Despite the term ‘never events’ these events continue to happen in the NHS. This paper considers ... more Despite the term ‘never events’ these events continue to happen in the NHS. This paper considers the findings from a review of the causes of nine surgical ‘never events'; looking at the learning from the investigations to provide ‘a window on the system’ and considering the multiple issues that need to be addressed to reduce future risk. The paper discusses why many of the causes described in investigation reports cannot be adequately addressed by the action plans that target each individual cause — things are never that simple — instead the causes should be seen as a reflection of the current state of safety within an organization, showing the underlying cultural and systems issues that need to be addressed at a wider level than that of the incident itself.
Adverse event-an unintended injury caused by medical management rather than the disease process. ... more Adverse event-an unintended injury caused by medical management rather than the disease process. Reliability-the probability that a system will function correctly and, as a result, the chance that evidence based care will be provided. Failure rate-the inverse of reliability-so a 15% failure rate represents 85% reliability. Standardisation-establishing a process which always functions in the same way, with no variation. Study sites and topics is research had NHS ethics approval. Seven NHS organisations were studied and we collected data from three erent organisations for each topic.
Background: In Britain over 39,000 reports were received by the National Patient Safety Agency re... more Background: In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK. Studies in primary care in the USA have found 13.6 % of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8 % of medical errors were found to be due to the unavailability of clinical information. Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinici...
Background Patient safety is concerned with preventable harm in healthcare, a subject that became... more Background Patient safety is concerned with preventable harm in healthcare, a subject that became a focus for study in the UK in the late 1990s. How to improve patient safety, presented both a practical and a research challenge in the early 2000s, leading to the eleven publications presented in this thesis. Research question The overarching research question was: What are the key organisational and systems factors that impact on patient safety, and how can these best be researched? Methods Research was conducted in over 40 acute care organisations in the UK and Europe between 2006 and 2013. The approaches included surveys, interviews, documentary analysis and non-participant observation. Two studies were longitudinal. Results The findings reveal the nature and extent of poor systems reliability and its effect on patient safety; the factors underpinning cases of patient harm; the cultural issues impacting on safety and quality; and the importance of a common language for quality and ...
International Journal for Quality in Health Care, 2019
Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic ... more Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy. Design: The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide. Setting: The research was carried out in two hospitals in each of five European countries. Participants: In total, 389 interviews with healthcare practitioners and 803 hours of observations. Intervention: None. Main outcome measure: None. Results: The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper.
In this book I have combined my grandfather's memoirs of the First World War with the history... more In this book I have combined my grandfather's memoirs of the First World War with the history of the war in the regions where he fought. He took part in the landings on Gallipoli, then went to Greece, Libya, Egypt, Mesopotamia (Iraq), with Lawrence of Arabia, Palestine and finally was on the Somme when the Armistice was declared. The reviews have been great including 'echoes of War Horse, only a true story' and 'a vivid story where the intensley personal animates the bigger history'
Aims To investigate perceived factors relating to the reliable application of four clinical care ... more Aims To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). Methods Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. Results Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. Conclusions Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data.
Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical... more Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery (t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care (t =-2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact.
Journal of health services research & policy, 2012
To explore health care professionals' experiences and perceptions of Failure Mode and Effect... more To explore health care professionals' experiences and perceptions of Failure Mode and Effects Analysis (FMEA), a team-based, prospective risk analysis technique.
... 2008). Reports have also described the im-portant factors in implementing WalkRoundsTM and th... more ... 2008). Reports have also described the im-portant factors in implementing WalkRoundsTM and the outcomes where leaders have resolved the safety concerns of staff (Pronovost et al, 2004; Feitelberg, 2006; Zimmerman, 2008). ...
Despite the term ‘never events’ these events continue to happen in the NHS. This paper considers ... more Despite the term ‘never events’ these events continue to happen in the NHS. This paper considers the findings from a review of the causes of nine surgical ‘never events'; looking at the learning from the investigations to provide ‘a window on the system’ and considering the multiple issues that need to be addressed to reduce future risk. The paper discusses why many of the causes described in investigation reports cannot be adequately addressed by the action plans that target each individual cause — things are never that simple — instead the causes should be seen as a reflection of the current state of safety within an organization, showing the underlying cultural and systems issues that need to be addressed at a wider level than that of the incident itself.
Adverse event-an unintended injury caused by medical management rather than the disease process. ... more Adverse event-an unintended injury caused by medical management rather than the disease process. Reliability-the probability that a system will function correctly and, as a result, the chance that evidence based care will be provided. Failure rate-the inverse of reliability-so a 15% failure rate represents 85% reliability. Standardisation-establishing a process which always functions in the same way, with no variation. Study sites and topics is research had NHS ethics approval. Seven NHS organisations were studied and we collected data from three erent organisations for each topic.
Background: In Britain over 39,000 reports were received by the National Patient Safety Agency re... more Background: In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK. Studies in primary care in the USA have found 13.6 % of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8 % of medical errors were found to be due to the unavailability of clinical information. Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinici...
Background Patient safety is concerned with preventable harm in healthcare, a subject that became... more Background Patient safety is concerned with preventable harm in healthcare, a subject that became a focus for study in the UK in the late 1990s. How to improve patient safety, presented both a practical and a research challenge in the early 2000s, leading to the eleven publications presented in this thesis. Research question The overarching research question was: What are the key organisational and systems factors that impact on patient safety, and how can these best be researched? Methods Research was conducted in over 40 acute care organisations in the UK and Europe between 2006 and 2013. The approaches included surveys, interviews, documentary analysis and non-participant observation. Two studies were longitudinal. Results The findings reveal the nature and extent of poor systems reliability and its effect on patient safety; the factors underpinning cases of patient harm; the cultural issues impacting on safety and quality; and the importance of a common language for quality and ...
International Journal for Quality in Health Care, 2019
Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic ... more Objective: The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy. Design: The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide. Setting: The research was carried out in two hospitals in each of five European countries. Participants: In total, 389 interviews with healthcare practitioners and 803 hours of observations. Intervention: None. Main outcome measure: None. Results: The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper.
In this book I have combined my grandfather's memoirs of the First World War with the history... more In this book I have combined my grandfather's memoirs of the First World War with the history of the war in the regions where he fought. He took part in the landings on Gallipoli, then went to Greece, Libya, Egypt, Mesopotamia (Iraq), with Lawrence of Arabia, Palestine and finally was on the Somme when the Armistice was declared. The reviews have been great including 'echoes of War Horse, only a true story' and 'a vivid story where the intensley personal animates the bigger history'
Aims To investigate perceived factors relating to the reliable application of four clinical care ... more Aims To investigate perceived factors relating to the reliable application of four clinical care practices targeting ventilator-associated pneumonias, in the context of a patient safety improvement initiative called the Safer Patients Initiative (SPI). Methods Qualitative case study. Seventeen semi-structured individual interviews with clinical operational leads, programme coordinators and executive managers who were involved in the implementation of the programme's critical care work stream during its pilot phase. The interviews had a focus on perceived aspects pertaining to the reliable implementation of the four clinical practices, promoted by the Institute for Healthcare Improvement as the 'ventilator care bundle'. Results Thematic analysis of the verbatim transcripts revealed three overarching themes experienced by the participants during the implementation of the clinical practices included in the SPI ventilator care bundle: the power of measurement, feedback to peers and experts and improvement tools specific to SPI. Consistent measurement of compliance with the four elements of the bundle and outcomes made the staff realize that their engagement in previous improvement work for ventilated patients was inadequate and motivated them to apply the introduced clinical practices more reliably. Feedback to experts and peers of staff compliance with the four clinical practices and outcome improvement was perceived as a very influential aspect of SPI. Small tests of change (Plan-Do-Study-Act cycles), teaching sessions and daily goal sheets were quoted as particularly useful tools throughout the implementation of the four clinical care practices. Conclusions Future initiatives that aim to improve the adherence of clinical staff with clinical practice guidelines in intensive care units could benefit from integrating in their methodology consistent measurement and feedback practices of both process compliance and outcome data.
Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical... more Rationale, aims and objectives Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). Method A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Results Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery (t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care (t =-2.454, P = 0.014). Conclusion This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact.
Journal of health services research & policy, 2012
To explore health care professionals' experiences and perceptions of Failure Mode and Effect... more To explore health care professionals' experiences and perceptions of Failure Mode and Effects Analysis (FMEA), a team-based, prospective risk analysis technique.
... 2008). Reports have also described the im-portant factors in implementing WalkRoundsTM and th... more ... 2008). Reports have also described the im-portant factors in implementing WalkRoundsTM and the outcomes where leaders have resolved the safety concerns of staff (Pronovost et al, 2004; Feitelberg, 2006; Zimmerman, 2008). ...
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