The Rise of Patient Safety-II: Should We Give Up Hope on Safety-I and Extracting Value From Patient Safety Incidents?:Comment on “False Dawns and New Horizons in Patient Safety Research and Practice”

Who could disagree with the seemingly common-sense reasoning that: “We must learn from the things that go wrong.”? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some researchers to argue that there is more to be gained by learning from the majority of healthcare episodes: the things that go right. Based on this premise, socalled Safety-II has emerged as a new paradigm. In this commentary, we consider the ongoing value of Safety-I based approaches and explore whether now is the time to abandon learning from “the bad” and re-energise data collection and analysis by focusing on “the good.

Generating learning from patient safety incident reports from general practice

Internationally, there is an emerging interest in the inadvertent harm caused to patients by the provision of healthcare services. Since the publication of the Institute of Medicine’s report, To Err is Human, in 1999, research and policy directives have predominantly focused on patient safety in hospital settings. More recently, the World Health Organization has highlighted 2-3% of primary care encounters result in a patient safety incident. Given around 330 million general practice consultations occur in the UK each year, unsafe primary care is a poorly understood, major threat to public health. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. Over 40,000 incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been to generate learning from the largely unstructured, free-text descriptions of incidents. My thesis describes the empirical development and application of methods to classify (structure) incident report data. This includes the development of coding frameworks specific to primary care, aligned to the WHO International Classification for Patient Safety, to describe the incident, contributory factors and incident outcomes. I have developed a mixed-methods approach which combines a structured process for coding reports and an exploratory data analysis with subsequent thematic analysis. Analyses of reports can generate hypotheses about priorities for systems improvement in primary care at a local and national level. Existing interventions or initiatives to minimise or mitigate patient safety risks can be identified through scoping reviews. Future research and quality improvement activities should deepen understanding about the risks to patients, and generate knowledge about how interventions made in practice can improve safety

Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners.

The purpose of this guide is to: • maximise opportunities to learn from patient safety incidents in your practice, and to share learning via organisational or national reporting systems; and, • outline a process for learning from patient safety incidents in your practice

Continuous, risk-based, consultation peer review in out-of-hours general practice:a qualitative interview study of the benefits and limitations

Background: Systems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practice to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care. Aim: To evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK. Design and setting: A qualitative interview study in South-West England. Method: Semi-structured interviews with intervention users (clinicians, peer-reviewers and clinical management), analysed by inductive thematic analysis and integrated into a programme theory. Results: 20 clinicians were interviewed between September 2018 - January 2019. Interviewees indicated the intervention supported clinician learning through improved peer-feedback; highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence; supporting standardisation of supervision, clinical governance and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation and organisational learning culture influenced the perception of the intervention as a support or stressor. Conclusion: Our findings demonstrate the potential of this methodology to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practice to their full potential. Our programme theory provides a theoretical basis to maximise its benefits and accommodate its potential limitations

Empowering junior doctors: a qualitative study of a QI programme in South West England

Aim To explore how the South-West Foundation Doctor Quality Improvement programme affected foundation year 1 (F1) doctors’ attitudes and ability to implement change in healthcare. Methods Twenty-two qualitative interviews were carried out with two cohorts of doctors. The first F1 group before and after their participation in the QI programme; the second group comprised those who had completed the programme between 1 and 5 years earlier. Qualitative data were analysed using thematic analysis techniques. Results Prior to taking part in the QI programme, junior doctors’ attitudes towards QI were mixed. Although there was agreement on the importance of QI in terms of patient safety, not all shared enthusiasm for engaging in QI, while some were sceptical that they could bring about any change. Following participation in the programme, attitudes towards QI and the ability to effect change were significantly transformed. Whether their projects were considered a success or not, all juniors reported that they valued the skills learnt and the overall experience they gained through carrying out QI projects. Participants reported feeling more empowered in their role as junior doctors, with several describing how they felt ‘listened to’ and able to ‘have a voice’, that they were beginning to see things ‘at systems level’ and learning to ‘engage more critically’ in their working environment. Conclusions Junior doctors are ideally placed to engage in QI. Training in QI at the start of their medical careers may enable a new generation of doctors to acquire the skills necessary to improve patient safety and quality of care