Building Clinical and Organizational Resilience to Reconcile Safety Threats, Tensions and Trade-Offs: Insights from Theory and Evidence

Jeffs, Lianne; Tregunno, Deborah; MacMillan, Kathleen; Espin, Sherry

doi:10.12927/hcq.2009.20971

Cited by 10 publications

(7 citation statements)

References 19 publications

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“…Several interviewees rationalised staff failure to listen in terms of overload in NHS services. The sites studied, despite being located in Trusts assessed as high achieving, may sometimes have functioned in the ‘unsafe zone’34 35 where ‘staff may not have adequate resources to prevent errors and mitigate safety threats’ 36. The failure to listen so frequently reported in our study may be associated with institutional cultures that normalise reduced attention to women's calls for help.…”

Section: Discussionmentioning

confidence: 80%

Women's safety alerts in maternity care: is speaking up enough?

et al. 2013

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This is the unspecified version of the paper.This version of the publication may differ from the final published version. Permanent repository link AbstractPatients' contributions to safety include speaking up about their perceptions of being at risk. Previous studies have found that dismissive responses from staff discouraged patients from speaking up. A Care Quality Commission investigation of a maternity service where serious incidents occurred found evidence that women had routinely been ignored and left alone in labour. Women using antenatal services hesitated to raise concerns that they felt staff might consider irrelevant.The Birthplace in England programme, which investigated the quality and safety of different places of birth for 'low risk' women, included a qualitative organisational case study in four NHS Trusts. The authors collected documentary, observational and interview data from March to December 2010 including interviews with 58 postnatal women. A framework approach was combined with inductive analysis using NVivo8 software.Speaking up, defined as insistent and vehement communication when faced with failure by staff to listen and respond, was an unexpected finding mentioned in half the women's interviews. Fourteen women reported raising alerts about safety issues they felt to be urgent. The presence of a partner or relative, and receiving continuity of care, were facilitating factors for speaking up. Several women described distress and harm that ensued from staff failure to listen.Women are speaking up, but this is not enough: organisation-focused efforts are required to improve staff response. Further research is needed in maternity services as well as acute and general health care on the effectiveness of safety-promoting interventions including real-time patient feedback, patient toolkits and patient-activated rapid response calls.3

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Section: Discussionmentioning

confidence: 80%

Women's safety alerts in maternity care: is speaking up enough?

et al. 2013

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“…, Jeffs et al . , Banja ). In this study, poor practice in the nursing management of CVCs, for example, may have become normalised to the point where it was considered acceptable and standard practice.…”

Section: Discussionmentioning

confidence: 99%

“…It has been argued that shortcuts and violations in the delivery of healthcare may, over time, become acceptable to the point that they become 'normalised' as a new standard of care (Amalberti et al 2006, Jeffs et al 2008, Banja 2010. In this study, poor practice in the nursing management of CVCs, for example, may have become normalised to the point where it was considered acceptable and standard practice.…”

Section: Discussionmentioning

confidence: 99%

Recognising and responding to ‘cutting corners’ when providing nursing care: a qualitative study

Jones

Johnstone

Duke

2016

Journal of Clinical Nursing

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“…The capacity to defend against the potential for minor mishaps having a cumulative effect and escalating into more serious breakdowns is an essential characteristic of a reliable process. It requires a focus on the adequacy of the organisational defenses that remain in reserve and provide 'resilience' to the risk of an event escalating into a major untoward event [32,33]. It is important that our systems catch errors before they escalate and also have defensive capacity beyond this in case the events develop further, i.e.…”

Section: Discussionmentioning

confidence: 99%

Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? - can the checklist help? Supporting evidence from analysis of a national patient incident reporting system

Panesar

Noble

Mirza³

et al. 2011

Journal of Orthopaedic Surgery and Research

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BackgroundSurgical procedures are now very common, with estimates ranging from 4% of the general population having an operation per annum in economically-developing countries; this rising to 8% in economically-developed countries. Whilst these surgical procedures typically result in considerable improvements to health outcomes, it is increasingly appreciated that surgery is a high risk industry. Tools developed in the aviation industry are beginning to be used to minimise the risk of errors in surgery. One such tool is the World Health Organization's (WHO) surgery checklist. The National Patient Safety Agency (NPSA) manages the largest database of patient safety incidents (PSIs) in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm. The aim of this study was to estimate how many incidents of wrong site surgery in orthopaedics that have been reported to the NPSA could have been prevented by the WHO surgical checklist.MethodsThe National Reporting and Learning Service (NRLS) database was searched between 1st January 2008- 31st December 2008 to identify all incidents classified as wrong site surgery in orthopaedics. These incidents were broken down into the different types of wrong site surgery. A Likert-scale from 1-5 was used to assess the preventability of these cases if the checklist was used.Results133/316 (42%) incidents satisfied the inclusion criteria. A large proportion of cases, 183/316 were misclassified. Furthermore, there were fewer cases of actual harm [9% (12/133)] versus 'near-misses' [121/133 (91%)]. Subsequent analysis revealed a smaller proportion of 'near-misses' being prevented by the checklist than the proportion of incidents that resulted in actual harm; 18/121 [14.9% (95% CI 8.5 - 21.2%)] versus 10/12 [83.3% (95%CI 62.2 - 104.4%)] respectively. Summatively, the checklist could have been prevented 28/133 [21.1% (95%CI 14.1 - 28.0%)] patient safety incidents.DiscussionOrthopaedic surgery is a high volume specialty with major technical complexity in terms of equipment demands and staff training and familiarity. There is therefore an increased propensity for errors to occur. Wrong-site surgery still occurs in this specialty and is a potentially devastating situation for both the patient and surgeon. Despite the limitations of inclusion and reporting bias, our study highlights the need to match technical precision with patient safety. Tools such as the WHO surgical checklist can help us to achieve this.

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Building Clinical and Organizational Resilience to Reconcile Safety Threats, Tensions and Trade-Offs: Insights from Theory and Evidence

Cited by 10 publications

References 19 publications

Women's safety alerts in maternity care: is speaking up enough?

Women's safety alerts in maternity care: is speaking up enough?

Recognising and responding to ‘cutting corners’ when providing nursing care: a qualitative study

Can the surgical checklist reduce the risk of wrong site surgery in orthopaedics? - can the checklist help? Supporting evidence from analysis of a national patient incident reporting system

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