Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

OBJECTIVE: A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident. METHODS: This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality. RESULTS: A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation. CONCLUSION: Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

A Retrospective Review of Serious Surgical Incidents in 5 Large UK Teaching Hospitals: A System-Based Approach.

OBJECTIVES: Surgical incidents are the most common serious patient safety incidents worldwide. We conducted a review of serious surgical incidents recorded in 5 large teaching hospitals located in one London NHS trust to identify possible contributing factors and propose recommendations for safer healthcare systems. METHODS: We searched the Datix system for all serious surgical incidents that occurred in any operating room, excluding critical care departments, and were recorded between October 2014 and December 2016. We used the London Protocol system analysis framework, which involved a 2-stage approach. A brief description of each incident was produced, and an expert panel analyzed these incidents to identify the most likely contributing factors and what changes should be recommended. RESULTS: One thousand fifty-one surgical incidents were recorded, 14 of which were categorized as "serious" with contributing factors relating to task, equipment and resources, teamwork, work environmental, and organizational and management. Operating room protocols were found to be unavailable, outdated, or not followed correctly in 8 incidents studied. The World Health Organization surgical safety checklist was not adhered to in 8 incidents, with the surgical and anesthetic team not informed about faulty equipment or product shortages before surgery. The lack of effective communication within multidisciplinary teams and inadequate medical staffing levels were perceived to have contributed. CONCLUSIONS: Multiple factors contributed to the occurrence of serious surgical incidents, many of which related to human failures and faulty equipment. The use of faulty equipment needs to be recognized as a major risk within departments and promptly addressed.

Support for Healthcare Professionals After Surgical Patient Safety Incidents: A Qualitative Descriptive Study in 5 Teaching Hospitals.

OBJECTIVE: Patient safety incidents can have a profound effect on healthcare professionals, with some experiencing emotional and psychological distress. This study explored the support medical and nonmedical operating room staff received after being involved in a surgical patient safety incident(s) in 5 UK teaching hospitals. METHODS: An invitation letter and information sheet were e-mailed to all medical and nonmedical operating room staff (N = 927) across the 5 sites. Semistructured interviews were arranged with a range of different healthcare professionals working in operating rooms across a wide variety of surgical specialities. Interviews were audio recorded, transcribed verbatim, and analyzed using an inductive thematic approach. RESULTS: We conducted 45 interviews with medical and nonmedical operating room staff, who emphasized the importance of receiving personalized support soon after the incident. Operating room staff described how the first "go to" people were their peers and reported feeling comforted when their peers empathized with their own experience(s). Other participants found it very difficult to seek support, perceiving it as a sign of weakness. Although family members played an important role in supporting second victims, some participants felt unable to discuss the incident with them, fearing that they might not understand. CONCLUSIONS: There should be clear support structures in place for operating room staff who have been involved in surgical incidents. Health organizations need to offer timely support to frontline staff after these incidents. Senior clinicians should be proactive in offering support to junior colleagues and empathize with their own experiences, thus shifting the competitive culture to one of openness and support.