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Supporting the ‘second victims’ of patient safety incidents

Researchers at our PSTRC have developed a unique range of online support to help the ‘second victims’ of patient safety incidents: clinicians and healthcare workers.

Patient safety incidents are any unintended or unexpected incident, such as a medical error or system failure, which could have, or did, lead to harm for a patient receiving healthcare. When things go wrong in the NHS the first priority is always to support the patient affected and their family. But this sometimes means that the needs of healthcare workers at the centre of patient safety incident investigations are almost forgotten, even when the impact can have far-reaching consequences for the person and their organisation.

Now health researchers from the PSTRC, the Yorkshire Quality and Safety Research Group and the Improvement Academy, based at the Bradford Institute for Health Research, have launched a website www.secondvictim.co.uk with a wealth of resources to support clinicians and organisations.

The project is focused on how clinicians are supported through these events; not because their needs are greater than the patient or their family’s – far from it, but because the impact of the event on the clinician has a knock-on effect on the care they are able to give their next patient. One clinician described it in this way:

It hit me for the first time that I’ve had something actually go wrong, then that opened a door to me imagining, second guessing everything all the time, imagining things going wrong. And how you can have an effect on a person’s life if something does go wrong. I think that’s what really hit me, and knocked my confidence for that time.

This clinician, with others, has told their story by film on the website. Users of the website have found these films helpful, and several have offered to share their own experiences. It’s been so useful for the project team to hear the real experiences of people who will be able to benefit from using the website, and to recognise the impact that making a mistake has on the clinician and their colleagues. In particular this story stands out because when the incident was investigated the clinician was found to be not at fault, due to a communication error about what needed to be done.

These stories clearly resonate with other clinicians, but importantly when clinicians talk about mistakes it enables learning; in this instance the way that treatment plans are communicated around the hospital could be improved, reducing the risk of a recurrence for another patient.

To hear these stories go to www.secondvictim.co.uk

Plugging in the safety gaps: An integrative approach to gathering safety information from patients via Electronic Health Records

By Dr Abigail Albutt (Research Fellow within the NIHR Yorkshire and Humber PSTRC) and the Patient Involvement in Patient Safety research team

I recently attended the Sixth Annual NIHR Imperial PSTRC Symposium held in London. This year the conference had a focus on using innovations in digital technology to enhance healthcare quality and safety. A keynote presentation came from Professor David Bates, Harvard University, who is an internationally renowned expert in patient safety. Professor Bates discussed the use of patient monitoring technologies on medical surgical wards where patients are not typically continuously monitored, and how such information technologies are vital to the delivery of high quality, safe patient care. Cal Leeming, Security Advisor at River Oakfield, followed to talk about the importance of cyber security which led to a thought provoking panel discussion about this topic.

Next, Professor Rebecca Lawton, Director of the NIHR Yorkshire and Humber PSTRC chaired a panel discussion about enhancing patient and public involvement and engagement (PPIE) in safety. This discussion revealed many useful tips about how to engage patients and the public in patient safety research, particularly those from ‘hard to reach’ groups. Going to where the people are rather than inviting them to you, and finding a shared language, were proposed as key success factors. The discussion moved on to the interesting idea of whether PPIE is necessary for healthcare staff-facing interventions. Ultimately, as all interventions affect patients; the consensus was that PPIE is always necessary.

I was delighted to present a poster at the symposium, outlining one of our projects exploring how we might advance patient involvement in patient safety specifically within a primary care setting. It is now widely accepted that patients can meaningfully provide feedback on the safety of their care, and recent efforts have concentrated on novel ways of gathering this feedback. Increasingly, patients are encouraged to access their Electronic Health Record (EHR), with access associated with improved patient satisfaction and enhanced patient safety, by identifying medication errors for example.

Dr Abigail Albutt at the Sixth Annual NIHR Imperial PSTRC Symposium.

Bringing together these bodies of literature, the poster described an interview study exploring primary care user perspectives on identifying errors in their EHR and providing feedback about care experiences via their EHR. Most patients felt they would benefit from interacting with their EHR, and the majority of patients interviewed welcomed the opportunity to identify and report errors and the possibility of using EHRs as a portal to provide feedback about their care experiences.

Download the full poster 

Presenting the poster generated much discussion around the process of implementing such a system in practice. These discussions reinforced the importance of the next phase of this study, talking to primary care staff, to ensure this potential integrative approach to gathering safety information from patients in primary care is acceptable to staff. I will be presenting this work orally at the British Journal of General Practice Research Conference in March which will provide a brilliant opportunity to talk to primary care staff and begin to progress the study to explore staff perceptions.

 

 

This research is funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). The views expressed in this article / presentation are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

 

 

Setting the agenda for future patient safety research

The research team at the NIHR Yorkshire and Humber Patient Safety Translational Research Centre (PSTRC) needs your help developing its future research agenda. We want you to challenge us with your ideas for patient safety research for the next 5-10 years, informed by your knowledge of delivering, receiving or researching care.

You can tell us what you think by suggesting research questions here: https://www.surveymonkey.co.uk/r/VJN3967

Or read on for some background about patient safety and about our PSTRC.

What is patient safety?
Patient safety is the ‘prevention of errors and adverse effects to patients associated with health care’.(1) We know that in the UK, Europe, Australia and the US, about 1 in 10 patients admitted to hospital suffer some harm that is preventable. Since the late 1990s there has been a focus on preventing this unintended harm to patients. The focus of attention can often be on serious failures in care, such as wrong site surgery, incorrect doses of medication or feeding tubes inserted into the lungs that cause harm or even death. Yet the 2010 Mid Staffordshire NHS Foundation Trust Inquiry led by Sir Robert Francis brought attention to the ‘considerable suffering’ patients experienced due to failures of basic care such as hydration and hygiene.(2) Reports such as this have highlighted how safety problems are rarely caused by individuals, but by “systems, procedures, conditions, environment and constraints”. (3)

Recently, patient safety researchers have called for a new focus on what goes right in healthcare, instead of the focus on deconstructing incidents, recognising that for most patients healthcare is successful and they are unharmed. They have argued that emphasis must be placed on understanding how staff members adapt their performance to prevent harm occurring in response to difficult and varying conditions. (4)

What is a patient safety translational research centre (PSTRC)?
A PSTRC develops and tests ideas and tools to improve the safety of patient care. Our Yorkshire and Humber PSTRC started delivering research in August 2017 and our priority research areas for the first two years are already set – they include enabling patients to play a central role in their own safety, the potential for digital technology to improve safety, how we create workplaces that people want to work in, and how we can enhance the safe use of medicines across care settings. You can find out more about our work on our website.

We now want to find out what you think the most important safety improvement research questions are so we can plan our future work. So far our advisory board, clinician and patient groups have given us an idea of what they think is important. Here’s a taste of what they have asked us – you can tell us if you agree.

  • Can you really hand over a patient safely in 15 minutes?
  • What do sheltered care homes have a protocol to dial 999 for every fall?
  • How do we reduce barriers to staff being heard in teams due to hierarchy, power, ethnicity, and gender?
  • Is it safe for patients to self-administer medicines on the ward?
  • Is there a link between patient safety incidents and a lack of activity on mental health wards?

Over to you

We want you to tell us what you think the most important patient safety research questions are. You may have ideas from a recent experience of care or from your experiences in delivering care. You may agree with some of the questions above or think that some vital areas for research are missing.

Tell us what you think by submitting research questions here: https://www.surveymonkey.co.uk/r/VJN3967

 

 

References

1 The World Health Organization. Patient Safety. 2018. Available online http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/patient-safety

2 The Mid Staffordshire NHS Foundation Trust Inquiry. Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009. 2010.

3 National Advisory Group on the Safety of Patients in England. A Promise to Learn – a Comittment to Act. Improving the Safety of Patients in England. 2013.

4 Braithwaite, J., Wears, R.L., Hollnagel, E. Resilient health care: turning patient safety on its head, International Journal for Quality in Health Care, 2015;27(5):418–420.

 

 

This project is funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

In the name of safety: Identifying and letting go of low-value safety practices

By Rebecca Lawton, Gillian Janes and Abi Albutt

Why is this necessary?

Within an NHS that has an acute shortage of time and resources, the often heard demand is ‘to do more with less’. However, evidence suggests that as much as 25% of healthcare is unecessary (Grol & Grimshaw, 2003). The NHS is characterised by a tendency to add more initiatives, protocols, interventions in an attempt, at least in part, to make care safer. Such processes and practices are not always evidence based but they may become integrated in a complex healthcare system and embedded within the culture of the institution.

There is increasing recognition that some clinical procedures are unnecessary and can do more harm than good. The Choosing Wisely campaign is actively encouraging health professionals to help patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary (http://www.choosingwisely.org/our-mission/). This campaign and much of the work to date has focussed on the removal of health technologies (Haas et al, 2012)  and clinical practices such as specific tests and treatments that offer little or no benefit (see for example Bekelis et al 2017). In other words, the focus has been on clinical practices. However, to build a safer healthcare system, reduce costs and improve the process of care we must also consider the necessity of non-clinical safety practices, rules and procedures that do not necessarily result in safety improvements or no longer add value (Norton et al 2017). Whilst there is a lack of published evidence on this topic, making progress on this issue could also help create the space and time needed for healthcare staff to deliver more effective, patient-centred care.

How might it be achieved?

Whilst a common language for the process of removing practices that are no longer useful is still lacking (Davidoff, 2015; Bekelis 2017), terms such as decommissioning and disinvestment are often used. These reflect the top-down strategies most often deployed for this purpose by which external policy makers and commissioners decide what practices are least cost ineffective or evidence based and discourage health professionals from their use, based on funding disincentives and guidelines (Roosenhas et al 2015). This approach to influencing the clinical practice of health professionals is challenging and difficult to implement (Haas et al, 2012) with limited success thus far.  It is plausible, however, that the staff themselves might know best which safety practices are not fit-for-purpose, do not result in benefits for safety or are just not possible to implement. While the use of bottom-up processes may prove more promising, there is little evidence on how to do this work or whether staff are able to identify low value safety practices that might represent opportunities for ‘disinvestment’ in the context of safety.

Moreover, if we are able to identify low-value safety practices, we do not yet know how easy it will be for staff to ‘stop’ doing these things. Enrico Coiera (2017) uses the term ‘mindful forgetting’ to highlight the conscious decision-making process that is needed to let go of low-value practices. In other words, concerted effort may be required. For example, there may be awareness that a safety rule, process or practice is not very effective, but this doesn’t mean it will automatically be stopped (Roman and Asch, 2014).  The best way to approach the cessation or ‘mindful forgetting’ of inefficient or unhelpful safety practices in healthcare however is little understood (Niven et al 2015; Bekelis et al, 2017) and may be even more difficult for staff than the adoption of new innovations (Ubel et al 2015). It may be that the use of evidence-based behaviour change techniques could be considered to support staff in the cessation of unhelpful safety practices.

How can you get involved?

Researchers in the Yorkshire and Humber Patient Safety Translational Research Centre are working to address this evidence gap. Initially, we are seeking to understand what safety rules, processes and practices frontline healthcare staff perceive as low-value. Where the evidence supports this we will then work with staff and patients to develop interventions to support and evaluate ‘mindful forgetting’ of these in practice.

If you work in frontline patient care and would like to contribute to this new patient safety initiative, tell us your example(s) of low-value safety rules, practices or processes for consideration.

Tell us here

 

References

Bekelis K; Skinner J, Gottlieb D, Goodney P (2017) et al  De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study BMJ 359:j4695 doi: 10.1136/bmj.j4695

Choosing Wisely campaign http://www.choosingwisely.org/our-mission/

Coeira E (2017) The Forgetting Health System Learn Health Sys. 1:e10023 https://doi/org/10/1002/lrh2.10023

Davidoff F (2015) On the Undiffusion of Established Practices  JAMA Internal Medicine 175(5): 809-811

Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care Lancet 362(9391): 1225-1230

Haas  M, Hall J, Viney R, Gallego G (2012) Breaking up is hard to do: why disinvestment in medical technology is harder than investment  Australian Health Review 36(2): 148-152

Roman BR, Asch DA (2014) Faded promises: the challenges of de-adopting low-value care Ann Intern Med 161(2): 149-151

Roosenhas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL (2015) “I won’t call it rationing…”:’ An ethnographic study of healthcare disinvestment in theory and practice Social Science and Medicine 128: 273-281

Ubel PA, Asch DA, Chase C (2015) Commentary: Creating Value in Health by Understanding and Overcoming Resistance to De-Innovation Health Affairs 34(2): 239-244