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Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report

Ensuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallib...

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Autor principal: Machen, Samantha
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2023
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10163506/
https://www.ncbi.nlm.nih.gov/pubmed/37130696
http://dx.doi.org/10.1136/bmjoq-2022-002020
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author Machen, Samantha
author_facet Machen, Samantha
author_sort Machen, Samantha
collection PubMed
description Ensuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult. This paper puts forward an argument for themed reviews of patient safety incidents and provides an illustrative template for theming incidents using a human factors classification tool. This allows groups of incidents relating to the same portfolio, for example, medication errors, falls, pressure ulcer, diagnostic error, to be analysed at the same time and result in recommendations based on a larger sample size of incidents and based on a systems approach. This paper will present extracts of the themed review template trialled and argues that thematic reviews, in this context, allowed for a better understanding of the system of safety around the mismanagement of the deteriorating patient.
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spelling pubmed-101635062023-05-07 Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report Machen, Samantha BMJ Open Qual Quality Improvement Report Ensuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult. This paper puts forward an argument for themed reviews of patient safety incidents and provides an illustrative template for theming incidents using a human factors classification tool. This allows groups of incidents relating to the same portfolio, for example, medication errors, falls, pressure ulcer, diagnostic error, to be analysed at the same time and result in recommendations based on a larger sample size of incidents and based on a systems approach. This paper will present extracts of the themed review template trialled and argues that thematic reviews, in this context, allowed for a better understanding of the system of safety around the mismanagement of the deteriorating patient. BMJ Publishing Group 2023-05-02 /pmc/articles/PMC10163506/ /pubmed/37130696 http://dx.doi.org/10.1136/bmjoq-2022-002020 Text en © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. https://creativecommons.org/licenses/by-nc/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ (https://creativecommons.org/licenses/by-nc/4.0/) .
spellingShingle Quality Improvement Report
Machen, Samantha
Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title_full Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title_fullStr Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title_full_unstemmed Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title_short Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
title_sort thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report
topic Quality Improvement Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10163506/
https://www.ncbi.nlm.nih.gov/pubmed/37130696
http://dx.doi.org/10.1136/bmjoq-2022-002020
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