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BACKGROUND: Safety has been described as a dynamic non-event and as constantly present in professionals' work processes. Investigating management of complex everyday situations may create an opportunity to elucidate safety management. Anaesthesia has been at the frontline of enhancing patient safety - testing and implementing knowledge from other high-reliability industries, such as aviation, in the complex, adaptive system of an operating room. The aim of this study was to explore factors supporting anaesthesia nurses and anaesthesiologists in managing complex everyday situations during intraoperative anaesthesia care processes. METHODS: Individual interviews with anaesthesia nurses (n = 9) and anaesthesiologists (n = 6) using cognitive task analysis (CTA) on case scenarios from previous prospective, structured observations. The interviews were analysed using the framework method. RESULTS: During intraoperative anaesthesia care, management of everyday complex situations is sustained through preparedness, support for mindful practices, and monitoring and noticing complex situations and managing them. The prerequisites are created at the organization level. Managers should ensure adequate resources in the form of trained personnel, equipment and time, team and personnel sustainability and early planning of work. Management of complex situations benefits from high-quality teamwork and non-technical skills (NTS), such as communication, leadership and shared situational awareness. CONCLUSION: Adequate resources, stability in team compositions and safe boundaries for practice with shared baselines for reoccurring tasks where all viewed as important prerequisites for managing complex everyday work. When and how NTS are used in a specific clinical context depends on having the right organizational prerequisites and a deep expertise of the relevant clinical processes. Methods like CTA can reveal the tacit competence of experienced staff, guide contextualized training in specific contexts and inform the design of safe perioperative work practices, ensuring adequate capacity for adaptation.
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Anestesia , Anestesiologia , Humanos , Reprodutibilidade dos Testes , Competência Clínica , Pesquisa Qualitativa , Equipe de Assistência ao PacienteRESUMO
The COVID-19 pandemic's effects on people's lives and society induced a need for rapid individual and collective sensemaking, including communication forums enabling stakeholders in the health ecosystem to share information, solve problems, and learn. This study specifically focused on the needs of the patients and family caregivers living with cystic fibrosis (CF) or primary ciliary dyskinesia (PCD), conditions that lead to chronic infections and inflammation in the airways. We explored how CF and PCD patients, family caregivers, and clinicians collectively received, processed, and used information about COVID-19 to facilitate self-care and health care decisions at the beginning of the pandemic. We applied macrocognitive theory to analyze qualitatively the questions and answers exchanged in a series of six webinars facilitated by a CF learning network at the beginning of the pandemic (March - April 2020). We identified three macrocognitive functions: sensemaking, decision-making, and replanning. We further generated nine themes: (a) understanding the nature of COVID-19, (b) exploring self-care needs and possibilities, (c) understanding health care possibilities, (d) making decisions about prevention and testing, (e) managing COVID-19 within families, (f) adjusting planned care, (g) replanning chronic care management, (h) defining COVID-19 health care strategies, and (i) refining health care policies. The exchange of questions and answers played a central role in facilitating important cognitive processes, which enabled a rapid anticipation of needs and adaptation of services to support patients, family caregivers, and clinicians during the COVID-19 pandemic.
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COVID-19 , Fibrose Cística , Humanos , COVID-19/epidemiologia , Pandemias , Fibrose Cística/epidemiologia , Suécia/epidemiologia , EcossistemaRESUMO
Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritisation and resource utilisation essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realised in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted, to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow.Practitioner summary: This study describes how a large tertiary paediatric hospital's patient flow management functions. The results offer a new understanding of how patient flow management is communicated and coordinated across organisational levels of the hospital and how authority and information might be better placed closer to clinical work for increased efficiency.
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Engenharia , Hospitais , Humanos , Criança , Eficiência , Cognição , Pesquisa QualitativaRESUMO
BACKGROUND: Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. METHODS: A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. RESULTS: Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. CONCLUSIONS: Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.
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Atenção à Saúde/organização & administração , Incidentes com Feridos em Massa , Terrorismo , Centros de Traumatologia , Adaptação Psicológica , Bombas (Dispositivos Explosivos) , Criança , Comportamento Cooperativo , Humanos , Entrevistas como Assunto , Equipe de Assistência ao Paciente/organização & administração , Resiliência PsicológicaRESUMO
BACKGROUND: Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers' is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. METHODS: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. RESULTS: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. CONCLUSIONS: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit's safety culture.
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Liderança , Segurança do Paciente , Humanos , Reprodutibilidade dos Testes , Gestão da Segurança , SuéciaRESUMO
BACKGROUND: Chronic care involves multiple activities that can be performed by individuals and healthcare staff as well as by other actors and artifacts, such as eHealth services. Thus, chronic care management can be viewed as a system where the individual interacts with people and eHealth services performing activities to maintain or improve health and functioning, called co-care. Yet, the system perspective is not reflected in concepts such as person-centered care and shared decision making. This limits the understanding of individuals' global experience of chronic care management and subsequently the ability to optimize chronic care. The aim of this study was threefold: (1) to propose a theory-based operationalization of co-care for chronic care management, (2) to develop a scale to measure co-care as a distributed system of activities, and (3) to evaluate the scale's psychometric properties. With the theory of distributed cognition as a theoretical underpinning, co-care was operationalized along three dimensions: experience of activities, needs support, and goal orientation. METHODS: Informed by the literature on patient experiences and work psychology, a scale denoted Distribution of Co-Care Activities (DoCCA) was developed with the three conceptualized dimensions, the activities dimension consisting of three sub-factors: demands, unnecessary tasks, and role clarity. It was tested with 113 primary care patients with chronic conditions in Sweden at two time points. RESULTS: A confirmatory factor analysis showed support for a second-order model with the three conceptualized dimensions, with activities further divided into the three sub-factors. Cronbach's alpha values indicated a good to excellent reliability of the subscales, and correlations across time points with panel data indicated satisfactory test-retest reliability. Convergent, concurrent and predictive validity of the scale were, overall, satisfactory. CONCLUSIONS: The psychometric evaluation supports a model consisting of activities (demands, unnecessary tasks, and role clarity), needs support and goal orientation that can be reliably measured with the DoCCA scale. The scale provides a way to assess chronic care management as a system, considering the perspective of the individuals with the chronic condition and how they perceive the work that must be done, across situations, either by themselves or through healthcare, eHealth, or other means.
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Psicometria , Análise Fatorial , Humanos , Reprodutibilidade dos Testes , Inquéritos e Questionários , SuéciaRESUMO
BACKGROUND: Patient safety issues in primary health care and in emergency departments have not been as thoroughly explored as patient safety issues in the hospital setting. Knowledge is particularly sparse regarding which patients have a higher risk of harm in these settings. The objective was to evaluate which patient-related factors were associated with risk of harm in patients with reports of safety incidents. METHODS: A case-control study performed in primary health care and emergency departments in Sweden. In total, 4536 patients (cases) and 44,949 controls were included in this study. Cases included patients with reported preventable harm in primary health care and emergency departments from January 1st, 2011 until December 31st, 2016. RESULTS: Psychiatric disease, including all psychiatric diagnoses regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio, 1.96; p < 0.001). Adjusted for income and education there was still an increased risk (odds ratio, 1.69; p < 0.001). The preventable harm in this group was to 46% diagnostic errors of somatic disease. CONCLUSION: Patients with psychiatric illness are at higher risk of preventable harm in primary care and the emergency department. Therefore, this group needs extra attention to prevent harm.
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Erros de Diagnóstico/estatística & dados numéricos , Serviço Hospitalar de Emergência , Transtornos Mentais/epidemiologia , Dano ao Paciente/estatística & dados numéricos , Atenção Primária à Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Estudos de Casos e Controles , Criança , Pré-Escolar , Escolaridade , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Humanos , Renda/estatística & dados numéricos , Lactente , Recém-Nascido , Masculino , Erros de Medicação/estatística & dados numéricos , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Dano ao Paciente/prevenção & controle , Fatores de Risco , Suicídio/estatística & dados numéricos , Suécia/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To (1) validate and (2) display initial results of surveys to health care professionals and patients on the importance and mitigation of specified risks for diagnostic and medication errors. DESIGN: For validation, psychometric properties were analysed by assessment of construct validity and internal consistency by factor analysis. Non-parametric analyses were used concerning areas of risk, and top ranking of solutions were reported descriptively. SETTING: Primary health care in Sweden. PARTICIPANTS: Health care professionals (HCPs); including physicians, nurses and practice managers, as well as patients who had experienced diagnostic or medication errors. MAIN OUTCOME MEASURES: Psychometric properties of the surveys. Median ratings for risks and top rankings of solutions for professionals and patients. RESULTS: There were 939 respondents to the HCP survey. Construct validity resulted in a model with four dimensions: Patient-provider level; Support systems for every day clinical work; Shared information and cooperation between different caregivers; Risks in the environment. Internal consistency was acceptable with Cronbach's α values above 0.7. Confirmatory factor analysis generally showed an acceptable fit. Initial results from the professionals showed the importance of continuity of care, a nationwide on-line medical platform and cooperation in transfer of care. The patient survey could not be validated because of low response rate. CONCLUSION: The HCP survey showed some contradicting results regarding model fit and may be tentatively acceptable but validity needs further study. HCP survey answers indicated that relational continuity of care and a nationwide on-line medical platform are highly valued. Current awareness Health care professionals and patients are rather untapped sources of knowledge regarding patient safety in primary health care Main statements Validation is performed on a new survey capturing rating of risks and solutions. The validation of the health care professional survey is tentatively acceptable. Survey answers indicate that health care professionals' and patients' perspectives are complementary.
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Erros de Medicação , Atenção Primária à Saúde , Feminino , Humanos , Masculino , Psicometria , Reprodutibilidade dos Testes , Inquéritos e Questionários , SuéciaRESUMO
OBJECTIVE: Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program. DESIGN: A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts. SETTING: Large university paediatric surgical service. PARTICIPANT(S): All 153 managers and staff. INTERVENTIONS: Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs. MAIN OUTCOME MEASURE(S): Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room). RESULTS: Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly. CONCLUSIONS: Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.
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Salas Cirúrgicas/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Segurança do Paciente/normas , Melhoria de Qualidade/organização & administração , Apendicectomia/normas , Criança , Comunicação , Humanos , Laparoscopia/normas , Salas Cirúrgicas/normas , Estudos de Casos Organizacionais , Pediatria/organização & administração , Assistência Perioperatória/estatística & dados numéricos , Estudos Prospectivos , Gestão da Segurança/métodos , Centro Cirúrgico Hospitalar/organização & administração , SuéciaRESUMO
OBJECTIVES: To codesign safety-netting strategies for primary and emergency care settings by integrating the experiences and ideas of patients, carers and clinicians. DESIGN: A codesign process involving two focus group discussions, eight individual interviews and five workshops. All sessions were audio recorded and transcribed verbatim. Data were analysed using qualitative content analysis and reported using the Consolidated criteria for Reporting Qualitative research guidelines. SETTING: Primary and emergency care in Sweden, focusing on the Stockholm region. PARTICIPANTS: 7 (5 women) individuals with patient expertise, 1 (man) individual with carer expertise, 18 (12 women) individuals with clinical expertise. RESULTS: Three main categories reflecting strategies for applying safety-netting were developed: first, conveying safety-netting advice, which involves understanding patient concerns, tailoring communication and using appropriate modalities for communicating; second, ensuring common understanding, which involves summarising information, asking a teach-back question and anticipating questions post consultation; and third, supporting safety-netting behaviour, which involves facilitating reconsultation, helping patients and carers to navigate the health system and explaining the care context and its purpose. CONCLUSIONS: Our study highlights the collaborative nature of safety-netting, engaging both the clinician and patient, sometimes supported by carers, in an iterative process. Adding to previous research, our study also emphasises the importance of anticipating postconsultation inquiries and facilitating reconsultation.
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Cuidadores , Serviços Médicos de Emergência , Grupos Focais , Pesquisa Qualitativa , Humanos , Suécia , Feminino , Masculino , Serviços Médicos de Emergência/normas , Atenção Primária à Saúde/normas , Adulto , Pessoa de Meia-Idade , Comunicação , Entrevistas como AssuntoRESUMO
BACKGROUND: A Swedish version of the USA Agency for Healthcare Research and Quality "Hospital Survey on Patient Safety Culture" (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care. METHODS: The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs's α. RESULTS: CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach's α values above 0.7 in a major part of the dimensions. CONCLUSIONS: The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.
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Hospitais/normas , Cultura Organizacional , Segurança do Paciente , Atenção Primária à Saúde/normas , Atitude do Pessoal de Saúde , Coleta de Dados , Pessoal de Saúde/psicologia , Pessoal de Saúde/estatística & dados numéricos , Administração Hospitalar , Humanos , Psicometria , Reprodutibilidade dos Testes , Inquéritos e Questionários , SuéciaRESUMO
BACKGROUND: In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems. METHODS: A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. Results were compared with those found in one local, and four national incident-reporting systems. RESULTS: We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable. CONCLUSIONS: No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety.
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Auditoria Médica/normas , Erros Médicos/tendências , Segurança do Paciente , Gestão da Segurança , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Estudos Retrospectivos , Suécia , Adulto JovemRESUMO
Psychological safety refers to an individual's experience of the work environment as conducive to interpersonal risk-taking without risk for reprisals. Fear of reprisals has been well documented in health care, including in Sweden. In the literature and our teaching, we have consistently found that when psychological safety is low, it can lead providers to violate the basic tenet "first, do no harm". Psychological safety resides at the team level. It is established and maintained by the leader. Several contributing leadership qualities and behaviors have been identified. Leaders can train how to support psychological safety by how they choose to set the stage, invite participation, and respond productively when they interact with their staff. Leaders may experience this as challenging and anxiety-provoking. However, leaders need to actively improve psychological safety in care teams to support learning, improvement, and co-creation in health and care.
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Transtornos de Ansiedade , Liderança , Humanos , Aprendizagem , SuéciaRESUMO
BACKGROUND: A promising approach to manage clinical uncertainty and thereby reduce the risk of preventable diagnostic harm is to use safety-netting advice (ie, communicating structured information to patients about when and where to reconsult healthcare). AIM: To explore clinicians' and patients' views on when and how safety-netting can be successfully applied in primary-care and emergency-care settings. DESIGN AND SETTING: An exploratory qualitative research design; we performed focus groups and interviews in a Swedish setting. PARTICIPANTS: Nine physicians working in primary or emergency care and eight patients or caregivers participated. The participants were an ethnically homogeneous group, originating from Western European or Australian backgrounds. METHOD: Data were analysed inductively, using the framework method. The results are reported according to the Standards for Reporting Qualitative Research guidelines for reporting qualitative research. RESULTS: In order to manage diagnostic uncertainty using safety-netting, clinicians and patients emphasised the need to understand the preconditions for the consultation (ie, the healthcare setting, the patient's capacity and existing power imbalance). Furthermore, participants raised the importance of establishing a mutual understanding regarding the patient's perspective and the severity of the situation before engaging in safety-netting advice. CONCLUSION: The establishment of a shared mental model between clinician and patient of the preconditions for the clinical encounter is a vital factor affecting how safety-netting advice is communicated and received and its ability to support patients in problem detection and planning after the visit. We suggest that successful safety-netting can be viewed as a team activity, where the clinician and patient collaborate in monitoring how the patient's condition progresses after the care visit. Furthermore, our findings suggest that to be successfully implemented, safety-netting advice needs to be tailored to the clinical context in general and to the patient-clinician encounter in particular.
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Tomada de Decisão Clínica , Clínicos Gerais , Humanos , Suécia , Incerteza , Segurança do Paciente , Austrália , Pesquisa Qualitativa , Encaminhamento e ConsultaRESUMO
Overdiagnosis and overtreatment receive increasing attention. More than 20 percent of health expenditure is without patient benefit, so-called low-value care. Several national and international initiatives have been launched to minimize low-value care. Arguably, the most widely spread initiative is Choosing Wisely. First launched by the American Board of Internal Medicine in 2012, this campaign has spread to more than 20 countries. The Swedish Society of Medicine has identified low-value care as a significant problem in Swedish health care and has established a working group to investigate if and how a campaign based on Choosing Wisely would be feasible in Sweden. Here, the working group reports on the history of Choosing Wisely, identifies potential challenges for deimplementation generally and in the Swedish context specifically.
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Atenção à Saúde , Medicina Interna , Humanos , Estados Unidos , SuéciaRESUMO
INTRODUCTION: Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care. OBJECTIVE: To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process. METHODS: Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool. RESULTS: High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia. CONCLUSION: The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.
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Enfermeiros Anestesistas , Carga de Trabalho , Humanos , Salas Cirúrgicas , Estudos Prospectivos , SuéciaRESUMO
OBJECTIVES: With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES. METHODS: The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected by human variability, to explore human adaptations observed in in situ simulations (ISS). The structured applicability of this novel approach to TES is described by application to empirical data from the standardised ISS management of paediatric time critical head injuries (TCHI). RESULTS: A case series is presented to illustrate the step-wise observation of key timings during ISSs, the construction of FRAM models and the visualisation of the propagation of human adaptations through the FRAM models. The key functions/actions that ensure the propagation are visible, as are the sequelae of the adaptations. CONCLUSIONS: The approach as described in this paper is a first step to illuminating how to explore, analyse and observe the consequences of positive and negative human adaptations within simulated complex systems. This provides TES with a structured methodology to visualise and reflect upon both Safety-I and Safety-II perspectives to enhance patient safety and patient outcomes.
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OBJECTIVES: Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances. DESIGN: An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive-deductive content analysis from a perspective of resilience engineering. PARTICIPANTS: A team of managers (ie, clinical coordinators, head nurses, senior medical doctors). RESULTS: The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems' limitations. CONCLUSIONS: Coordination supports a coherent goal setting by increased team collaboration and is supported by team members' abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was 'stretched' or 'needed reorganisation' and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.
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Cuidados Críticos , Unidades de Terapia Intensiva Neonatal , Humanos , Recém-Nascido , Pesquisa Qualitativa , Reprodutibilidade dos Testes , SuéciaRESUMO
PURPOSE: The objectives of our study were to determine drug use, type and incidence of all adverse event associated with drug or drug-related processes (Adverse Drug Events, ADE) among pediatric inpatients in relation to hospital unit and length of stay. PATIENTS AND METHODS: 600 pediatric (0-18 years) admissions at a Swedish university hospital during one year were included and stratified in blocks to 150 neonatal, surgical/orthopedic, medicine and emergency-medicine unit admissions, respectively. Adverse events were identified from medical records using a pediatric trigger tool. All triggers identifying an adverse event related to drugs and drug-related devices were included. Data on drug use were extracted from the hospital drug-data warehouse. RESULTS: In total, 17794 daily drug orders were administrated to 486 (81.0% exposed) admissions. Parental nutrition, potassium salts and morphine constituted half of all high-risk drugs prescribed. Two-thirds of intravenous irritating drug doses consisted of vancomycin, esomeprazole and meropenem. In 129 (21.5%) admissions, at least one ADE was identified, out of which 21 ADE were classified as more severe (National Coordinating Council Medication Error Reporting Prevention-Index, NCCMERP≥F). The ADE incidence was 47.4 (95% confidence interval: 39.4-57.3) per 1000 admission days and varied by unit category. In neonatal units, 56.9 (49.5-65.4) ADEs/1000 admission days were detected, in surgery/orthopedic 54.2 (40.3-72.8), in medicine 44.1 (33.1-58.7), and in emergency-medicine 14.3 (7.7-26.7) ADEs/1000 admission days were found. The most common types of ADEs were identified by triggers that were not directly aiming at drugs including insufficiently treated pain (incidence peaking already in the first days), skin, tissue or vascular harm (peaking at the end of the first week) and hospital-acquired infections (peaking in later admission days). CONCLUSION: Adverse drug events are common in pediatric patients. The incidence of ADEs and type of ADE varies by hospital unit and length of hospital stay.
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OBJECTIVES: Trauma is the leading cause of death in children. The lack of an accepted definition of what constitutes a high-quality stabilisation of a traumatically injured child has limited the evaluation of direct interventions in simulation-based education and service-delivery models to improve trauma care. The aim of this study was to create a framework that delineates quality by exploring the perceptions of the multi-disciplinary team providing and improving this initial care. METHODS: Interviews were conducted with 36 experienced UK trauma team members and governance administrators (clinical directors to executive board level), from three standard UK trauma units. This study used a phenomenographic approach to explore the relationships and hierarchy between the contrasting perceptions of quality and evaluation of quality in this acute context. RESULTS: The findings show that defining quality is a more complex concept than simple proxy measurements, such as time to CT scanning. They also show that the concept of quality requires the consideration of a spectrum of perspectives that range from the simple to the more sophisticated.This study highlights the importance of teamwork, individualised perspectives and the culture of care provision, when describing quality. A novel framework to delineate quality is presented, comprising System, Team, Process, Individual, Data and Culture. CONCLUSIONS: This study has created a framework of understanding of acute paediatric trauma care quality and its measurement from the perspectives of team members and administrators. A framework and future tools to capture and disseminate the System, Team, Process, Individual, Data and Culture perspectives of the quality of trauma stabilisations could be a key advance in the care of severely injured children.