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1 – 10 of over 4000
Article
Publication date: 20 September 2011

Dee Gray and Sion Williams

This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting…

1654

Abstract

Purpose

This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting and learning approach from adverse incidents, could contribute towards individual and organisational approaches to patient safety.

Design/methodology/approach

The study formed part of a series of six iterative action research cycles involving the collaboration of students (all National Health Service (NHS) staff) in the co‐creation of knowledge and materials relating to understanding and learning from adverse incidents. This fifth qualitative study involved (n=20) anaesthetists who participated in a two phase teaching intervention (n=20 first phase, n=10 second phase) which was premised on transformative learning, value placed on learning from adverse incidents and reframing the learning experience.

Findings

An evaluation of the teaching intervention demonstrated that how students learned from adverse incidents, in addition to being provided with opportunities to transform negative experiences through re‐framing learning, was significant in breaking out of practices which had become routine; propositional knowledge on learning from adverse incidents, along with the provision of a safe learning environment in which to challenge assumptions about learning from adverse incidents, were significant factors in the re‐framing process. The testing of a simulated dual learning/reporting system was indicated as a useful mechanism with which to reinforce a positive learning culture, to report and learn from adverse incidents and to introduce new approaches which might otherwise have been lost.

Practical implications

The use of a “re‐framed learning approach” and identification of additional leverage points (values placed on learning and effects of dual reporting and learning) will be of significant worth to those working in the field of individual and organisational learning generally, and of value specifically to those whose concern is the need to learn from adverse incidents.

Originality/value

This paper contributes to individual and organisational learning by looking at a specific part of the learning system associated specifically with adverse incidents.

Article
Publication date: 5 October 2010

Kerry Walsh, Calvin Burns and Jiju Antony

The purpose of this study is to assess attitudes toward and use of an electronic adverse incident reporting system in all four hospitals in one National Health Service…

1502

Abstract

Purpose

The purpose of this study is to assess attitudes toward and use of an electronic adverse incident reporting system in all four hospitals in one National Health Service Scotland Health Board area.

Design/methodology/approach

A questionnaire was used to assess medical consultants', managers', and nurses' attitudes and perceptions about electronic adverse incident reporting. Actual adverse incident reporting data were also analysed.

Findings

The main findings from this study are that consultants, managers, and nurses all had positive attitudes about responsibility for reporting adverse incidents. All respondents indicated that the design of and information collected by the electronic adverse incident reporting system (Datix) was adequate but consultants had more negative attitudes and perceptions than managers and nurses about Datix. All respondents expressed negative attitudes about the amount and type of feedback they receive from reporting, and consultants expressed more negative attitudes about how Datix is managed than managers and nurses. Analysis of adverse incident reporting data found that the proportion of consultants using Datix to report incidents was significantly lower than that of managers and nurses.

Practical implications

The findings suggest that there are no additional barriers to incident reporting associated with the use of a bespoke electronic adverse incident reporting system as compared to other types of systems. Although an electronic adverse incident reporting system may be able to increase incident reporting and facilitate organisational learning by making it easier to report incidents and analyse incident reporting data, strong leadership within hospitals/healthcare professions (or healthcare subcultures) is still required in order to promote and sustain incident reporting to improve patient safety.

Originality/value

This is the first study to investigate attitudes toward and reporting behaviour on a bespoke electronic adverse incident reporting system in hospitals.

Details

Leadership in Health Services, vol. 23 no. 4
Type: Research Article
ISSN: 1751-1879

Keywords

Article
Publication date: 1 December 2004

Sally Giles, Gary Cook, Michael Jones, Brian Todd, Margaret Mason and Kieran Walshe

The aim of this study was to develop a multi‐professionally agreed list of adverse events, which may act as a prompt for clinical incident reporting in trauma and…

Abstract

The aim of this study was to develop a multi‐professionally agreed list of adverse events, which may act as a prompt for clinical incident reporting in trauma and orthopaedics and to determine what healthcare professionals understand by the term adverse event. A modified Delphi process with healthcare professionals working in trauma and orthopaedics (242) in three NHS trusts was performed. The process involved initial brainstorming sessions, a two‐round Likert‐style postal questionnaire and final focus group discussion. The initial brainstorming sessions generated a list of 224 adverse events to be included in the first round of the postal questionnaire. They included 83 causes of adverse events, 36 health and safety related adverse events and 105 clinical adverse events. Following the second round questionnaire and focus group discussion, a final list of 20 adverse events was produced. There were variations between professional groups in terms of validity scoring of individual adverse events. Overall, medical staff gave a lower rating to the adverse events than the other two professional groups. There were also variations between professional groups in terms of response rates. The modified Delphi process proved to be a successful tool for generating a multi‐professionally agreed list of adverse events and for understanding what healthcare professionals understand by the term adverse event.

Details

Clinical Governance: An International Journal, vol. 9 no. 4
Type: Research Article
ISSN: 1477-7274

Keywords

Article
Publication date: 16 October 2009

David Buckley, Jill Reyment and Paul Curtis

The objective of this study is to investigate the existence of a diurnal pattern in the occurrence of adverse clinical management events.

Abstract

Purpose

The objective of this study is to investigate the existence of a diurnal pattern in the occurrence of adverse clinical management events.

Design/methodology/approach

The approach takes the form of a retrospective record review of adverse clinical management events occurring in the 63 facilities of a statutory public health provider in rural south‐eastern Australia. Between January 2006 and December 2007, 2,463 clinical management incidents were reported by clinical staff to a specially designed database.

Findings

Adverse clinical management incidents exhibit a marked diurnal pattern. This pattern was evident in both medicine and surgery as well as across facilities of differing acuity. The acrophase or peak of the daily cycle occurs at 14:30 hrs (95%CI 13:25 and 15:34 hrs). Although surgical events peaked earlier in the day (14.02hrs: 95%CI 12:32‐15:32) compared with medicine events (15:26hrs: 95%CI 13:07‐15:32), this difference was not statistically significant.

Research limitations/implications

As the activity rate in the hospital is unknown, this finding study reports the time of the day when most adverse events occur and not their rate as a function of procedural volume.

Practical implications

The existence of a diurnal pattern provides valuable information for strategies aimed at improving patient safety and health care quality. Interventions can now be more accurately targeted.

Originality/value

The paper is the first to move beyond descriptive data of the timing of adverse events and offers a model using chronobiological methods. The demonstration of the existence of diurnal patterns should improve programmes to reduce adverse events.

Details

Clinical Governance: An International Journal, vol. 14 no. 4
Type: Research Article
ISSN: 1477-7274

Keywords

Article
Publication date: 9 October 2007

Jeffrey Braithwaite, Mary T. Westbrook, Joanne F. Travaglia, Rick Iedema, Nadine A. Mallock, Debbi Long, Peter Nugus, Rowena Forsyth, Christine Jorm and Marjorie Pawsey

The purpose of this study is to evaluate the effects of a health system‐wide safety improvement program (SIP) three to four years after initial implementation.

1670

Abstract

Purpose

The purpose of this study is to evaluate the effects of a health system‐wide safety improvement program (SIP) three to four years after initial implementation.

Design/methodology/approach

The study employs multi‐methods studies involving questionnaire surveys, focus groups, in‐depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven‐million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak‐level responses to adverse events.

Findings

A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information‐handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co‐ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events.

Originality/value

Few studies into health systems change employ wide‐ranging research methods and metrics. This study helps to fill this gap.

Details

International Journal of Health Care Quality Assurance, vol. 20 no. 7
Type: Research Article
ISSN: 0952-6862

Keywords

Article
Publication date: 9 May 2016

Zhaleh Abdi, Hamid Ravaghi, Mohsen Abbasi, Bahram Delgoshaei and Somayeh Esfandiari

The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks…

1445

Abstract

Purpose

The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU).

Design/methodology/approach

Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation.

Findings

In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility.

Originality/value

The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

Details

International Journal of Health Care Quality Assurance, vol. 29 no. 4
Type: Research Article
ISSN: 0952-6862

Keywords

Open Access
Article
Publication date: 6 September 2019

Mohamed M. Ahmed, Guangchuan Yang, Sherif Gaweesh, Rhonda Young and Fred Kitchener

This paper aims to present a summary of the performance measurement and evaluation plan of the Wyoming connected vehicle (CV) Pilot Deployment Program (WYDOT Pilot).

1232

Abstract

Purpose

This paper aims to present a summary of the performance measurement and evaluation plan of the Wyoming connected vehicle (CV) Pilot Deployment Program (WYDOT Pilot).

Design/methodology/approach

This paper identified 21 specific performance measures as well as approaches to measure the benefits of the WYDOT Pilot. An overview of the expected challenges that might introduce confounding factors to the evaluation effort was outlined in the performance management plan to guide the collection of system performance data.

Findings

This paper presented the data collection approaches and analytical methods that have been established for the real-life deployment of the WYDOT CV applications. Five methodologies for assessing 21 specific performance measures contained within eight performance categories for the operational and safety-related aspects. Analyses were conducted on data collected during the baseline period, and pre-deployment conditions were established for 1 performance measures. Additionally, microsimulation modeling was recommended to aid in evaluating the mobility and safety benefits of the WYDOT CV system, particularly when evaluating system performance under various CV penetration rates and/or CV strategies.

Practical implications

The proposed performance evaluation framework can guide other researchers and practitioners identifying the best performance measures and evaluation methodologies when conducting similar research activities.

Originality/value

To the best of the authors’ knowledge, this is the first research that develops performance measures and evaluation plan for low-volume rural freeway CV system under adverse weather conditions. This paper raised some early insights into how CV technology might achieve the goal of improving safety and mobility and has the potential to guide similar research activities conducted by other agencies.

Details

Journal of Intelligent and Connected Vehicles, vol. 2 no. 2
Type: Research Article
ISSN: 2399-9802

Keywords

Article
Publication date: 20 February 2009

Helen Payne and Daryl May

In 2000, a national initiative “Enhancing the Healing Environment” (EHE) was launched by the King's Fund to celebrate the millennium. This aimed to support nurse‐led teams…

Abstract

Purpose

In 2000, a national initiative “Enhancing the Healing Environment” (EHE) was launched by the King's Fund to celebrate the millennium. This aimed to support nurse‐led teams to undertake an environment improvement programme in their National Health Service (NHS) hospital. Sheffield Care Trust (SCT) decided to carry out this project in its intensive treatment suite, a psychiatric intensive care unit (PICU) providing care for up to six patients. There were no known examples of an EHE project being undertaken in a PICU elsewhere in the NHS. The purpose of this paper is to examine the impact of EHE design principles in improving the patient experience, from the perspectives of staff and patients.

Design/methodology/approach

A focus group and individual interviews were used as the primary method of data collection. Secondary data comprised sets of statistics related to pre‐ and post‐refurbishment periods.

Findings

It was found that staff and patients liked many aspects of the changed environment. Staff felt improved openness of space, natural light, fresh air, reduced noise levels and greater choice of spaces to provide care, were most important. Patients cited a high quality, comfortable and homely environment (not like a typical NHS ward) as important; they also valued high standards of cleanliness, tidiness, choice and being able to view the outside, open windows and let in fresh air. Experiencing high quality clinical care was equally important. Incidence of physical assaults decreased markedly in the new environment.

Practical implications

NHS mental health services trusts will understand the benefits of applying EHE principles in PICUs or similar environments. Some project management shortcomings are identified and improvements suggested.

Originality/value

This paper is of value to NHS mental health trusts which need to decide on the effectiveness of different design principles for PICUs or similar environments.

Details

Journal of Facilities Management, vol. 7 no. 1
Type: Research Article
ISSN: 1472-5967

Keywords

Article
Publication date: 31 October 2008

John Storey and David Buchanan

The purpose of this article is to advance critical debate in relation to a very critical issue in current healthcare management – namely “patient safety”. This is…

4214

Abstract

Purpose

The purpose of this article is to advance critical debate in relation to a very critical issue in current healthcare management – namely “patient safety”. This is currently a very high profile issue. In its various guises such as clinical governance, integrated governance and healthcare governance the question of avoiding or at least minimising harm to patients is attracting a huge amount of attention. Considerable resources especially within the acute sector are allocated to the problem. But, despite the systematic attention, progress in healthcare compared with certain other sectors is slow and mistakes continue to occur. Hospital acquired infections and clinical errors have become a matter of acute public concern. Evaluations of the health service are critically influenced by adverse judgements on this dimension of care.

Design/methodology/approach

The authors draw primarily upon relevant literature in order to make sense of recent empirical research in eight acute hospital trusts in the UK. The analysis, however, is relevant to healthcare systems around the world.

Findings

The authors reveal how the massive investment in systems, service improvement mechanisms and clinical government regimes may not in themselves be enough. One reason why they may not be enough is that there can be a problem of gaining acceptance and legitimacy. Staff may see such managers as “policing” and “interfering”. There is then the danger of a vicious circle – more control but less effective control because of a feeling of alienation. The policing element is at best a final safety net not the prompt for improvement. They then identify six barriers and each is accompanied by a recommendation for its resolution.

Practical implications

There are a number of implications for practice and for systems reform, which stem from the analysis. Two main recommendations stand out: they need to be handled together. First, the traditional model of the autonomous professional needs to be challenged by subjecting clinical practice to shared clinical governance procedures. Second, and simultaneously, there is a need to attend to underlying values. There is a need to revisit the issue of underpinning values so that clinical values and system‐wide/managerial values are congruent rather than separate or even in conflict. At this point, governance and leadership should come together.

Originality/value

This paper provides useful information from the literature on current healthcare management.

Details

Journal of Health Organization and Management, vol. 22 no. 6
Type: Research Article
ISSN: 1477-7266

Keywords

Article
Publication date: 1 January 1997

Jill Gladstone and Sue Sutherland

Recent developments in medical treatments have resulted in the increased use of infusion devices for the administration of highly potent drugs. Drug administration is one…

Abstract

Recent developments in medical treatments have resulted in the increased use of infusion devices for the administration of highly potent drugs. Drug administration is one of the highest risk areas of clinical practice and infusion devices are associated with a substantial number of adverse drug events. Locally, there was a perception that adverse drug events involving infusion devices appeared to be increasing, and there was anecdotal evidence to suggest that the available number of devices was inadequate to meet the increasing demand. A two‐part, observational audit, carried out in an acute district general hospital, was used to identify weak areas in the systems associated with the use of infusion devices and to implement actions to rectify the weaknesses and consequently reduce the risk to patients and staff.

Details

Journal of Clinical Effectiveness, vol. 2 no. 1
Type: Research Article
ISSN: 1361-5874

1 – 10 of over 4000