Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

WHY IS THE AREA IMPORTANT?: A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable. WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?: We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE: Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Analysis of the use of a mobile simulation unit using the principles of a managed educational network.

INTRODUCTION: One of the challenges of delivering safe, reliable, quality health care is ensuring the workforce have access to the right training at the right time wherever they are practising. Like other high reliability fields, healthcare education has recognised the important role of simulation based education in embedding a culture of readiness for practice. Managed clinical networks (MCNs) have a proven track record in enhancing services for patients. Adapting this approach to ensuring the healthcare workforce has access to the right training at the right time can provide a more equitable national approach to simulation based education. One of the advantages of the MCN concept has been the flexibility to respond to local needs while reliably delivering national standards. METHODS: This article shares 5 years of data from a mobile simulation unit (MSU) analysed using the principles of a national managed educational network (MEN). An action research approach was used to identify how the MSU was changing the delivery of simulation based education as part of a national MEN for clinical skills education. One of the key deliverables of the Scottish Clinical Skills Strategy was to support the training needs of the National Health Service workforce, particularly in remote and rural Scotland. The MSU was proposed as part of the solution to the 'inequity of provision of clinical skills education using simulation'. Between 2014 and 2018, data were collected by the Clinical Skills Managed Educational Network (CSMEN) team on the performance of the MSU. Venues visited, job titles of participants and courses attended (a mix of local and national) were recorded by the venue hosts and collated by CSMEN staff. RESULTS: Evidence of the impact of the MSU using the seven MEN principles to analyse the data (functioning with explicit management arrangements, embedding systems of accountability, agreed expected outcomes, using an evidence base, having a multiprofessional and multidisciplinary focus, engaging in a system of dissemination, generating better value for money and engaging in research and development) are shared. CONCLUSION: Few examples of mobile simulation facilities exist in the UK, and none have the longevity of the CSMEN MSU. The results of the analysis supported the business case for an upgraded new MSU and identified the need to explore in more depth the variation in impact across the venues visited. However, some localities did not use the MSU during 2014-2018 and there are still some unanswered questions around its impact in some venues, which require further exploration.

Validity and reliability of metrics for translation of regional anaesthesia performance from cadavers to patients.

BACKGROUND: Our goal is to develop metrics that quantify the translation of performance from cadavers to patients. Our primary objective was to develop steps and error checklists from a Delphi questionnaire. Our second objective was to show that our test scores were valid and reliable. METHODS: Sixteen UK experts identified 15 steps conducive to good performance and 15 errors to be avoided during interscalene block on the soft-embalmed cadaver and patients. Thereafter, six experts and six novices were trained, and then tested. Training consisted of psychometric assessment, an anatomy tutorial, volunteer scanning, and ultrasound-guided needle insertion on a pork phantom and on a soft-embalmed cadaver. For testing, participants conducted a single interscalene block on a dedicated soft-embalmed cadaver whilst wearing eye tracking glasses. RESULTS: We developed a 15-step checklist and a 15-error checklist. The internal consistency of our steps measures were 0.83 (95% confidence interval [CI]: 0.78-0.89) and 0.90 (95% CI: 0.87-0.93) for our error measures. The experts completed more steps (mean difference: 3.2 [95% CI: 1.5-4.8]; P<0.001), had less errors (mean difference: 4.9 [95% CI: 3.5-6.3]; P<0.001), had better global rating scores (mean difference: 6.8 [95% CI: 3.6-10.0]; P<0.001), and more eye-gaze fixations (median of differences: 128 [95% CI: 0-288]; P=0.048). Fixation count correlated negatively with steps (r=-0.60; P=0.04) and with errors (r=0.64; P=0.03). CONCLUSIONS: Our tests to quantify ultrasound-guided interscalene nerve block training and performance were valid and reliable.

Using video-reflexive ethnography to capture the complexity of leadership enactment in the healthcare workplace.

Current theoretical thinking asserts that leadership should be distributed across many levels of healthcare organisations to improve the patient experience and staff morale. However, much healthcare leadership education focusses on the training and competence of individuals and little attention is paid to the interprofessional workplace and how its inherent complexities might contribute to the emergence of leadership. Underpinned by complexity theory, this research aimed to explore how interprofessional healthcare teams enact leadership at a micro-level through influential acts of organising. A whole (interprofessional) team workplace-based study utilising video-reflexive ethnography occurred in two UK clinical sites. Thematic framework analyses of the video data (video-observation and video-reflexivity sessions) were undertaken, followed by in-depth analyses of human-human and human-material interactions. Data analysis revealed a complex interprofessional environment where leadership is a dynamic process, negotiated and renegotiated in various ways throughout interactions (both formal and informal). Being able to "see" themselves at work gave participants the opportunity to discuss and analyse their everyday leadership practices and challenge some of their sometimes deeply entrenched values, beliefs, practices and assumptions about healthcare leadership. These study findings therefore indicate a need to redefine the way that medical and healthcare educators facilitate leadership development and argue for new approaches to research which shifts the focus from leaders to leadership.

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

BACKGROUND: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. METHODS: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. RESULTS: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. DISCUSSION: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. CONCLUSION: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Exploring situational awareness in emergency medicine: developing a shared mental model to enhance training and assessment.

Non-technical skills (NTS) are gaining increasing prominence within the field of emergency medicine. Situational awareness (SA), one key component of NTS, is a key skill for emergency physicians (EPs) during initial training and throughout their career. Furthermore, the majority of frameworks used to evaluate clinical performance incorporate SA as one key component. This review seeks to define and explore the concept of SA within the context of emergency medicine. We describe SA at an individual, team and departmental level. Development of this ability enables EPs to function effectively within the challenging environment of the emergency department (ED). Enhancing our understanding of SA may develop the cognitive process that underpins our clinical performance. We propose a model for consideration to support evaluation and training of SA within the ED, linking the model to the novice expert continuum.

Dimensions, discourses and differences: trainees conceptualising health care leadership and followership.

CONTEXT: As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today's interprofessional health care workplace. METHODS: Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees' conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which were subsequently mapped onto leadership discourses found in the literature. RESULTS: Although diversity existed in terms of medical trainees' understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees' understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees' conceptualisations of leadership and followership. CONCLUSIONS: Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.

Constructing and evaluating a validity argument for the final-year ward simulation exercise.

The authors report final-year ward simulation data from the University of Dundee Medical School. Faculty who designed this assessment intend for the final score to represent an individual senior medical student's level of clinical performance. The results are included in each student's portfolio as one source of evidence of the student's capability as a practitioner, professional, and scholar. Our purpose in conducting this study was to illustrate how assessment designers who are creating assessments to evaluate clinical performance might develop propositions and then collect and examine various sources of evidence to construct and evaluate a validity argument. The data were from all 154 medical students who were in their final year of study at the University of Dundee Medical School in the 2010-2011 academic year. To the best of our knowledge, this is the first report on an analysis of senior medical students' clinical performance while they were taking responsibility for the management of a simulated ward. Using multi-facet Rasch measurement and a generalizability theory approach, we examined various sources of validity evidence that the medical school faculty have gathered for a set of six propositions needed to support their use of scores as measures of students' clinical ability. Based on our analysis of the evidence, we would conclude that, by and large, the propositions appear to be sound, and the evidence seems to support their proposed score interpretation. Given the body of evidence collected thus far, their intended interpretation seems defensible.

A national approach for the use of simulation to educate and train the NHS workforce: the First National Clinical Skills Strategy.

INTRODUCTION: There have been a number of drivers for the use of simulation in healthcare education for the NHS workforce. The development of an accessible and efficient national approach to its implementation has been challenging. METHODS: An action research approach was used to develop a national strategy using several data inputs. RESULTS: From sampling across practitioners and territorial health boards geographical and professional groups, access was the main challenge to the use of simulation. CONCLUSION: Four priority areas were identified, which formed the basis of the national strategy Partnership for Care, which included a mobile unit, a managed educational network, a programme board and an alliance of stakeholders.

Introducing simulation-based education to healthcare professionals: exploring the challenge of integrating theory into educational practice.

BACKGROUND: Introducing simulation-based education to the curricular programme of healthcare professionals can be challenging. This study explored the early experiences of healthcare professionals in the use of simulation. This was in the context of the Kuwait-Scotland transformational health innovation network programme. METHODS: Two cohorts of healthcare professionals undertook a simulation module as part of faculty development programme in Kuwait. Participants' initial perceptions of simulators were gathered using a structured questionnaire in the clinical skills centre. Their subsequent ability to demonstrate the application of simulation was evaluated through analyses of the video-recordings of teaching sessions they undertook and written reflections of their experiences of using simulation. RESULTS: In theory, participants were able to identify simulators' classification and fidelity. They also recognised some of the challenges of using simulators. In their teaching sessions, most participants focused on using part-task trainers to teach procedural skills. In their written reflections, they did not articulate a justification for their choice of simulator or its limitations. CONCLUSION: This study demonstrated a theory-to-practice gap in the early use of simulation by healthcare educators. The findings highlight the need for deliberate practice and adequate mentorship for educators to develop confidence and competence in the use of simulation as part of their educational practice.

Performance of technology-driven simulators for medical students--a systematic review.

BACKGROUND: Simulation-based education has evolved as a key training tool in high-risk industries such as aviation and the military. In parallel with these industries, the benefits of incorporating specialty-oriented simulation training within medical schools are vast. Adoption of simulators into medical school education programs has shown great promise and has the potential to revolutionize modern undergraduate education. MATERIALS AND METHODS: An English literature search was carried out using MEDLINE, EMBASE, and psychINFO databases to identify all randomized controlled studies pertaining to "technology-driven" simulators used in undergraduate medical education. A validity framework incorporating the "framework for technology enhanced learning" report by the Department of Health, United Kingdom, was used to evaluate the capabilities of each technology-driven simulator. Information was collected regarding the simulator type, characteristics, and brand name. Where possible, we extracted information from the studies on the simulators' performance with respect to validity status, reliability, feasibility, education impact, acceptability, and cost effectiveness. RESULTS: We identified 19 studies, analyzing simulators for medical students across a variety of procedure-based specialities including; cardiovascular (n = 2), endoscopy (n = 3), laparoscopic surgery (n = 8), vascular access (n = 2), ophthalmology (n = 1), obstetrics and gynecology (n = 1), anesthesia (n = 1), and pediatrics (n = 1). Incorporation of simulators has so far been on an institutional level; no national or international trends have yet emerged. CONCLUSIONS: Simulators are capable of providing a highly educational and realistic experience for the medical students within a variety of speciality-oriented teaching sessions. Further research is needed to establish how best to incorporate simulators into a more primary stage of medical education; preclinical and clinical undergraduate medicine.

Making sense of feedback experiences: a multi-school study of medical students' narratives.

CONTEXT: Until recently, the perspective of students in the feedback process has been ignored, with strategies for improvement focusing on the tutor and feedback delivery. We employed an original narrative interviewing approach to explore how medical students make sense of their experiences of feedback. METHODS: A qualitative design was adopted employing three individual and 10 group interviews to elicit narratives of feedback experiences from 53 medical students at three 5-year undergraduate programmes in the UK during 2011. Thematic analysis was undertaken of students' understandings of feedback and of their narratives of positive and negative experiences of feedback at medical school. In addition, thematic and discourse analysis of the linguistic and paralinguistic features of talk within the narratives was conducted. RESULTS: Students typically constructed feedback as a monologic process that happened 'to' them rather than 'with' them. They shared 352 distinct narratives of feedback experiences, which were rich in linguistic and paralinguistic features of talk. Through the analysis of the interplay between the 'whats' and 'hows' of student talk, i.e. emotion, pronominal and metaphoric talk and laughter, we were able to understand how students find meaning in their experiences. Students used laughter as a coping strategy, emotion talk as a means to convince the audience of the impact of feedback, pronominal and metaphoric talk to describe their relationship (often adversarial) with their feedback providers and to communicate feelings that they might otherwise struggle to articulate. CONCLUSIONS: This research extends current feedback literature by focusing on medical students' lived experiences of feedback and their emotional impact through narrative. We go on to discuss the educational implications of our findings and to make recommendations for improvement of the feedback process for students, tutors and for institutions.

Exploring stakeholders' views of medical education research priorities: a national survey.

CONTEXT: Setting research priorities is important when exploring complex issues with limited resources. Only two countries (Canada and New Zealand) have previously conducted priority-setting exercises for medical education research (MER). This study aimed to identify the views of multiple stakeholders on MER priorities in Scotland. METHODS: This study utilised a two-stage design to explore the views of stakeholders across the medical education continuum using online questionnaires. In Stage 1, key informants outlined their top three MER priorities and justified their choices. In Stage 2, participants rated 21 topics generated in Stage 1 according to importance and identified or justified their top priorities. A combination of qualitative (i.e. framework analysis) and quantitative (e.g. exploratory factor analysis) data analyses were employed. RESULTS: Views were gathered from over 1300 stakeholders. A total of 21 subthemes (or priority areas) identified in Stage 1 were explored further in Stage 2. The 21 items loaded onto five factors: the culture of learning together in the workplace; enhancing and valuing the role of educators; curriculum integration and innovation; bridging the gap between assessment and feedback, and building a resilient workforce. Within Stage 2, the top priority subthemes were: balancing conflicts between service and training; providing useful feedback; promoting resiliency and well-being; creating an effective workplace learning culture; selecting and recruiting doctors to reflect need, and ensuring that curricula prepare trainees for practice. Participant characteristics were related to the perceived importance of the factors. Finally, five themes explaining why participants prioritised items were identified: patient safety; quality of care; investing for the future; policy and political agendas, and evidence-based education. CONCLUSIONS: This study indicates that, across the spectrum of stakeholders and geography, certain MER priorities are consistently identified. These priority areas are in harmony with a range of current drivers in UK medical education. They provide a platform of evidence on which to base decisions about MER programmes in Scotland and beyond.

Levels of reflective thinking and patient safety: an investigation of the mechanisms that impact on student learning in a single cohort over a 5 year curriculum.

Existing research into learning about patient safety focuses on identifying how educational interventions improve educational outcomes but few studies offer evidence that inform educators about the mechanisms involved in learning about patient safety. The current evidence based in undergraduates is also limited to outcomes that relate to knowledge and skills. A realist approach involving three cycles of data collection in a single cohort of students over 5 years used different outcomes in Kirkpatrick's framework to identify the mechanisms that influence students learning about patient safety. Data source 1. Focus groups identified an overarching theoretical model of the mechanisms that influence patient safety learning for medical students. Data source 2 Identified if the mechanisms from data source 1 could be demonstrated at the outcome level of knowledge and attitudes. Data source 3 Established associations between mechanisms and outcomes at skills and behavioural level, in a standardised simulated ward setting. Data source 1: The interpretation of data from seven focus groups involving sixty students identified reflection at two levels of Mezirow's descriptions; reflection and critical reflection as mechanisms that influence learning about error. Data source 2: Sixty-one students participated. The associations found, reflection and knowledge of actions to take for patient safety, r = 0.44 (P = 0.00) and critical reflection and intentions regarding patient safety, r = 0.40 (P = 0.00) Data source 3: Forty-eight students participated. The correlation identified associations between critical reflection and planned changes following feedback was, r = 0.48 (P = 0.00) and reflection and knowledge based errors r = -0.30 (P = 0.03). A realist approach identified two different levels of reflection were associated with different patient safety outcomes for this cohort of students. Critical reflection was associated with attitudes and reflection was associated with knowledge of actions and error behaviours. These findings give educators greater depth of information about the role of reflection in patient safety.

Junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of errors.

AIMS: The aim of the study was to explore and compare junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors. METHODS: A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura's Social Cognitive Theory and Human Error Theory (HET). RESULTS: Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2-12.4)] than F2s [4.0 IQR (0-10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001). CONCLUSION: Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.

How can student experience enhance the development of a model of interprofessional clinical skills education in the practice placement setting?

The practice placement setting offers opportunities and challenges for engaging students in high-quality interprofessional learning. The Fife Interprofessional Clinical Skills Model for Education was established to develop structured interprofessional learning opportunities for students during their clinical attachments in NHS Fife. This short report describes the delivery and evaluation of the model, which was piloted with students from the nursing, medicine and allied health professions. Scheduled workshops were delivered within primary and secondary care locations. The learning activities involved exploring and comparing their professional identities, discussing roles and responsibilities within the healthcare team and practicing nontechnical clinical skills. Students who participated in the workshops reported that they developed a better understanding of each other's roles and responsibilities and also identified that this would be transferable knowledge to their future practice. Exploring the student experience has assisted in developing relevant and accessible interprofessional learning opportunities within the practice placement setting.

Simulated patient programmes in Europe: collegiality or separate development?

BACKGROUND: Simulated patients (SPs) are widely used in medical education yet little is known about how individual schools recruit, develop, use, evaluate and maintain SPs. Opportunities for sharing SP development expertise and materials among institutions are not often utilised. AIMS: In order for different SP programmes to learn from each other, there needs to be some basis for establishing meaningful comparisons. METHOD: In 2006, the Association of Standardized Patient Educators (ASPE) piloted a survey instrument that would facilitate comparisons of SP educational practices in different institutions. Four European countries at varying stages of SP programme development were selected as representative of the spread of SP experience in Europe (Belgium, Ireland, Scotland and the Netherlands). Key SP contacts were identified in each medical school. Contacts were asked to complete a 49-item questionnaire developed collaboratively between ASPE and the authors. The overall response rate was 86%. RESULTS: There were considerable differences between countries in terms of their approach to developing SPs and quality assuring their performance. Whilst SP education was regarded as an expensive enterprise, there was little evidence of resource sharing between different centres in the same country. CONCLUSIONS: There is a clear need to facilitate closer collaboration between centres in developing and quality assuring SPs.

Diagnostic recognition of facial changes associated with chronic conditions: use of an e-learning tool to enhance medical student education.

Facial characteristics serve as reliable indicators of numerous diseases, and their recognition can assist junior medical students in making an accurate diagnosis. At present, however, there is little data to support the incorporation of physiognomy in medical education. This pilot study involved the design, implementation and evaluation of e-learning tutorials as a means of teaching students to appreciate how careful observation of facial characteristics can enhance diagnosis.