants an opportunity to practice their communication skills.

CONCLUSIONS

This enhanced induction programme has provided targeted training to a group of trainees identified at risk of difficulty.

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems

Participation in projects to improve patient safety is a key component of general practice (GP) specialty training, appraisal and revalidation. Patient safety training priorities for GPs at all career stages are described in the Royal College of General Practitioners' curriculum. Current methods that are taught and employed to improve safety often use a 'find-and-fix' approach to identify components of a system (including humans) where performance could be improved. However, the complex interactions and inter-dependence between components in healthcare systems mean that cause and effect are not always linked in a predictable manner. The Safety-II approach has been proposed as a new way to understand how safety is achieved in complex systems that may improve quality and safety initiatives and enhance GP and trainee curriculum coverage. Safety-II aims to maximise the number of events with a successful outcome by exploring everyday work. Work-as-done often differs from work-as-imagined in protocols and guidelines and various ways to achieve success, dependent on work conditions, may be possible. Traditional approaches to improve the quality and safety of care often aim to constrain variability but understanding and managing variability may be a more beneficial approach. The application of a Safety-II approach to incident investigation, quality improvement projects, prospective analysis of risk in systems and performance indicators may offer improved insight into system performance leading to more effective change. The way forward may be to combine the Safety-II approach with 'traditional' methods to enhance patient safety training, outcomes and curriculum coverage.

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care

Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes.

Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond.

Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers.

Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care.

Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

Human factors in general practice - early thoughts on the educational focus for specialty training and beyond

In the third article in the series, we describe the outputs from a series of roundtable discussions by Human Factors experts and General Practice (GP) Educational Supervisors tasked with examining the GP (family medicine) training and work environments through the lens of the systems and designed-centred discipline of Human Factors and Ergonomics (HFE). A prominent issue agreed upon proposes that the GP setting should be viewed as a complex sociotechnical system from a care service and specialty training perspective. Additionally, while the existing GP specialty training curriculum in the United Kingdom (UK) touches on some important HFE concepts, we argue that there are also significant educational gaps that could be addressed (e.g. physical workplace design, work organisation, the design of procedures, decision-making and human reliability) to increase knowledge and skills that are key to understanding workplace complexity and interactions, and supporting everyday efforts to improve the performance and wellbeing of people and organisations. Altogether we propose and illustrate how future HFE content could be enhanced, contexualised and integrated within existing training arrangements, which also serves as a tentative guide in this area for continuing professional development for the wider GP and primary care teams.

The past, present and future of patient safety education and research in primary care

In the first series of related articles, we describe how assurance of patient safety in primary care was traditionally viewed by the medical profession hierarchy as being wholly dependent at the individual level upon a combination of education and training, knowledge, skill, experience and commitment to professional development. As well as summarising the evidence underpinning what we know about patient safety in primary care, we outline how contemporary thinking has evolved to recognise that the safety issue is complex, problematic and systemic, and that it is now beginning to attract the attention of national policymakers, educators and research funders in some countries. We also describe a range of recently developed educational safety concepts and methods that have been implemented as part of current national programme initiatives in the United Kingdom and internationally. Finally, we reflect on international progress on patient safety in primary care thus far; propose a future direction for related education, development and research; and briefly introduce the Human Factors based topics to be addressed in the forthcoming series of interrelated articles in this journal.

Involving people with intellectual disabilities in the formal assessment of psychiatrists’ skills

Purpose

It is widely recognised that people with intellectual disabilities receive a poorer quality of healthcare than their non-disabled counterparts. Training for healthcare professionals in intellectual disability is often scant or non-existent. The purpose of this work is to explore the usefulness of employing actors with intellectual disabilities as simulated patients in the assessment of trainee psychiatrists.

Design/methodology/approach

The development of a structured clinical exam “station” designed to assess the ability of trainee psychiatrists to communicate with a simulated patient played by an actor with an intellectual disability is described. The paper also assesses the potential benefits of this kind of assessment and the experience of actors and examiners taking part in this process.

Findings

The station was found to perform well in discriminating between candidates of various abilities and was well received by actors, examiners and observers. The station is now routinely used in the formal assessment of trainee psychiatrists in the UK.

Practical implications

The use of people with intellectual disabilities in training and assessment appears to be advantageous in terms of improving knowledge, attitudes and skills amongst healthcare professionals and gives increased opportunities for people with intellectual disabilities to undertake valued social roles.

Originality/value

Few institutions currently employ actors with intellectual disabilities as simulated patients as part of their training programmes and as a result there is little in the way of literature on this subject. This paper describes an alternative approach to teaching and assessment which falls in line with recommendations from the UK Department of Health to involve service users in the training of healthcare professionals.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams

OBJECTIVES

To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting.

DESIGN

Qualitative study using semistructured interviews. Data were analysed thematically.

SUBJECTS AND SETTING

Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards.

RESULTS

27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence.

CONCLUSIONS

The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted.