Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care

Bowie, Paul; McNaughton, Elaine; Bruce, David; Holly, Deirdre; Forrest, Eleanor; Macleod, Marion; Kennedy, Simon; Power, Ailsa; Toppin, Denis; Black, Irene; Pooley, Janet; Taylor, Audrey; Swanson, Vivien; Kelly, Moya; Ferguson, Julie; Stirling, Suzanne Anderson; Wakeling, Judy; Inglis, Angela; McKay, John; Sargeant, Joan

doi:10.1097/ceh.0000000000000098

Cited by 19 publications

(6 citation statements)

References 25 publications

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“…The findings of this study suggest that while the underlying concept of NEs, avoiding serious preventable patient safety incidents, would be supported in general practice, the name ‘NEs’ could reduce the coherence and cognitive participation of GPs in practice. There was an initial buy-in to the underlying NE concept by participants when situated within a learning and systems approach to implementation,20 however, the content of the individual NEs on the list also influenced engagement. Some NEs were considered more relevant and amenable to simple solutions than others which could influence implementation.…”

Section: Discussionmentioning

confidence: 99%

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of ‘never events’

et al. 2019

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ObjectivesTo examine general practitioner (GP) understanding of the never event (NE) concept in general practice, and to identify potential enablers and barriers to implementation in UK general practice.DesignQualitative study using focus groups. The data were analysed thematically and were informed by the normalisation process theory.SettingGeneral practice in Northwest England and Southwest Scotland.Participants25 GPs took part in five focus groups. 13 GPs were female and 12 male with an age range of 28–60.ResultsThe NE approach of avoiding serious preventable adverse outcomes from healthcare fitted with participants expectations of the delivery of care but the implementation of strategies to prevent the specific NE was considered complex and variable. The main themes identified participants’ understandings and perceived limitations of the NE concept; the embedded layers of responsibility to implement NE within practices and the work required for implementation within general practices. Participants’ accounts highlighted the differential nature of work in general practice and that the implementation of initiatives to address specific NE should be situated within a learning and systems approach to implementation. Some NEs were considered more relevant and amenable to simple solutions than others which could influence implementation.ConclusionsThe NE concept was considered overall an important approach to help address key primary care patient safety issues. The utility of individual NEs may vary depending on the complexity of the initiatives that would be needed to manage related risks to as low as reasonably practicable.

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Section: Discussionmentioning

confidence: 99%

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of ‘never events’

et al. 2019

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“…According to Bowie et al (2003) , the adjective “significant” is a general term commonly applied to events or incidents described as critical, adverse, near misses, or errors. As Charmaz (2006) points out, meaningful scenes allow the freezing and lengthening of time so that it is possible to dialogue with them.…”

Section: Methodsmentioning

confidence: 99%

Students’ Experiences in Suddenly Transformed Living and Educational Environments by COVID-19

Hernández-Hernández

Sáncho-Gil

2021

Front. Psychol.

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This manuscript builds on research about how university students felt affected by the Covid19 pandemic and, especially, by the irruption of non-face-to-face classes and mixed teaching methods in this context. How have young people experienced this situation? How has it affected their wellbeing and the learning strategies should develop have had to incorporate into their virtual relationships? their virtual relationships? How have they related and relate to virtual tools for a task that they have always experienced face-to-face? To answer these questions, the TRAY-AP project that investigates how university students learn collected 89 scenes that show the effects of the Covid 19 on their lives and the university. We grouped these scenes into seven key concepts to detect how students were emotionally affected, especially by moving from face-to-face to virtual learning. From this analysis, although primarily negative, the emotional effects have also allowed them to generate positive strategies for readaptation and collaboration with other colleagues. All of which opens the way to rethink the predominant pedagogical and knowledge relations in the university.

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“…Encouragingly from our experiences some organisations are providing primary care with access to reporting systems traditionally used in secondary care. Recent research also reports development of a systems-based approach to the analysis of 'significant events' in primary care [46].…”

Section: Incident Reporting and Learningmentioning

confidence: 99%

Is the ‘never event’ concept a useful safety management strategy in complex primary healthcare systems?

Bowie

Baylis²,

Price³

et al. 2021

International Journal for Quality in Health Care

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Why is the area important? A sub-group of rare but serious patient safety incidents, known as ‘never events,’ is judged to be ‘avoidable.’ There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of ‘preventable harm’ with zero tolerance ‘never events,’ especially around the lack of evidence for such harm ever being totally preventable. What is already known and gaps in knowledge? We consider whether the ideal of reducing preventable harm to ‘never’ is better for patient safety than, for example, the goal of managing risk materializing into harm to ‘as low as reasonably practicable,’ which is well-established in other complex socio-technical systems and is demonstrably achievable. We reflect on the ‘never event’ concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care ‘never event’ lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. Future areas for advancing research and practice Despite their rarity, if there is to be a policy focus on ‘never events,’ then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The ‘never event’ term is well intentioned but largely aspirational—however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

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Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care

Cited by 19 publications

References 25 publications

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of ‘never events’

Never events in general practice: a focus group study exploring the views of English and Scottish general practitioners of ‘never events’

Students’ Experiences in Suddenly Transformed Living and Educational Environments by COVID-19

Is the ‘never event’ concept a useful safety management strategy in complex primary healthcare systems?

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