Committed to Safety: Ten Case Studies on Reducing Harm to Patients

Presents case studies of healthcare organizations, clinical teams, and learning collaborations to illustrate successful innovations for improving patient safety nationwide. Includes actions taken, results achieved, lessons learned, and recommendations

Safer healthcare at home: Detecting, correcting and learning from incidents involving infusion devices

OBJECTIVE: Complex medical devices such as infusion pumps are increasingly being used in patients’ homes with little known about the impact on patient safety. Our aim was to better understand the risks to patient safety in this situation and how these risks might be minimised, by reference to incident reports. DESIGN: We identified 606 records of incidents associated with infusion devices that had occurred in a private home and were reported to the UK National Reporting and Learning Service (2005–2015 inclusive). We used thematic analysis to identify key themes. RESULTS: In this paper we focus on two emergent themes: detecting and diagnosing incidents; and locating the patient, lay caregivers and their family in incident reports. The majority of incidents were attributed to device malfunction, and resulted in the patient being under-dosed. Delays in recognising and responding to problems were identified, alongside challenges in identifying the cause. We propose a process model for fault diagnosis and correction. Patients and caregivers did not feature strongly in reports; we highlight how the device is in the home but of the care system, and propose an agent model to describe this; we also identify ways of mitigating this disjoint. CONCLUSION: Devices need to be appropriately tailored to the setting in which they are employed, and within a system of care that ensures they are used optimally and safely. Suggested features to improve patient safety include devices that can provide better feedback to identify problems and support resolution, alongside greater monitoring and technical support by care providers for both patients and frontline professionals. The proposed process and agent models provide a structure for reviewing safety and learning from incidents in home health care

The friends and family test : a qualitative study of concerns that influence the willingness of English National Health Service staff to recommend their organisation

Peer reviewedPublisher PD

Moving from a "human-as-problem" to a "human-as-solution" cybersecurity mindset

Cybersecurity has gained prominence, with a number of widely publicised security incidents, hacking attacks and data breaches reaching the news over the last few years. The escalation in the numbers of cyber incidents shows no sign of abating, and it seems appropriate to take a look at the way cybersecurity is conceptualised and to consider whether there is a need for a mindset change.To consider this question, we applied a "problematization" approach to assess current conceptualisations of the cybersecurity problem by government, industry and hackers. Our analysis revealed that individual human actors, in a variety of roles, are generally considered to be "a problem". We also discovered that deployed solutions primarily focus on preventing adverse events by building resistance: i.e. implementing new security layers and policies that control humans and constrain their problematic behaviours. In essence, this treats all humans in the system as if they might well be malicious actors, and the solutions are designed to prevent their ill-advised behaviours. Given the continuing incidences of data breaches and successful hacks, it seems wise to rethink the status quo approach, which we refer to as "Cybersecurity, Currently". In particular, we suggest that there is a need to reconsider the core assumptions and characterisations of the well-intentioned human's role in the cybersecurity socio-technical system. Treating everyone as a problem does not seem to work, given the current cyber security landscape.Benefiting from research in other fields, we propose a new mindset i.e. "Cybersecurity, Differently". This approach rests on recognition of the fact that the problem is actually the high complexity, interconnectedness and emergent qualities of socio-technical systems. The "differently" mindset acknowledges the well-intentioned human's ability to be an important contributor to organisational cybersecurity, as well as their potential to be "part of the solution" rather than "the problem". In essence, this new approach initially treats all humans in the system as if they are well-intentioned. The focus is on enhancing factors that contribute to positive outcomes and resilience. We conclude by proposing a set of key principles and, with the help of a prototypical fictional organisation, consider how this mindset could enhance and improve cybersecurity across the socio-technical system

Alcohol, assault and licensed premises in inner-city areas

This report contains eight linked feasibility studies conducted in Cairns during 2010. These exploratory studies examine the complex challenges of compiling and sharing information about incidents of person-to-person violence in a late night entertainment precinct (LNEP). The challenges were methodological as well as logistical and ethical. The studies look at how information can be usefully shared, while preserving the confidentiality of those involved. They also examine how information can be compiled from routinely collected sources with little or no additional resources, and then shared by the agencies that are providing and using the information.Although the studies are linked, they are also stand-alone and so can be published in peer-reviewed literature. Some have already been published, or are ‘in press’ or have been submitted for review. Others require the NDLERF board’s permission to be published as they include data related more directly to policing, or they include information provided by police.The studies are incorporated into the document under section headings. In each section, they are introduced and then presented in their final draft form. The final published form of each paper, however, is likely to be different from the draft because of journal and reviewer requirements. The content, results and implications of each study are discussed in summaries included in each section.Funded by the National Drug Law Enforcement Research Fund, an initiative of the National Drug StrategyAlan R Clough (PhD) School of Public Health, Tropical Medicine and Rehabilitation Sciences James Cook UniversityCharmaine S Hayes-Jonkers (BPsy, BSocSci (Hon1)) James Cook University, Cairns.Edward S Pointing (BPsych) James Cook University, Cairns

Discovering new kinds of patient safety incidents

Every year, large numbers of patients in National Health Service (NHS) care suffer because of a patient safety incident. The National Patient Safety Agency (NPSA) collects large amounts of data describing individual incidents. As well as being described by categorical and numerical variables, each incident is described using free text. The aim of the work was to find quite small groups of similar incidents, which were of types that were previously unknown to the NPSA. A model of the text was produced, such that the position of each incident reflected its meaning to the greatest extent possible. The basic model was the vector space model. Dimensionality reduction was carried out in two stages: unsupervised dimensionality reduction was carried out using principal component analysis, and supervised dimensionality reduction using linear discriminant analysis. It was then possible to look for groups of incidents that were more tightly packed than would be expected given the overall distribution of the incidents. The process for assessing these groups had three stages. Firstly, a quantitative measure was used, allowing a large number of parameter combinations to be examined. The groups found for an ‘optimum’ parameter combination were then divided into categories using a qualitative filtering method. Finally, clinical experts assessed the groups qualitatively. The transition probabilities model was also examined: this model was based on the empirical probabilities that two word sequences were seen in the text. An alternative method for dimensionality reduction was to use information about the subjective meaning of a small sample of incidents elicited from experts, producing a mapping between high and low dimensional models of the text. The analysis also included the direct use of the categorical variables to model the incidents, and empirical analysis of the behaviour of high dimensional spaces

Can the Heinrich ratio be used to predict harm from medication errors?

The purpose of this study was to establish whether, for medication errors, there exists a fixed Heinrich ratio between the number of incidents which did not result in harm, the number that caused minor harm, and the number that caused serious harm. If this were the case then it would be very useful in estimating any changes in harm following an intervention. Serious harm resulting from medication errors is relatively rare, so it can take a great deal of time and resource to detect a significant change. If the Heinrich ratio exists for medication errors, then it would be possible, and far easier, to measure the much more frequent number of incidents that did not result in harm and the extent to which they changed following an intervention; any reduction in harm could be extrapolated from this

Administrative Compensation for Medical Injuries: Lessons From Three Foreign Systems

Examines "no-fault" systems in New Zealand, Sweden, and Denmark, in which patients injured by medical negligence can file for compensation through governmental or private adjudicating organizations. Considers lessons for U.S. medical malpractice reform

Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents' characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.; Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.; We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled "active failure" within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.; This review of studies from hospital-based CIRS provides an overview of reported CIs' contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner