Operationalising FRAM in Healthcare: A critical reflection on practice

Resilience Engineering principles are becoming increasingly popular in healthcare to improve patient safety. FRAM is the best-known Resilience Engineering method with several examples of its application in healthcare available. However, the guidance on how to apply FRAM leaves gaps, and this can be a potential barrier to its adoption and potentially lead to misuse and disappointing results. The article provides a self-reflective analysis of FRAM use cases to provide further methodological guidance for successful application of FRAM to improve patient safety. Five FRAM use cases in a range of healthcare settings are described in a structured way including critical reflection by the original authors of those studies. Individual reflections are synthesised through group discussion to identify lessons for the operationalisation of FRAM in healthcare. Four themes are developed: (1) core characteristics of a FRAM study, (2) flexibility regarding the underlying epistemological paradigm, (3) diversity with respect to the development of interventions, and (4) model complexity. FRAM is a systems analysis method that offers considerable flexibility to accommodate different epistemological positions, ranging from realism to phenomenology. We refer to these as computational FRAM and reflexive FRAM, respectively. Prac-titioners need to be clear about their analysis aims and their analysis position. Further guidance is needed to support practitioners to tell a convincing and meaningful "system story" through the lens of FRAM

Effect of removal of the zona pellucida on subsequent development of mouse blastocysts in vitro.

Removal of the zona pellucida allowed mouse blastocysts incapable of hatching in vitro to develop in culture. Blastocysts denuded by pronase always developed further than those of identical age that had hatched spontaneously. More blastocysts mechanically denuded and treated with pronase developed egg cylinder-like structures than did blastocysts mechanically denuded and not treated with pronase. Plastic support gave better development of blastocysts than did glass

Ultrastructural study of concanavalin-A binding to the surface of preimplantation mouse embryos.

Receptors for Con-A were labelled (using the peroxidase-diaminobenzidine technique) on the plasma membrane of unfertilized and fertilized mouse eggs, cleavage stage embryos, trophoblast and inner cell mass (ICM) of the blastocyst. Embryos were exposed to Con-A concentrations of 10 microgram/ml, 50 microgram/ml, or 1,000 microgram/ml and the lowest concentration was observed to be the most suitable for discerning differences between stages of embryonic development. On the surface of unfertilized and fertilized eggs and 2-cell embryos, reaction product appeared as a thin, discontinuous layer. The surface of 4- and 16-cell stage embryos had a thicker, continuous, although non-uniform, layer of the reaction product. On the surface of the cells of the late morula, and on the trophoblastic cells of the blastocyst, clustering of reaction product was observed. Cells of ICM of intact blastocyst were free of the reaction product, showing that either Con-A and/or peroxidase cannot penetrate tight junctions between trophoblastic cells. Reaction product in the form of a thin, uniform layer covered the free surface of the cells of the ICM after they had been isolated (using immunosurgery) and exposed to 50 microgram/ml of Con-A. The amount and distribution of Con-A receptors is discussed, along with their redistribution and mobility in relation to the agglutinability of preimplantation mouse embryos