27 Jun 2023Part of our HSR UK Conference 2023 series
Ensuring the well-being and safety of patients is critical to healthcare delivery. The traditional approach to patient safety has often relied on root cause analysis and the identification of contributory factors in incidents. However, healthcare is complex, and people are constantly adapting and adjusting how they work to account for the different people they’re working with, tasks that need to be done using a variety of tools within different environments. Root cause analysis and identifying contributory factors can sometimes fail to understand how safety is being maintained by these adaptations and adjustments and can often focus only on what went wrong. This blog post by Catherine Leon (LSHTM) aims to introduce the concept of patient safety, highlighting the need for new ways to adapt patient safety practices by drawing insights from a thematic review of anticoagulation-related incident reports.
Understanding the Complex System
This work takes another look at incident reports to see whether it’s possible to use them to find ways that safety was supported or improved.
Two frameworks, the Systems Engineering Initiative for Patient Safety (SEIPS) tool and the Resilience Capacities frameworks, were used to explore the complex interactions within the healthcare system and how these promote safety. Using SEIPS allowed a comprehensive analysis of the system's components, including:
- People: patients, healthcare professionals;
- Tools: electronic health records, medications;
- Tasks: administration, prescribing; documentation; and
- Environments: external factors such as the Covid-19 pandemic, or significant policy changes.
The Resilience Capacities (Responding, Anticipating, Monitoring, and Learning) framework provided insight into the actions performed by an individual, a team or an organisation to maintain safety.
The anticoagulation incident reports that are the focus of this study shed light on the interactions between the system's components. It found that these can either facilitate or act as barriers to patient safety. The reports described the huge role that people have in maintaining safety by questioning, identifying issues, and collaborating with healthcare professionals when things don’t go according to plan. Communication was a crucial factor in promoting safety, as individuals involved in events needed this dialogue to devise new plans and strategies and used various tools to facilitate discussions. Electronic health records (EHR) were found to play a dual role, both facilitating safety by providing access to critical information and acting as a barrier when technicalities surrounding prescribing and scheduling led to missed anticoagulant doses.
Expanding Learning and Enhancing Safety
The findings from the thematic review suggest that incident reports contain valuable information about the ways that safety is supported by the complex system interactions and resilience capacities that may be overlooked by traditional root cause analysis. This expanded understanding enables healthcare providers to move beyond simple linear causes and contributory factors, towards gaining more detailed insights into the complexities of the healthcare system.
By harnessing this information, organisations can enhance patient safety by promoting proactive anticipation and system-level learning. Rather than focusing negatively on what went wrong, this approach recognises the huge amount of time and effort that is spent in making sure patients are safe. It can identify areas where individuals are being relied upon to rescue risky situations and therefore, where better safeguards could be introduced at a system-level. This shift in approach has the potential to improve staff morale, improve patient outcomes, reduce incidents, and foster a culture of continuous improvement within healthcare settings.
What next?
Patient safety is multifaceted and requires a comprehensive understanding of the complex systems within which healthcare is delivered. By examining incident reports through the lens of systems thinking and resilience capacities, we can gain valuable insights into the interactions, both facilitative and inhibitory, that impact patient safety, both of which are essential.
This recognition of the contribution of the complex system and identifying what supported safety along with the factors that contribute to risk will be used in future work that aims to identify ways to measure the safety of insulin when patients move between different care settings, for example between home and hospital. Like anticoagulants, insulin is a medicine that is used long-term, and requires communication and collaboration between people in all care settings, including the patient, to make sure that it is used safely. Hospital admissions and discharges are times of change when there is a risk of things going wrong. Integrated care systems aim to improve care by bringing all services into a single, co-ordinated organisation. Digital systems, supported by appropriate governance arrangements, can be used to allow access to information for all who need it to make decisions safely.
Further research is being undertaken to explore in detail the complex, interacting components that influence how insulin is used safely in these digital systems during transfer of care. These will be used to develop additional measures that can proactively enhance patient safety.
This blog is based on a presentation by an NIHR ARC North Thames researcher at the forthcoming HSR UK Conference 2023. “Thematic review of anticoagulation incident reports using complex systems and resilience frameworks” will be presented by Catherine Leon, London School of Hygiene and Tropical Medicine.
Click here to find out more about Catherine’s PhD project.
