This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety:
Past harm: this encompasses both psychological and physical measures
Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems
Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis
Anticipation and preparedness: the ability to anticipate
Here, Dr Sara Ryan questions whether inquiries or investigations are an effective way of holding stakeholders to account and discusses the need for more qualitative research to better understand bereaved family experiences of inquiries and investigations.
Political Quarterly (1).pdf
There are calls for greater use of ‘soft’ intelligence around quality and safety.
Little research examines the challenges and opportunities soft data present.
This study in the English NHS found clinicians and managers saw utility in soft data.
Dominant approaches to interpretation risked obscuring their greatest value.
Soft data might better be used to disrupt understanding and challenge consensus.
The authors conducted a qualitative interview study with 22 accident investigators from different domains in Sweden. They found a wide range of factors that led investigations away from the ideal, most which more resembled factors involved in organisational accidents, rather than reflecting flawed thinking.
One particular limitation of investigation was that many investigations stop the analysis at the level of “preventable causes”, the level where remedies that were currently practical to implement could be found. This could potentially limit the usefulness of using investigations to get
WHO's definition of an After Action Review and resources
Guidance for After Action Review
After Action Review infographic
3 minute video explaining the AAR practice as promoted by WHO, including the definition, the different methodologies and available resources.
After Action Reviews and simulation exercises
Darzi Alumni, Claire Cox , who was hosted by the Kent Sussex and Surrey Academic Health Science Network, summarises the barriers and assumptions held with in the system of learning from deaths and serious incidents.
1 deaths and serious incidents.pdf
There is an urgent need to respond to the challenges experienced by carers at the point of transition and beyond, by ensuring early and coordinated planning, effective information sharing and communication and clear transition processes and guidelines. A person‐centred and family‐centred approach is required to minimise negative impact on the health and well‐being of the young adult with intellectual disabilities and their carers.
A sequential qualitative method study was conducted and integrated with the quantitative study performed by Matos, Weits, and van Hunsel to complete a mixed method study.
The qualitative phase expands the understanding of the quantitative results from a previous study by broadening the knowledge on external barriers and internal barriers that patient organizations face when implementing PV activities. The strategies to stimulate patient-organisation participation are the creation of more awareness campaigns, more research that creates awareness, education for patient organisations, commun