What does 'learning' and 'organisational learning' mean in the context of patient safety? Protocol for a systematic hermeneutic conceptual review

Introduction: Learning is essential for improving patient safety and is often cited as necessary following a patient safety incident (PSI). Both individual and organisational learning are needed to enable improvements in health systems. However, there is no clear consensus on what ‘learning’ or ‘organisational learning’ actually means in the context of a PSI. Learning theories can be applied to healthcare in order to improve patient safety interventions. In this systematic hermeneutic conceptual review, we aim to define learning and organisational learning in the context of patient safety and to identify the theoretical approaches to learning and interventions utilised. / Methods and analysis: This review will be undertaken in two phases, utilising a systematic hermeneutic approach. Phase one will focus on ascertaining taxonomy domains through identification of the concept and theoretical frameworks of ‘learning’ and ‘organisational learning’ from the literature. These taxonomy domains and the World Health Organisation’s World Alliance for Patient Safety International Classification for Patient Safety will inform a thematic framework for phase two. Phase two will be a more detailed search and focus on learning and related applied interventions in the context of patient safety incidents utilising the thematic framework from phase one. Data will be analysed using framework method analysis. / Ethics and dissemination: This review does not require ethical approval. The results will be published in a peer-reviewed journal

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020

INTRODUCTION: Regulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary Care Trusts (NSCTs) are legally required to report annually both quantitative and qualitative information related to patient deaths within their care within their publicly available Quality Accounts as part of a countrywide patient safety programme: The Learning from Deaths (LfDs) programme. METHOD: All LfDs reports published between 2017 (programme inception) and 2020 were reviewed and evaluated through a critical realist lens, quantitatively reported using descriptive statistics and qualitatively using reflexive thematic analysis. RESULTS: In 2017/2018, 44% of NSCTs reported all six statutory elements of the LfDs reporting regulations, in 2019/2020 35% of NSCTs were reporting this information. A small number of NSCTs did not report any parts of the LfDs regulatory requirements between 2017 and 2020. Multiple qualitative themes arose from this study suggesting problematic engagement with the LfDs programme, erroneous reporting accuracy and errors in written communication. CONCLUSIONS: The LfDs programme has, to some extent, reduced variation and improved consistency to the way that NSCTs identify, report and investigate deaths. However, 3 years into the LfDs programme, the majority of NSCTs are not reporting as required by law. This makes the validity of National statutory reporting in Quality Accounts within the NHS in England questionable as a regulatory process

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020

INTRODUCTION: The imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched in the National Health Service (NHS) in England. NHS Secondary Care Trusts (NSCTs) are legally required to publish quantitative and qualitative information relating to deaths due to problems in care within their organisation, including any learning derived from these deaths. METHOD: All LfDs report from 2017 to 2020 were reviewed and evaluated, quantitatively and qualitatively using sequential content and reflexive thematic analysis, through a critical realist lens to understand what we can learn from LfDs reporting and the mechanisms enabling or preventing engagement with the LfDs programme. RESULTS: The majority of NSCTs have identified learning, actions and, to a lesser degree, assessed the impact of these actions. The most frequent learning relates to missed/delayed/uncoordinated care and communication/cultural issues. System issues and lack of resources feature infrequently. There is significant variation among NSCTs as to what 'learning' in this context actually means and a lack of oversight combining patient safety initiatives. DISCUSSION: Engagement of NSCTs with the LfDs programme varies significantly. Learning as a result of the LfDs programme is occurring. The ability, significance or value of this learning in preventing future patient deaths remains unclear. Consensus about what constitutes effective learning with regard to patient safety needs to be defined and agreed on

NHS Hospital 'Learning from Deaths' reports: A qualitative and quantitative analysis of the first year of a countrywide patient safety programme

Introduction: Potentially preventable deaths occur worldwide within healthcare organisations. Organisational learning from incidents is essential to improve quality of care. In England, inconsistencies in how NHS secondary care trusts reviewed, investigated and shared learning from deaths, resulted in the introduction of national guidance on ‘Learning from Deaths’ (LfDs) in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and learning from deaths’. Amendments to NHS Quality Account regulations, legally require NHS trusts in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended trusts would share this learning and take measurable action to prevent future deaths. / Method: We undertook qualitative and quantitative secondary data analysis of all NHS secondary care trust LfDs reports within their 2017/18 Quality Accounts, to review how organisations are using the LfDs programme to learn from and prevent, potentially preventable deaths. / Results: All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) trusts. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of trusts (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 trusts (48%) have shared or plan to share the learning within their own organisation. The majority of trusts (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 trusts (17%) mentioned involvement of bereaved families. / Conclusions: The wide variation in reporting demonstrates that some trusts have engaged fully with LfDs, while other trusts appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfD reports have previously been identified in national and international reports and inquiries. Further work is needed to strengthen the LfDs programme

NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

OBJECTIVES: To review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths. INTRODUCTION: Potentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on 'LfDs' in 2017. This guidance provides a 'framework for identifying, reporting, investigating and LfDs'. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths. METHOD: We undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222). RESULTS: All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families. CONCLUSIONS: The wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries

Engineering Melon Plants with Improved Fruit Shelf Life Using the TILLING Approach

Background: Fruit ripening and softening are key traits that have an effect on food supply, fruit nutritional value and consequently, human health. Since ethylene induces ripening of climacteric fruit, it is one of the main targets to control fruit over ripening that leads to fruit softening and deterioration. The characterization of the ethylene pathway in Arabidopsis and tomato identified key genes that control fruit ripening. [br/] Methodology/Principal Findings: To engineer melon fruit with improved shelf-life, we conducted a translational research experiment. We set up a TILLING platform in a monoecious and climacteric melon line, cloned genes that control ethylene production and screened for induced mutations that lead to fruits with enhanced shelf life. Two missense mutations, L124F and G194D, of the ethylene biosynthetic enzyme, ACC oxidase 1, were identified and the mutant plants were characterized with respect to fruit maturation. The L124F mutation is a conservative mutation occurring away from the enzyme active site and thus was predicted to not affect ethylene production and thus fruit ripening. In contrast, G194D modification occurs in a highly conserved amino acid position predicted, by crystallographic analysis, to affect the enzymatic activity. Phenotypic analysis of the G194D mutant fruit showed complete delayed ripening and yellowing with improved shelf life and, as predicted, the L124F mutation did not have an effect. [br/] Conclusions/Significance: We constructed a mutant collection of 4023 melon M2 families. Based on the TILLING of 11 genes, we calculated the overall mutation rate of one mutation every 573 kb and identified 8 alleles per tilled kilobase. We also identified a TILLING mutant with enhanced fruit shelf life. This work demonstrates the effectiveness of TILLING as a reverse genetics tool to improve crop species. As cucurbits are model species in different areas of plant biology, we anticipate that the developed tool will be widely exploited by the scientific community

Using jasmonates and salicylates to reduce losses within the fruit supply chain

The fresh produce industry is constantly growing, due to increasing consumer demand. The shelf-life of some fruit, however, is relatively short, limited by microbial contamination or visual, textural and nutritional quality loss. Thus, techniques for reducing undesired microbial contamination, spoilage and decay, as well as maintaining product’s visual, textural and nutritional quality are in high demand at all steps within the supply chain. The postharvest use of signalling molecules, i.e. jasmonates and salicylates seems to have unexplored potential. The focus of this review is on the effects of treatment with jasmonates and salicylates on the fresh produce quality, defined by decay incidence and severity, chilling injury, maintenance of texture, visual quality, taste and aroma, and nutritional content. Postharvest treatments with jasmonates and salicylates have the ability to reduce decay by increasing fruit resistance to diseases and reducing chilling injury in numerous products. These treatments also possess the ability to improve other quality characteristics, i.e. appearance, texture maintenance and nutritional content. Furthermore, they can easily be combined with other treatments, e.g. heat treatment, ultrasound treatment. A good understanding of all the benefits and limitations related to the postharvest use of jasmonates and salicylates is needed, and relevant information has been reviewed in this paper

Berry Flesh and Skin Ripening Features in Vitis vinifera as Assessed by Transcriptional Profiling

Background Ripening of fleshy fruit is a complex developmental process involving the differentiation of tissues with separate functions. During grapevine berry ripening important processes contributing to table and wine grape quality take place, some of them flesh- or skin-specific. In this study, transcriptional profiles throughout flesh and skin ripening were followed during two different seasons in a table grape cultivar ‘Muscat Hamburg’ to determine tissue-specific as well as common developmental programs. Methodology/Principal Findings Using an updated GrapeGen Affymetrix GeneChip® annotation based on grapevine 12×v1 gene predictions, 2188 differentially accumulated transcripts between flesh and skin and 2839 transcripts differentially accumulated throughout ripening in the same manner in both tissues were identified. Transcriptional profiles were dominated by changes at the beginning of veraison which affect both pericarp tissues, although frequently delayed or with lower intensity in the skin than in the flesh. Functional enrichment analysis identified the decay on biosynthetic processes, photosynthesis and transport as a major part of the program delayed in the skin. In addition, a higher number of functional categories, including several related to macromolecule transport and phenylpropanoid and lipid biosynthesis, were over-represented in transcripts accumulated to higher levels in the skin. Functional enrichment also indicated auxin, gibberellins and bHLH transcription factors to take part in the regulation of pre-veraison processes in the pericarp, whereas WRKY and C2H2 family transcription factors seems to more specifically participate in the regulation of skin and flesh ripening, respectively. Conclusions/Significance A transcriptomic analysis indicates that a large part of the ripening program is shared by both pericarp tissues despite some components are delayed in the skin. In addition, important tissue differences are present from early stages prior to the ripening onset including tissue-specific regulators. Altogether, these findings provide key elements to understand berry ripening and its differential regulation in flesh and skin.This study was financially supported by GrapeGen Project funded by Genoma España within a collaborative agreement with Genome Canada. The authors also thank The Ministerio de Ciencia e Innovacion for project BIO2008-03892 and a bilateral collaborative grant with Argentina (AR2009-0021). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Peer reviewe

ATR-FTIR spectroscopy non-destructively detects damage-induced sour rot infection in whole tomato fruit

Main conclusion ATR-FTIR spectroscopy with subsequent multivariate analysis non-destructively identifies plant–pathogen interactions during disease progression, both directly and indirectly, through alterations in the spectral fingerprint. Plant–environment interactions are essential to understanding crop biology, optimizing crop use, and minimizing loss to ensure food security. Damage-induced pathogen infection of delicate fruit crops such as tomato (Solanum lycopersicum) are therefore important processes related to crop biology and modern horticulture. Fruit epidermis as a first barrier at the plant–environment interface, is specifically involved in environmental interactions and often shows substantial structural and functional changes in response to unfavourable conditions. Methods available to investigate such systems in their native form, however, are limited by often required and destructive sample preparation, or scarce amounts of molecular level information. To explore biochemical changes and evaluate diagnostic potential for damage-induced pathogen infection of cherry tomato (cv. Piccolo) both directly and indirectly, mid-infrared (MIR) spectroscopy was applied in combination with exploratory multivariate analysis. ATR-FTIR fingerprint spectra (1800–900 cm−1) of healthy, damaged or sour rot-infected tomato fruit were acquired and distinguished using principal component analysis and linear discriminant analysis (PCA–LDA). Main biochemical constituents of healthy tomato fruit epidermis are characterized while multivariate analysis discriminated subtle biochemical changes distinguishing healthy tomato from damaged, early or late sour rot-infected tomato indirectly based solely on changes in the fruit epidermis. Sour rot causing agent Geotrichum candidum was detected directly in vivo and characterized based on spectral features distinct from tomato fruit. Diagnostic potential for indirect pathogen detection based on tomato fruit skin was evaluated using the linear discriminant classifier (PCA–LDC). Exploratory and diagnostic analysis of ATR-FTIR spectra offers biological insights and detection potential for intact plant–pathogen systems as they are found in horticultural industries