Positive approaches to safety: Learning from what we do well.

Historical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations. In this article, we discuss some of the theoretical limitations of the prevailing approach to patient safety and introduce emerging, complementary approaches in this field of practice. Safety-II and resilience engineering represent a new paradigm of safety, characterized by focusing on the entirety of work, with a system-wide lens, rather than single incidents of failure. More overtly positive approaches are available, specifically focusing on success-both outstanding success and everyday success-including exnovation, appreciative inquiry, learning from excellence and positive deviance. These approaches are not mutually exclusive. The new methods described in this article are not intended as replacements of the current methods, rather they are presented as complementary tools, designed to allow the reader to take a balanced and holistic view of patient safety.

Trainee doctors' experiences of learning and well-being while working in intensive care during the COVID-19 pandemic: a qualitative study using appreciative inquiry.

OBJECTIVES: Concern about trainee work-related well-being has been raised in recent years and is the subject of several reviews, reports and research studies. This study aimed to understand the experiences of trainees working in a large intensive care unit during the first surge of the COVID-19 pandemic from an educational and operational perspective in order to highlight what worked and what could be improved. DESIGN: A qualitative study using peer-to-peer semistructured interviews, developed using appreciative inquiry methodology, was conducted during July 2020. Responses were analysed using a thematic analysis technique. SETTING: A large, tertiary intensive care unit in the UK. PARTICIPANTS: All trainees in anaesthesia and intensive care working on the intensive care unit during the first surge were invited to participate. RESULTS: Forty interviews were conducted and four over-arching themes were identified. These were: feeling safe and supported; physical demands; the emotional burden of caring; and a sense of fulfilment, value and personal development. Positive aspects of the organisational response to the pandemic included communication, personal protective equipment supply, team working and well-being support. Suggestions for improvement focused on rest facilities, rota patterns and hierarchies, creating opportunities for reflection and ensuring continued educational and training opportunities despite operational demands. CONCLUSIONS: Trainees described opportunities for learning and fulfilment, as well as challenges, in working through a pandemic. Trainees described their needs and how well these were met during the pandemic. Ideas for improvement most frequently related to basic needs including safety and fatigue, but suggestions also related to supporting learning and development. The appreciative inquiry methodology of the project facilitated effective reflection on positive aspects of trainee experiences.

Feasibility of performing non-contrast magnetic resonance angiography in pregnant subjects with familial aortopathies.

BACKGROUND: Pregnancy is associated with an increased risk of aortic pathology. We sought to assess the feasibility of performing non-contrast 3D steady-state free-precession (SSFP) magnetic resonance angiography (MRA) in pregnant subjects with inherited aortopathy. METHODS: Fifteen pregnant subjects (age 27±4yr) with positive genotyping for aortopathy (Marfan, Loeys-Dietz, Ehlers-Danlos) and/or a family history of aortic dissection underwent non-contrast 3D-SSFP MRA at 1.5T (Avanto, Siemens Healthcare, Erlangen, Germany) using a modified ECG-triggered orientated in a sagittal-oblique plane with a respiratory navigator at the diaphragmatic level (mean acquisition time 4.1±1.9min). Imaging was performed during the mid-trimester (21±5weeks). Image analysis was performed off-line using Cvi42 software (Circle Cardiovascular Imaging, Calgary, Canada). An assessment of image quality (score 0-3) was made before performing inner edge to inner edge measurements of the thoracic aorta at 7 levels from the multiplanar reconstructions by two independent blinded observers. RESULTS: Non-contrast 3D-MRA was successfully acquired in all 15 subjects. Image quality was deemed excellent in 87% (13/15) of cases after a mean acquisition time of 4.1±1.9min. There was a high level of agreement for aortic measurements, with low intra- and inter-observer variability (ICC ranges; 0.95-0.99 and 0.92-0.98, respectively). All pregnancies reached term (≥37/40) with a mean gestation at delivery of 38.0±0.5weeks. The mode of delivery was vaginal in 9 out of 15 subjects (60%). CONCLUSIONS: Non-contrast SSFP MRA imaging provides a quick and reproducible method of assessing the thoracic aorta in pregnancy.