North British Patient Safety Research symposium

Lancaster 8th of May 2008

Conference Proceedings

Lancaster Patient Safety Research Unit presentations

1. Analysis of the UK National Reporting and Learning System data from 2006: what has been done so far, what can we learn from it and where can we go next?

Jon Arnot-Smith, Anaesthetics Registrar

A brief look at the critical incident data available via the UK National Reporting and Learning System for 2006 – how can such a mass of information be approached technically to yield useful results, and what should be done with those results once available? Technical, conceptual and ethical considerations for future analyses are also discussed.

2. Situated Learning: Interferences and interventions against the rule.

Irene Swarbrick, PhD Student

Part of the NHS discourse of patient safety urges ‘harnessing learning’ from adverse incidents in patient care (DoH 2002, p2). My work considers learning before events, the ‘learning for practice’ of junior hospital doctors, and the impact of their learning to practice on patient safety. My approach draws on the feminist material semiosis of Donna Haraway (1988), John Law’s version of Actor Network - material relationality (2004), and the Situated Learning Theory of Lave and Wenger (1991). One of my analytical concerns is Lave and Wenger’s construct of legitimate peripheral participation – the process through which learners become increasingly involved participants in a community of practice, as they move towards full community participation and expert status. Fuller et al (2005) have identified a number of limitations with legitimate peripheral participation, not least that it does not readily map onto modern work environments in industrialised societies. My work uses a feminist lens to explore the impact on patient safety, and on learning for practice, of differing forms of legitimate peripheral participation. I also examine the everyday interferences accomplished by junior hospital doctors in a modern work environment of the NHS, in order to promote and ensure their learning opportunities for safe practice.

3. Patient safety related incidents in an Acute NHS Trust: An exploratory time series analysis

Lisha Deng, PhD Student

Patient safety plays an important role in healthcare. The goal of our research is to develop statistical models to explain the pattern of variation in patient safety related incidents and to implement systems for real-time monitoring of incident reporting data with a view to early detection of any changes in the pattern of variation. We will use the incident reporting system within an Acute NHS Trust to model the time series of past incidents. Our specific objective is to study the incident reports from five hospitals that together form the Acute Trust and to investigate what factors influence the rate of incidents. Questions of interest include: are there long-term trends or seasonal patterns for the number of incidents? does the rate of incidents differ amongst the five hospitals? If so, can the differences between hospitals be explained by their sizes and other known factors, such as the patient mix?

To answer questions of this kind, we first describe how a standard class of statistical models, known as Poisson log-linear regression models, can be used to obtain a provisional model for the variation in the rate of incidents. These models fail to explain the true nature of the data because they ignore its time-series character. To address this failing, we describe a time series analysis of the residuals from the best-fitting Poisson log-linear regression model. In future work, we will combine the Poisson log-linear regression and the time-series of residual variation into a single model that can be used both to explain the historical pattern of variation and to provide early warnings of unexplained departures from the historical pattern.

4. Professional Identity and patient safety perception. A qualitative analysis

James Shillito, Research Assistant

Industrial safety systems thinking has recently been promoted widely in healthcare as a means of improving the safety of care (Kohn et al. 1999).This reflects the increasing pressure from healthcare professionals and service users alike for higher quality care and the avoidance of unnecessary risk.

However, there are important differences between the two settings. In particular, healthcare staff may be more likely to see themselves as belonging to a particular professional group than as ‘equivalent actors’ within a safety system (Amalberti 2005). Key to this is the notion of personal identity.

The formation, understanding and expression of identity (Brown, 1986).and the part played in this by our relations to others (Markus & Kitayama, 1991,Hatch & Schultz, 2004) are central themes in social psychology. There is, however, very little work on professional identity in healthcare workers either in general or specifically on the relationship between identity and notions of risk and safety. Identity influences an individual’s understanding of his/her (professional) environment, including the notions of risk and safety (Lupton, 1999).

The issue of professional identities and the consequences they might have remains largely explored. This presentation will concentrate on examining issues of personality, culture and professional identity, and how they relate to risk and safety.

5. Male doctors and emotions. A hidden issue in patient safety?The impact of professional and gender identity in medical profession.

Dr Konstantinos Arfanis, research Fellow

The literature on masculinity and emotions is somewhat extensive and on first look it can appear contradicting. On closer inspection though, one can see how different approaches can be put together to better understand how masculinity is lived and understood today, and the impact it has in the lives of everyday men.

What is presented in relation to own gender awareness has large implications when it is combined with professional identity (often being acquired in early training and continuing to develop long after graduation), and is an important factor in moderating the level to which a male doctor will allow his emotions and feelings to surface.

Data from the healthcare sector mainly regards the way doctors and nurses deal with patients’ emotions. The –very scarce and limited- remaining data almost exclusively comes from studies that examined how doctors deal with a patient’s death, or how student doctors learn to deal (better put, hide) their own emotions in their professional surroundings (Kasman et al, 1993; Redinbaugh et al; 2003 Garg et al, 1997).

There are two important issues. The first one refers to the way doctors –irrespective of their gender- learn to behave and think, either through their training, or as a continuous process meant to help them deal with their everyday life in a hospital. The issue of the ‘unmoved, unemotional doctor’ has recently begun to be challenged both in academia and in everyday practice.

The second parameter has to do with the suggestion that male doctors have to deal with additional demands to remain unemotional and unmoved, as part of their gender and social identity.

This presentation is aimed at bringing the aforementioned issues to light and communicate ideas for future research.

University of Aberdeen Presentations

1. Patient Safety Climate in Scottish Hospitals

Çakil Saraç, PhD Student

Recently safety culture became a significant concept for healthcare organizations determined to improve patient safety. It is first important to understand the dynamics of a construct to produce a change. Therefore, to transform safety culture, one should first aim to discover the underlying cultural factors prevalent within an organization (Nieva & Sorra, 2003). Many studies have investigated various variables (both organizational and individual factors) in relation to safety culture with different measurements, techniques and models in order to explain the contributing casino uk factors. No national safety culture study has been conducted yet to understand the situation in Scottish hospitals. The proposed research is therefore interested in understanding the status of Scottish hospitals in relation to safety culture in order to play australian pokies online analyze and suggest solutions to improve patient safety in Scotland. This presentation will outline a new study that is being designed to examine the safety climate (questionnaire measure of culture) in Scottish hospitals. The aims and objectives of the proposed research will be achieved by asking participants to fill out the self-report questionnaires to assess the existing levels of safety climate and their safety behaviours. In order to explore the relationships between self-reported safety behaviour and actual patient safety events within the organization, incident reporting data will be collected from the hospital records. Finally, overall data will be analysed by multilevel statistical techniques at multi levels of the organization and results will be discussed in the light of the current literature.

2. Handovers in healthcare: A literature review.

Michelle A. Raduma, PhD Student

In organisations such as healthcare, which operate continuous processes, patient care continuity is maintained across multiple treatment settings and staff shift changes via handovers. The main function of a handover is to provide healthcare practitioners with important patient information to facilitate clinical decisions and patient care planning. However, the literature in healthcare suggests that this aim is not always met and handovers have been identified as a high risk situation that can cause gaps in the continuity of care due to communication and/or teamwork failures (Cook, Render, & Woods, 2000), which may be the most important contributors to preventable adverse events in healthcare (Slagle, Kuntz, France et al, 2007). This paper presents the main findings from a literature review on handover research in healthcare with the aim of identifying the problems associated with poor handover, and the methods used to investigate handovers in healthcare. This is with the long term aim of designing an intervention to improve handover between healthcare practitioners.

3. Key methodological steps and pitfalls in designing and evaluating questionnaires for patient safety research

Jeanette Winter, Research Fellow

Questionnaires are widely used in safety research since they provide information about people’s knowledge, beliefs, attitudes and behaviours. This presentation will provide an overview of methods used to design and evaluate questionnaires which meet psychometric standards and which target the audience of interest. Additionally, attention will be drawn to potential pitfalls that exist while designing and evaluating questionnaires, utilizing real-life examples wherever possible. The presented methodological guideline will help to develop valid, reliable, and standardised questionnaires to measure precisely self-reported safety outcomes and understand their underlying key processes.

4. A DEEDS Approach to Understanding Anaesthetists’ Cognitive Skills

Dr Evie Fioratou, Research Fellow

In this presentation, I will explore the role of cognitive skills in anaesthesia from a DEEDS approach, a philosophical and empirical coalition in cognitive science comprising the Dynamical, Embodied, Extended, Distributed, and Situated approaches to knowledge and cognition. This approach places an emphasis on the interaction between kasyna brain, body, and the surrounding social and material world. In the case of anaesthesia, I will argue for the importance of studying the dynamic interaction between the anaesthetist, the surgeon, the patient, and all the external resources in the OR environment (e.g., monitors, charts) in order to understand the implications of such dynamic an interaction on cognitive skills. Furthermore, the development of cognitive skills in anaesthesia training will also be considered from a DEEDS perspective, in which “scaffolding”, embodied, and emergent experiences play crucial roles. The practical relevance for applications to simulation training will thus be outlined as well as some suggestions for future work.

York, Leeds and Bradford Presentations

1. Yorkshire Quality and Safety Programme

John Wright , Ian Watt, Richard Thompson, Rebecca Lawton, Sam Carruthers, Gerry Armitage, Angela Grange & Penny Rhodes

This applied programme grant brings together leading academics from the University of Leeds and York to develop innovative research to improve quality and safety in patient care in a Bradford NHS laboratory. The following themes will be developed.

I. Measuring and learning from errors

a) Drug error reporting system. This project will build on existing research to pilot and evaluate a specific drug error reporting system by rolling it out to a multicentre study.

b) Development of a proactive error management tool. This project will identify important causes of drug administration errors and use this data to develop predictors of errors which can be measured in a self-administered questionnaire.

c) Understanding barriers to reporting. This qualitative research will explore limitations of current reporting systems and use results to develop systems that improve learning from error.

II. Improving safety and quality

a) Action research as a change mechanism to improve safety and quality. Action research provides a change management model that is based on an iterative cycle of measurement, analysis, testing and action. Bradford Teaching Hospitals Trust will promote a programme of action research based on IHI methods of measurement and improvement for patient safety. This work builds on experience with the Hospital Mortality Reduction programme, Pursuing Perfection and the Safer Patient Initiative.

b) Electronic solutions for improving safey and quality. Bradford NHS community is the first in the UK to have shared electronic primary care records in secondary care (SystemOne). This provides a unique opportunity to test ideas aimed at improving safety at transitions of care and provide enhanced monitoring. This project will explore applications for e-consultation, medicines reconciliation and drug surveillance systems.

c) Implementation of research. This work builds on our experience of developing and evaluating cost-effective change programmes in routing clinical practice across a health economy.

d) Equipment solutions for improving safety and quality. The number of patients dying or being paralysed by maladministered spinal injections needs to be reduced to zero. This project will conduct a prospective hazard analysis and pre-implementation evaluation of non-Luer spinal connectors.

III. Involving patients

a) Patients views about safety and strategies to promote involvement. This project builds on existing experience in developing a conceptual framework for patient involvement in patient safety and will explore potential interventions to promote greater involvement

b) Development of a patient record. We plan to use patient diaries and interviews to develop a patient record that can be used as a documentation record in parallel to clinical records for in-patients.

c) Access and appropriateness of care. We will incorporate specific projects to investigate barriers to uptake of care that impact on patient quality and safety.

2. Pre-Implementation Evaluation of Non-Luer Spinal Connectors

Dr Rebecca Lawton, Dr Peter Gardner, Ben GreenInstitute of Psychological Sciences, University of Leeds

‘Cross-connection’ errors occur when drugs meant for one route of administration are administered via an inappropriate route. Such errors are made possible by the extensive use of ‘Luer’ connectors for a variety of procedures. Cross-connections can be fatal, as in the case of Wayne Jowett, who died in 2001 following the administration of an intravenous cancer drug into his spine. The DH is keen to introduce a design solution to this problem, in which dedicated spinal connectors will prevent inappropriate devices being connected to spinal needles and infusion lines. Since May 2006, the above research team has been funded by the DH Patient Safety Research Portfolio to investigate the potential for and implementation of non-Luer compatible equipment for spinal procedures. We are currently in our final phase of research, in which prototype non-Luer devices are being evaluated in clinical practice and implementation guidance for the wider roll-out of the equipment is being developed. A series of equipment trials are taking place in various clinical contexts (paediatric and adult haematology, theatre anaesthetics, and obstetric anaesthetics) at both high- and low-usage sites. We will report on interim findings of these trials.

3. Patient involvement in Patient Safety

Yvonne Birks, Jill Hall Maggie Peat, Ian Watt, Dorothy McCaughan