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Content ArticlePromoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
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Content Article
In this blog, Clare Rayner, an occupational physician, describes how an international collaboration to help understand Long Covid was established by harnessing the power of technology and social media. This collective, between a group of UK doctors experiencing prolonged health problems after Covid-19 infection and a globally renowned rehabilitation clinic at Mount Sinai Hospital in New York, aims to help both patients and healthcare professionals by disseminating learning about Long Covid from both sides of the Atlantic. -
Content ArticleIn this blog for The BMJ, several doctors who are experiencing long term impacts of Covid-19 share their report of a meeting with the World Health Organization's Covid-19 response team in August 2020. They highlighted the importance of patient-led research and and engaging with patients with Long Covid.
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Content ArticleThe aim of this study from Liu et al. was to assess the impact of the Fetal Medicine Foundation (FMF) first trimester screening algorithm for pre-eclampsia on health disparities in perinatal death among minority ethnic groups.
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Content ArticleThe objective of this study from Carey et al. was to explore medical oncology outpatients' perceived experiences of errors in their cancer care. A cross-sectional survey was conducted. English-speaking medical oncology outpatients aged 18 years or older were recruited from 9 Australian cancer treatment centres. One hundred forty-eight participants perceived that an error had been made in their care, of which one third reported that the error was associated with severe harm. Of those who perceived an error had been made, less than half reported that they had received an explanation for the error and only one third reported receiving an apology or being told that steps had been taken to prevent the error from reoccurring. Patients with university or vocational level education and those who received radiotherapy or “other” treatments were significantly more likely to report an error in care. The authors concluded that here is significant scope to improve communication with patients and appropriate responses by the healthcare system after a perceived error in cancer care.
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Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content ArticleWhile men over 50 tend to suffer the most acute symptoms of coronavirus, women who get Long Covid outnumber men by as much as four to one.
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Content ArticleThe Safer Healthcare and Biosafety Network (SHBN) is seeking input from occupational health managers based in the UK to support the establishment of a new annual UK national database of blood and body fluid exposures in healthcare workers.
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Content ArticleWomen have consistently reported lower satisfaction with postnatal care compared with antenatal and labour care. The aim of this research was to examine whether women’s experience of inpatient postnatal care in England is associated with variation in midwifery staffing levels. It found that negative experiences for women on postnatal wards were more likely to occur in trusts with fewer midwives. Low staffing could be contributing to discharge delays and lack of support and information, which may in turn have implications for longer term outcomes for maternal and infant wellbeing. This analysis of survey data supports previous findings that increased midwifery staffing is associated with benefits. This is the first study to examine the effects of organisational staffing on women’s experience of postnatal care.
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Content ArticleHistorically, patients have always been considered the passive recipients of healthcare. This way of thinking affected everything from how people were cared for in a clinician’s office or hospital bed, to how they participated in clinical trials. It’s also meant that patients have previously had no role in the production or review of medical literature after research has been completed. However, this is changing, and now patients and members of the public are increasingly involved in new and meaningful ways at more steps in the research process, including as potential reviewers of medical papers. This has enormous benefits for science and healthcare. But patients and members of the public are not always provided with the relevant resources to participate effectively and efficiently, and this is something that journals need to work on.
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Content ArticleThe Covid-19 pandemic has precipitated a huge increase in the use of digital technology in healthcare. This is a welcome development following years of slow progress in embedding digital technologies into England’s NHS. This Nuffield Trust report explores the approach that other countries have taken to advance digital health. It asks four key research questions: How have policy-makers in different countries defined the objectives of digitalisation within healthcare? What policy approaches have been used in different countries to support and promote digitalisation in healthcare? What worked well, what were the challenges and how were they overcome? What are the implications for NHS digital health policy?
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Content ArticleThe use of healthcare complaints to improve quality and safety has been limited by a lack of reliable analysis tools and uncertainty about the insights that can be obtained. The Healthcare Complaints Analysis Tool, developed by Alex Gillespie and Tom W. Reader was used to analyse a benchmark national data set, conceptualise a systematic analysis, and identify the added value of complaint data.
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Content ArticlePatients and families are important contributors to the diagnostic team, but their perspectives are not reflected in current diagnostic measures. Patients/families can identify some breakdowns in the diagnostic process beyond the clinician’s view. Bell et al. developed a framework with patients/families to help organisations identify and categorise patient-reported diagnostic process-related breakdowns (PRDBs) to inform organisational learning. The framework describes 7 patient-reported breakdown categories (with 40 subcategories), 19 patient-identified contributing factors and 11 potential patient-reported impacts. Patients identified breakdowns in each step of the diagnostic process, including missing or inaccurate main concerns and symptoms; missing/outdated test results; and communication breakdowns such as not feeling heard or misalignment between patient and provider about symptoms, events, or their significance. The PRDB framework can help organisations identify and reliably categorise PRDBs, including some that are invisible to clinicians; guide interventions to engage patients and families as diagnostic partners; and inform whole organisational learning.
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Content ArticlePulmonary arterial hypertension (PAH) is a rare disease characterised by pulmonary vascular remodelling and elevated pulmonary pressure, which eventually leads to right heart failure and death. Registries worldwide have noted a female predominance of the disease, spurring particular interest in hormonal involvement in the disease pathobiology. Several experimental models have shown both protective and deleterious effects of oestrogens, suggesting that complex mechanisms participate in PAH pathogenesis. In fact, oestrogen metabolites as well as receptors and enzymes implicated in oestrogen signalling pathways and associated conditions such as BMPR2 mutation contribute to PAH penetrance more specifically in women. Conversely, females have better right ventricular function, translating to a better prognosis. Along with right ventricular adaptation, women tend to respond to PAH treatment differently from men. As some young women suffer from PAH, contraception is of particular importance, considering that pregnancy in patients with PAH is strongly discouraged due to high risk of death. When contraception measures fail, pregnant women need a multidisciplinary team-based approach. This article from Cheron et al. aims to review epidemiology, mechanisms underlying the higher female predominance, but better prognosis and the intricacies in management of women affected by PAH.
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Content ArticleCurrent UK health policy recommends the transition of maternity services towards provision of Midwifery Continuity of Carer (MCoCer) models. Quality of healthcare is correlated with the quality of leadership and management yet there is little evidence available to identify what is required from midwifery managers when implementing and sustaining MCoCer. Turner et al. developed a theoretical framework that represents midwifery managers’ experiences of implementing and sustaining MCoCer models within the UK’s National Health Service (NHS).
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Content ArticleHealthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. This study found from Maben et al. found, where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.
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Content ArticleThis article in Social Science and Medicine examines the role of patients in naming and defining Long Covid. Patients with the condition, many of whom had ‘mild’ illness initially, used different evidence and advocacy to demonstrate a longer, more complex course of illness than was laid out in initial reports from Wuhan.
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Content ArticleDebriefs (or After Action Reviews) are increasingly used in training and work environments as a means of learning from experience. Tannenbaum and Cerasoli assessed the efficacy of debriefs with a quantitative review and found organisations can improve individual and team performance by approximately 20% to 25% by using properly conducted debriefs.
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Content ArticleFailure to attend scheduled hospital appointments disrupts clinical management and consumes resource estimated at £1 billion annually in the UK NHS alone. Accurate stratification of absence risk can maximise the yield of preventative interventions. The wide multiplicity of potential causes, and the poor performance of systems based on simple, linear, low-dimensional models, suggests complex predictive models of attendance are needed. In this paper, Nelson et al. quantify the effect of using complex, non-linear, high-dimensional models enabled by machine learning.
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Content ArticleHigh Reliability Organisations (HRO), including healthcare and aviation, have a common focus on risk management. The human element is a ‘weak link’ which may result in accidents or adverse events taking place. Surgeons and other healthcare professionals can learn from aviation's rigorous approach to the role of human factors (HF) in such events, and how we can minimise them. Air Accident Investigation Branch (AAIB) reports show that fatal accidents are frequently caused by pilots flying outside their own personal limits, those of the aircraft or environment. Similarly, patient morbidity or mortality may occur if surgeons work outside personal their capability, with poor procedure selection and patient optimisation, or with a team or theatre environment not suited to the procedure. The authors of this study introduce the personal limitations checklist – a tool adapted from aviation that allows surgeons to define their limits in advance of any decision to operate, and develop critical self-reflection. It also allows management of patient expectations, shared decision making, and flattening of team hierarchy. The minimum skills, patient characteristics, team and theatre resources for any given procedure to proceed are defined. If the surgeon is ‘out of limits’, redressing these factors, seeking additional assistance, or thorough patient consenting may be required for the safe conduct of the procedure. The authors explore external pressures that could cause a surgeon to exceed both personal and organisational limits.
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Content ArticleThe COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or ‘layoff period’) can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of ‘currency’ may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.
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Content ArticleTargeting the analysis of socio-technical complexity, the System-Theoretic Accident Model and Processes (STAMP) was developed to engineer safer systems. Since its inception in the early 2000s, STAMP and its associated techniques, namely the System-Theoretic Process Analysis (STPA) and the Causal Analysis based on System Theory (CAST), have attracted increasing interest as suitable approaches for safety studies. Nonetheless, a literature review on their applications is lacking. This paper from Patriarca et al. fills this gap via a scoping literature survey on contributions indexed in academic journals and conference proceedings.
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Content ArticleThe composition and background of members of state medical boards, including public or citizen members, can impact the functionality and public perception of medical boards in the United States. This study from Doug Wojcieszak analysed the number of public members on each state medical board and their professional backgrounds or expertise to regulate the medical profession. The findings show that for nearly half of state medical boards public members comprise at least a quarter of their voting members; however, more than half of public members for all state medical boards have no measurable medical experience or background, including in patient safety. The need for public members to have medical expertise or background – especially in patient safety -- is discussed along with potential policy recommendations.
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Content Article
The architecture of safety: hospital design (2007)
Patient Safety Learning posted an article in Design for safety
This paper reviews recent research literature reporting the effects of hospital design on patient safety. -
Content ArticleIn 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
