Understanding safety in healthcare: the system evolution, erosion and enhancement model

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety

A qualitative study of patient involvement in medicines management after hospital discharge: an under-recognised source of systems resilience

YesIntroduction: There are risks to the safety of medicines management when patient care is transferred between healthcare organisations, for example when a patient is discharged from hospital. Using the theoretical concept of resilience in healthcare, this study aimed to better understand the proactive role that patients can play in creating a safer, resilient medicines management at a common transition of care. Methods: Qualitative interviews with 60 cardiology patients six weeks after their discharge from two UK hospitals explored patients’ experiences with their discharge medicines. Data were initially subjected to an inductive thematic analysis and a subsequent theory-guided deductive analysis. Results: During interviews twenty-three patients described medicines management resilience strategies in two main themes: identifying system vulnerabilities; and establishing self-management strategies. Patients could anticipate problems in the system that supplied them with medicines and took specific actions to prevent them. They also identified when errors had occurred both before and after medicines had been supplied and took corrective action to avoid harm. Some reported how they had not foreseen problems or experienced patient safety incidents. Patients recounted how they ensured information about medicines changes was correctly communicated and acted upon, and identified their strategies to enhance their own reliability in adherence and resource management. Conclusion: Patients experience the impact of vulnerabilities in the medicines management system across the secondary-primary care transition but many are able to enhance system resilience through developing strategies to reduce the risk of medicines errors occurring. Consequently, there are opportunities – with caveats – to elicit, develop and formalise patients’ capabilities which would contribute to safer patient care and more effective medicines management

Listening and question-asking behaviors in resident and nurse handoff conversations: A prospective observational study

OBJECTIVE: To characterize interactivity during resident and nurse handoffs by investigating listening and question-asking behaviors during conversations. MATERIALS AND METHODS: Resident (n = 149) and nurse (n = 126) handoffs in an inpatient medicine unit were audio-recorded. Handoffs were coded based on listening behaviors (active and passive), question types (patient status, coordination of care, clinical reasoning, and framing and alignment), and question responses. Comparisons between residents and nurses for listening and question-asking behaviors were performed using the Wilcoxon rank-sum tests. A Poisson regression model was used to investigate differences in the question-asking behaviors between residents and nurses, and the association between listening and question-asking behaviors. RESULTS: There were no significant differences between residents and nurses in their active (18% resident vs 39% nurse handoffs) or passive (88% resident vs 81% nurse handoffs) listening behaviors. Question-asking was common in resident and nurse handoffs (87% vs 98%) and focused primarily on patient status, co-ordination, and framing and alignment. Nurses asked significantly more questions than residents (Mresident = 2.06 and Mnurse = 5.52) by a factor of 1.76 (P \u3c 0.001). Unit increase in listening behaviors was associated with an increase in the number of questions during resident and nurse handoffs by 7% and 12%, respectively. DISCUSSION AND CONCLUSION: As suggested by the Joint Commission, question-asking behaviors were common across resident and nurse handoffs, playing a critical role in supporting resilience in communication and collaborative cross-checks during conversations. The role of listening in initiating question-asking behaviors is discussed

Medication Safety in Emergency Medical Services: Approaching an Evidence-Based Method of Verification to Reduce Errors

Lack of verification is often cited as a root cause of medication errors; however, medication errors occur in spite of conventional verification practices and it appears that human factors engineering (HFE) can inform the design of a more effective method. To this end, an HFE-driven process was designed and implemented in an urban, Midwestern emergency medical service agency. Medication error data were collected over a 54-month period, 27 months before and after implementation. A decrease in the average monthly error rate was realized for all medications administered (49.0%) during the post-intervention time period. The average monthly error rate for fentanyl, a commonly administered analgesic, demonstrated a 71.1% error rate decrease. This study is the first to evaluate the effectiveness of a team-based cross-check process for medication verification to prevent errors in the prehospital setting

Podsticanje rezilijentnosti preduzeća u Srbiji

U globalnom svetu u kome živimo, poslovno okruženje je u tesnoj vezi sa različitim jezicima i kulturama. Usled toga, poslovni rizik prelazi lokalne i regionalne granice, što dovodi do njegovog deljenja među firmama u globalnom okruženju. Otpornost se može posmatrati ne samo sa aspekta zajednice, već i sa aspekta organizacije. U ovoj studiji, autor istražuje samo organizacione aspekte otpornosti. Cilj ovih istraživanja je da se ukaže na značaj potrebe za poboljšanjem otpornosti i utvrđivanje mogucnosti za njegovim ostvarenjem. Kvalitativne metode ́ , kao i obimna literatura, predstavljaju teorijski okvir istraživanja. Nalazi naše studije pokazali su da su jak sistem motivacije koji može da pokrene pojedinca da uči, napreduje i da se prilagodi svojoj okolini, kao i fleksibilnost organizacije najefikasniji načini za unapređivanje rezilijentnosti malih i srednjih preduzeca

Strengthening the resilience of small and medium-sized enterprises

In the global world, we live in, business environment is interdependent and increasingly diverse speaking of culture. Therefore, operational risks exceed local and regional limits, which results in the risk which is shared by companies in global environment. However, not only can resilience be observed from the aspect of community, but also from the aspect of organization. In this study, authors research only organizational aspects of resilience. The goal of these researches is to indicate the significance of the need for improving resilience and determining possibilities for its achievement. Qualitative methods, as well as the extensive literature being a theoretical research frame have been used for this purpose

On the rationale of resilience in the domain of safety: A literature review

Resilience is becoming a prevalent agenda in safety research and organisational practice. In this study we examine how the peer-reviewed safety science literature (a) formulates the rationale behind the study of resilience; (b) constructs resilience as a scientific object; and (c) constructs and locates the resilient subject. The results suggest that resilience engineering scholars typically motivate the need for their studies by referring to the inherent complexities of modern socio-technical systems; complexities that make these systems inherently risky. The object of resilience then becomes the capacity to adapt to such emerging risks in order to guarantee the success of the inherently risky system. In the material reviewed, the subject of resilience is typically the individual, either at the sharp end or at higher managerial levels. The individual is called-upon to adapt in the face of risk to secure the continuous performance of the system. Based on the results from how resilience has been introduced in safety sciences we raise three ethical questions for the field to address: (1) should resilience be seen as people thriving despite of, or because of, risk?; (2) should resilience theory form a basis for moral judgement?; and finally (3) how much should resilience be approached as a trait of the individual

A Human Reliability-Centered Approach to the Development of Job Aids for Reviewers of Medical Devices That Use Radiological Byproduct Materials.

The U.S. Nuclear Regulatory Commission (NRC) is engaged in an initiative to risk-inform the regulation of byproduct materials. Operating experience indicates that human actions play a dominant role in most of the activities involving byproduct materials, which are radioactive materials other than those used in nuclear power plants or in weapons production, primarily for medical or industrial purposes. The overall risk of these activities is strongly influenced by human performance. Hence, an improved understanding of human error, its causes and contexts, and human reliability analysis (HRA) is important in risk-informing the regulation of these activities. The development of the human performance job aids was undertaken by stages, with frequent interaction with the prospective users. First, potentially risk significant human actions were identified based on reviews of available risk studies for byproduct material applications and of descriptions of events for byproduct materials applications that involved potentially significant human actions. Applications from the medical and the industrial domains were sampled. Next, the specific needs of the expected users of the human performance-related capabilities were determined. To do this, NRC headquarters and region staff were interviewed to identify the types of activities (e.g., license reviews, inspections, event assessments) that need HRA support and the form in which such support might best be offered. Because the range of byproduct uses regulated by NRC is so broad, it was decided that initial development of knowledge and tools would be undertaken in the context of a specific use of byproduct material, which was selected in consultation with NRC staff. Based on needs of NRC staff and the human performance related characteristics of the context chosen, knowledge resources were then compiled to support consideration of human performance issues related to the regulation of byproduct materials. Finally, with information sources and an application context identified, a set of strawman job aids was developed, which was then presented to prospective users for critique and comment. Work is currently under way to develop training materials and refine the job aids in preparation for a pilot evaluation