Examining the application of STAMP in the analysis of patient safety incidents

This thesis examines the application of Systems-Theoretic Accident Model and Processes (STAMP) in healthcare and the analysis of patient safety incidents. Healthcare organisations have a responsibility for the safety of the patients they are treating. This includes the avoidance of unintended or unexpected harm to people during the provision of care. Patient safety incidents, that is adverse events where patients are harmed, are investigated and analysed as accidents are in other safety-critical industries, to gain an understanding of failure and to generate recommendations to prevent similar incidents occurring in the future. However, there is some dissatisfaction with the current quality of incident analysis in healthcare. There is dissatisfaction with the recommendations that are generated from healthcare incident analysis which are felt to produce weak and ineffective remedial actions, often including retraining of individuals and small policy change. Issues with current practice have been linked to the use of Root Cause Analysis (RCA), an analysis method that often results in the understanding of an accident as being the result of a linear chain of events. This type of simple linear approach has been the target of criticism in safety science research and is not felt to be effective in the analysis of incidents in complex systems, such as healthcare. Research in accident analysis methods has developed from a focus on technical failure and individual human actions to consideration of the interactions between people, technology and the organisation. Accident analysis methods have been developed that guide investigations to consideration of the whole system and interactions between system components. These system approaches are judged to be superior to simple linear approaches by the research community, however, they are not currently used in healthcare incident investigation practice. The systems approach of STAMP is felt to be a promising method for the improvement of healthcare incident analysis. STAMP strongly embodies the concepts of systems theory and analyses human decision-making. The application of STAMP in healthcare was investigated through three case studies, which applied STAMP in: 1. The analysis of the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005-2009. 2. The analysis of a common small-scale hospital-based medication prescription error. 3. The analysis of patient suicide in the community-based services of a Mental Health Trust. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP and discussion of the STAMP applications against criteria for accident analysis models and methods. Healthcare stakeholders were generally positive about the utility of STAMP, finding it to provide a system view and guide consideration of interactions between system components. They also felt it would help them generate recommendations and were positive about the future application of STAMP in healthcare. However, many felt it to be a complicated method that would need specialist expertise to apply. The STAMP applications demonstrated the ability of STAMP to consider the whole system and guide an analysis to the generation of recommendations for system measures to prevent future incidents. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare. The research also discusses the other factors that influence incident analysis beyond that of the analytical approach used and how these need to be considered to maximise the effectiveness of STAMP

The evaluation of medical devices with healthy people?

Much of the research of thermal and physical comfort is completed with healthy participants in regular life scenarios. The translation of these findings into clinical settings for people with disease, deficiency or restrictions adds a level of complexity. As an example this study evaluated the effectiveness of a patient warming mattress device on body temperature and ratings of thermal comfort/sensation. Hypothermia has been linked to higher mortality rates in trauma patients admitted to hospital. Patient warming devices have been developed to assist the temperature of the patient and studies on these report varied effects. Laboratory trials with shivering inhibition (Goheen et al, 1997, Greif et al, 2000) found improvements from forced air and resistive blankets but without shivering inhibition (Williams et al, 2005) showed no benefit in warming from 35°C. A physical evaluation of the warming mattress device with a thermal manikin reported an energy contribution to the user (~70W). To support the physical evaluation a user trial was conducted. Nine healthy volunteer participants (27.78+4.99 Years) were exposed to three conditions using a repeated measures counterbalanced design. The participants were cooled in an environment with an air temperature of 0°C (60 minutes) then exposed to 30 minutes of a warming intervention. 1.Hot mattress HM. Mattress preheated to 18°C, under standard blankets 2.Warmed mattress WM. Mattress turned on at start of warming period, under standard blankets 3.Cold mattress CM. Control condition, no power to mattress, under standard blankets. During the cooling phase, aural and mean skin temperature (Tsk) significantly decreased for all conditions (p<0.01). Tsk increased following each warming intervention but aural temperature continued to decline. Significant increase in overall mean thermal comfort was seen during the first ten minutes of the warming phase for HM in comparison to CM and WM (p<0.05) but not at 20 and 30 minutes. This was mirrored by the overall mean thermal sensation rating across the same timeframe. HM increased thermal sensation from very cold to cool with CM and WM showing and increase from very cold to cold. This study revealed the effect of the device (HM) gave short term comfort and sensation gains at the start of the warming phase but the passive insulation provided (CM) also allowed re-warming to occur. This was the expected thermoregulatory response for a group of healthy participants. This group does not necessarily represent the hospital population with pathology that inhibits their normal responses to cold, e.g. circulatory shut-down, shock or trauma. For accurate application, the trial data needs to be closely matched with the limitations of the health condition in the target population. The challenge is now to explore the relationship between data from healthy cohorts and how that can be used for groups of patients with known physical and physiological conditions and limitations. The validity of a patient’s subjective assessment of their condition lying in a hospital bed is currently unclear. Evidence needs to show whether a patient in a hospital bed can accurately report joint position, thermal comfort, skin wettedness, pressure points etc to assist in the management of their condition

Towards effective and efficient participatory systems approaches to healthcare work system design

Context: The study is focused on patient and public involvement in the regional service development process in one county in the UK, with a wider scope provided through review of literature. Objectives: The research has two main objectives: firstly to investigate the current state of service user and staff participation in the regional health service development process in the UK; and secondly to critically analyse the level of participation and systems awareness in the participatory methods used. Methodology: A single case descriptive case study is used alongside a scoping review of relevant literature that follows a systematic approach. Main results: The case study explored a complex service development process with the main findings being: i) varied levels of collaboration between multiple organisations of commissioners, providers and user representatives; ii) incomplete information loops with an unclear structure of information flow from service user/staff into the development process and a lack of feedback on changes made to service users; iii) difficulties in representing the views of a diverse population of service users, compounded by some single issue focus amongst service development participants; iv) an engagement gap with staff for service development events. The literature review uncovered practical issues in the application of participatory approaches and a lack of application of systems methods and models in the most widely used participatory approaches. Conclusion: The review of literature and description of practice found a gap between the practical application of participatory approaches in healthcare system design and theory on systems approaches to healthcare. We propose it would be beneficial to bridge the gap between structured systems approaches to healthcare system design and the current efforts of participatory design occurring in practice

Examining the application of STAMP in the analysis of patient safety incidents

This thesis examines the application of Systems-Theoretic Accident Model and Processes (STAMP) in healthcare and the analysis of patient safety incidents. Healthcare organisations have a responsibility for the safety of the patients they are treating. This includes the avoidance of unintended or unexpected harm to people during the provision of care. Patient safety incidents, that is adverse events where patients are harmed, are investigated and analysed as accidents are in other safety-critical industries, to gain an understanding of failure and to generate recommendations to prevent similar incidents occurring in the future. However, there is some dissatisfaction with the current quality of incident analysis in healthcare. There is dissatisfaction with the recommendations that are generated from healthcare incident analysis which are felt to produce weak and ineffective remedial actions, often including retraining of individuals and small policy change. Issues with current practice have been linked to the use of Root Cause Analysis (RCA), an analysis method that often results in the understanding of an accident as being the result of a linear chain of events. This type of simple linear approach has been the target of criticism in safety science research and is not felt to be effective in the analysis of incidents in complex systems, such as healthcare. Research in accident analysis methods has developed from a focus on technical failure and individual human actions to consideration of the interactions between people, technology and the organisation. Accident analysis methods have been developed that guide investigations to consideration of the whole system and interactions between system components. These system approaches are judged to be superior to simple linear approaches by the research community, however, they are not currently used in healthcare incident investigation practice. The systems approach of STAMP is felt to be a promising method for the improvement of healthcare incident analysis. STAMP strongly embodies the concepts of systems theory and analyses human decision-making. The application of STAMP in healthcare was investigated through three case studies, which applied STAMP in: 1. The analysis of the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005-2009. 2. The analysis of a common small-scale hospital-based medication prescription error. 3. The analysis of patient suicide in the community-based services of a Mental Health Trust. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP and discussion of the STAMP applications against criteria for accident analysis models and methods. Healthcare stakeholders were generally positive about the utility of STAMP, finding it to provide a system view and guide consideration of interactions between system components. They also felt it would help them generate recommendations and were positive about the future application of STAMP in healthcare. However, many felt it to be a complicated method that would need specialist expertise to apply. The STAMP applications demonstrated the ability of STAMP to consider the whole system and guide an analysis to the generation of recommendations for system measures to prevent future incidents. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare. The research also discusses the other factors that influence incident analysis beyond that of the analytical approach used and how these need to be considered to maximise the effectiveness of STAMP

The evaluation of medical devices with healthy people?

Much of the research of thermal and physical comfort is completed with healthy participants in regular life scenarios. The translation of these findings into clinical settings for people with disease, deficiency or restrictions adds a level of complexity. As an example this study evaluated the effectiveness of a patient warming mattress device on body temperature and ratings of thermal comfort/sensation. Hypothermia has been linked to higher mortality rates in trauma patients admitted to hospital. Patient warming devices have been developed to assist the temperature of the patient and studies on these report varied effects. Laboratory trials with shivering inhibition (Goheen et al, 1997, Greif et al, 2000) found improvements from forced air and resistive blankets but without shivering inhibition (Williams et al, 2005) showed no benefit in warming from 35°C. A physical evaluation of the warming mattress device with a thermal manikin reported an energy contribution to the user (~70W). To support the physical evaluation a user trial was conducted. Nine healthy volunteer participants (27.78+4.99 Years) were exposed to three conditions using a repeated measures counterbalanced design. The participants were cooled in an environment with an air temperature of 0°C (60 minutes) then exposed to 30 minutes of a warming intervention. 1.Hot mattress HM. Mattress preheated to 18°C, under standard blankets 2.Warmed mattress WM. Mattress turned on at start of warming period, under standard blankets 3.Cold mattress CM. Control condition, no power to mattress, under standard blankets. During the cooling phase, aural and mean skin temperature (Tsk) significantly decreased for all conditions (p<0.01). Tsk increased following each warming intervention but aural temperature continued to decline. Significant increase in overall mean thermal comfort was seen during the first ten minutes of the warming phase for HM in comparison to CM and WM (p<0.05) but not at 20 and 30 minutes. This was mirrored by the overall mean thermal sensation rating across the same timeframe. HM increased thermal sensation from very cold to cool with CM and WM showing and increase from very cold to cold. This study revealed the effect of the device (HM) gave short term comfort and sensation gains at the start of the warming phase but the passive insulation provided (CM) also allowed re-warming to occur. This was the expected thermoregulatory response for a group of healthy participants. This group does not necessarily represent the hospital population with pathology that inhibits their normal responses to cold, e.g. circulatory shut-down, shock or trauma. For accurate application, the trial data needs to be closely matched with the limitations of the health condition in the target population. The challenge is now to explore the relationship between data from healthy cohorts and how that can be used for groups of patients with known physical and physiological conditions and limitations. The validity of a patient’s subjective assessment of their condition lying in a hospital bed is currently unclear. Evidence needs to show whether a patient in a hospital bed can accurately report joint position, thermal comfort, skin wettedness, pressure points etc to assist in the management of their condition

Towards effective and efficient participatory systems approaches to healthcare work system design

Context: The study is focused on patient and public involvement in the regional service development process in one county in the UK, with a wider scope provided through review of literature. Objectives: The research has two main objectives: firstly to investigate the current state of service user and staff participation in the regional health service development process in the UK; and secondly to critically analyse the level of participation and systems awareness in the participatory methods used. Methodology: A single case descriptive case study is used alongside a scoping review of relevant literature that follows a systematic approach. Main results: The case study explored a complex service development process with the main findings being: i) varied levels of collaboration between multiple organisations of commissioners, providers and user representatives; ii) incomplete information loops with an unclear structure of information flow from service user/staff into the development process and a lack of feedback on changes made to service users; iii) difficulties in representing the views of a diverse population of service users, compounded by some single issue focus amongst service development participants; iv) an engagement gap with staff for service development events. The literature review uncovered practical issues in the application of participatory approaches and a lack of application of systems methods and models in the most widely used participatory approaches. Conclusion: The review of literature and description of practice found a gap between the practical application of participatory approaches in healthcare system design and theory on systems approaches to healthcare. We propose it would be beneficial to bridge the gap between structured systems approaches to healthcare system design and the current efforts of participatory design occurring in practice