ObjectivesThe current research project sought to map out the regulatory landscape for patient saf... more ObjectivesThe current research project sought to map out the regulatory landscape for patient safety in the English National Health Service (NHS).MethodWe used a systematic desk-based search using a variety of sources to identify the total number of organisations with regulatory influence in the NHS; we researched publicly available documents listing external inspection agencies, participated in advisory consultations with NHS regulatory compliance teams and reviewed the websites of all regulatory agencies.ResultsOur mapping revealed over 126 organisations who exert some regulatory influence on NHS provider organisations in addition to 211 Clinical Commissioning Groups. The majority of these organisations set standards and collect data from provider organisations and a considerable number carry out investigations. We found a multitude of overlapping functions and activities. The variability in approach and overlapping functions suggest that there is no overall integrated regulatory ...
The aviation industry calls the most frequently recurring factors that lead to incidents ‘the Dir... more The aviation industry calls the most frequently recurring factors that lead to incidents ‘the Dirty Dozen.’ The ‘Dirty Dozen’ includes, for example, stress, distractions and interruptions, team norms etc. The article adapts the concept of the Dirty Dozen from aviation to explore resilience in operating theatres. Taking a Safety II perspective, the article introduces the ‘Durable Dozen’: 12 regulatory, organisational, team and individual behaviours that enable theatre teams to resolve safety threats.
Every safety-critical industry devotes considerable time and resource to investigating and analys... more Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the soci...
The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisat... more The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisations in assessing safety. The Health Foundation funded a large-scale programme to assess the value and impact of applying the Framework in regional and frontline care settings. We explored the experiences and reflections of key participants in the programme. The study was conducted in the nine healthcare organisations in England and Scotland testing the Framework (three regional improvement bodies, six frontline settings). Post hoc interviews with clinical and managerial staff were analysed using template analysis. Participants reported that the Framework promoted a substantial shift in their thinking about how safety is actively managed in their environment. It provided a common language, facilitated a more inquisitive approach and encouraged a more holistic view of the components of safety. These changes in conceptual understanding, however, did not always translate into broader change...
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours deteriorations (p=0.04 for Phase 3 vs Phase 1 for both measures (CI 1.04 to 4.08; CI 1.03 to 4.33), and for Phase 3 vs Phase 2 (p=0.006 and p=0.001 (CI 1.22 to 5.15; CI 1.62 to 9.0)), respectively). The Phase 1 and 2 handover protocols were effective at identifying patients whose clinical condition warranted review overnight. Performance on both surrogate outcome measures, length of handover and distractions, deteriorated in Phase 3. A carefully designed prioritisation process within the H@N handover can be effective at flagging acutely unwell patients. However, the protocol we introduced was unsustainable. In a complex healthcare system, sustainable implementation of new processes may be threatened by conflicting goals.
Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2000
Human factors research in medicine typically focuses on understanding and controlling those facto... more Human factors research in medicine typically focuses on understanding and controlling those factors which lead to adverse events. However, it is also important to understand the factors that lead to excellence in complex, dynamic medical systems so that clinicians can learn from ‘what goes right’ as well as ‘what goes wrong.’ This paper discusses the application of a framework of surgical excellence, developed from a multi-center UK study on human factors and the outcomes of the arterial switch operation (ASO), to other medical domains (cardiac intensive care unit and hematology/oncology ward).
This article describes the Manchester Patient Safety Framework (MaPSaF) and summarizes some early... more This article describes the Manchester Patient Safety Framework (MaPSaF) and summarizes some early experiences with using it to help healthcare organizations and teams reflect on their progress in developing a mature patient safety culture.
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours dete...
The paper summarises previous theories of accident causation, human error, foresight, resilience ... more The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety. Significance for public healthThe article identifies lessons from previous theories of human error and accident causation, foresight, resilience engineering and system migration and introduces a new framework for understanding patient safety in healthcare; the System Evolution, Erosion and Enhancement (SEEE) model. The article is significant for public health because healthcare organizations around the world need to understand how safety evolves and erodes to develop and implement interventions to reduce patient...
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours dete...
Operating theatre teams work in an imperfect system characterised by time pressure, goal conflict... more Operating theatre teams work in an imperfect system characterised by time pressure, goal conflicts, lack of team stability and steep authority gradients between consultants and other team members. Despite this, they often foresee and forestall errors that could harm patients. The paper discusses the strengths and limitations of using Reason's three buckets model of error prevention as a framework for training operating theatre staff how to foresee and forestall incidents.
Nursing standard (Royal College of Nursing (Great Britain) : 1987)
Patient safety incidents have physical and emotional consequences for those involved, including p... more Patient safety incidents have physical and emotional consequences for those involved, including patients, carers, relatives and healthcare staff. This article, the fifth of seven in this series, focuses on Step Five of the Seven Steps to Patient Safety (National Patient Safety Agency (NPSA) 2004): involve and communicate with patients and the public. The article discusses how to communicate with patients and their carers who have been involved in a patient safety incident that led to moderate harm, severe harm or death.
AS A RESULT OF PROFESSIONAL, public and political pressure, the medical field is becoming increas... more AS A RESULT OF PROFESSIONAL, public and political pressure, the medical field is becoming increasingly aware of the need to understand the role played by human error in adverse events (ie near misses, critical incidents and deaths). In a recent edition of the British Medical ...
Patients, clinicians and managers all want to be reassured that their healthcare organisation is ... more Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. The Francis Inquiry report into patient treatment at the Mid Staffordshire NHS Foundation Trust set out 29 recommendations on measurement, more than on any other topic, and set the measurement of safety an absolute priority for healthcare organisations. The Berwick review found that most healthcare organisations at present have very little capacity to analyse, monitor or learn from safety and quality information. This paper summarises the findings of a more extensive report and proposes a framework which can ...
We demonstrate the use of dynamic longitudinal models to investigate error management in cardiac ... more We demonstrate the use of dynamic longitudinal models to investigate error management in cardiac surgery. Case study data were collected from a multicentre study of the neonatal arterial switch operation (ASO). Information on two types of negative events, or 'errors', observed during surgery, major and minor events, was extracted from case studies. Each event was judged to be recovered from (compensated) or not (uncompensated). The aim of the study was to model compensation given the occurrence of past events within a case. Two models were developed, one for the probability of compensating for a major event and a second model for the probability of compensating for a minor event. Analyses based on dynamic logistic regression models suggest that the total number of preceding minor events, irrespective of compensation status, is negatively related with the ability to compensate for major events. The alternative use of random effects models is investigated for comparison purposes.
ObjectivesThe current research project sought to map out the regulatory landscape for patient saf... more ObjectivesThe current research project sought to map out the regulatory landscape for patient safety in the English National Health Service (NHS).MethodWe used a systematic desk-based search using a variety of sources to identify the total number of organisations with regulatory influence in the NHS; we researched publicly available documents listing external inspection agencies, participated in advisory consultations with NHS regulatory compliance teams and reviewed the websites of all regulatory agencies.ResultsOur mapping revealed over 126 organisations who exert some regulatory influence on NHS provider organisations in addition to 211 Clinical Commissioning Groups. The majority of these organisations set standards and collect data from provider organisations and a considerable number carry out investigations. We found a multitude of overlapping functions and activities. The variability in approach and overlapping functions suggest that there is no overall integrated regulatory ...
The aviation industry calls the most frequently recurring factors that lead to incidents ‘the Dir... more The aviation industry calls the most frequently recurring factors that lead to incidents ‘the Dirty Dozen.’ The ‘Dirty Dozen’ includes, for example, stress, distractions and interruptions, team norms etc. The article adapts the concept of the Dirty Dozen from aviation to explore resilience in operating theatres. Taking a Safety II perspective, the article introduces the ‘Durable Dozen’: 12 regulatory, organisational, team and individual behaviours that enable theatre teams to resolve safety threats.
Every safety-critical industry devotes considerable time and resource to investigating and analys... more Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the soci...
The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisat... more The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisations in assessing safety. The Health Foundation funded a large-scale programme to assess the value and impact of applying the Framework in regional and frontline care settings. We explored the experiences and reflections of key participants in the programme. The study was conducted in the nine healthcare organisations in England and Scotland testing the Framework (three regional improvement bodies, six frontline settings). Post hoc interviews with clinical and managerial staff were analysed using template analysis. Participants reported that the Framework promoted a substantial shift in their thinking about how safety is actively managed in their environment. It provided a common language, facilitated a more inquisitive approach and encouraged a more holistic view of the components of safety. These changes in conceptual understanding, however, did not always translate into broader change...
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours deteriorations (p=0.04 for Phase 3 vs Phase 1 for both measures (CI 1.04 to 4.08; CI 1.03 to 4.33), and for Phase 3 vs Phase 2 (p=0.006 and p=0.001 (CI 1.22 to 5.15; CI 1.62 to 9.0)), respectively). The Phase 1 and 2 handover protocols were effective at identifying patients whose clinical condition warranted review overnight. Performance on both surrogate outcome measures, length of handover and distractions, deteriorated in Phase 3. A carefully designed prioritisation process within the H@N handover can be effective at flagging acutely unwell patients. However, the protocol we introduced was unsustainable. In a complex healthcare system, sustainable implementation of new processes may be threatened by conflicting goals.
Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2000
Human factors research in medicine typically focuses on understanding and controlling those facto... more Human factors research in medicine typically focuses on understanding and controlling those factors which lead to adverse events. However, it is also important to understand the factors that lead to excellence in complex, dynamic medical systems so that clinicians can learn from ‘what goes right’ as well as ‘what goes wrong.’ This paper discusses the application of a framework of surgical excellence, developed from a multi-center UK study on human factors and the outcomes of the arterial switch operation (ASO), to other medical domains (cardiac intensive care unit and hematology/oncology ward).
This article describes the Manchester Patient Safety Framework (MaPSaF) and summarizes some early... more This article describes the Manchester Patient Safety Framework (MaPSaF) and summarizes some early experiences with using it to help healthcare organizations and teams reflect on their progress in developing a mature patient safety culture.
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours dete...
The paper summarises previous theories of accident causation, human error, foresight, resilience ... more The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety. Significance for public healthThe article identifies lessons from previous theories of human error and accident causation, foresight, resilience engineering and system migration and introduces a new framework for understanding patient safety in healthcare; the System Evolution, Erosion and Enhancement (SEEE) model. The article is significant for public health because healthcare organizations around the world need to understand how safety evolves and erodes to develop and implement interventions to reduce patient...
We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paedia... more We developed protocols to handover patients from day to hospital at night (H@N) teams. NHS paediatric specialist hospital. We observed four handover protocols (baseline, Phases 1, 2 and 3) over 2 years. A mixed-method study (observation, interviews, task analysis, prospective risk assessment, document and case note review) explored the impact of different protocols on performance. In Phase 1, a handover protocol was introduced to resolve problems with the baseline H@N handover. Following this intervention, two further revisions to the handover occurred, driven by staff feedback (Phases 2 and 3). Variations in performance between handover protocols on three process measures, start time efficiency, total length of handover, and number of distractions and interruptions, were identified. Univariate regression analysis showed statistically significant differences between handover protocols on two surrogate outcome measures: number of flagging omissions and the number of out of hours dete...
Operating theatre teams work in an imperfect system characterised by time pressure, goal conflict... more Operating theatre teams work in an imperfect system characterised by time pressure, goal conflicts, lack of team stability and steep authority gradients between consultants and other team members. Despite this, they often foresee and forestall errors that could harm patients. The paper discusses the strengths and limitations of using Reason's three buckets model of error prevention as a framework for training operating theatre staff how to foresee and forestall incidents.
Nursing standard (Royal College of Nursing (Great Britain) : 1987)
Patient safety incidents have physical and emotional consequences for those involved, including p... more Patient safety incidents have physical and emotional consequences for those involved, including patients, carers, relatives and healthcare staff. This article, the fifth of seven in this series, focuses on Step Five of the Seven Steps to Patient Safety (National Patient Safety Agency (NPSA) 2004): involve and communicate with patients and the public. The article discusses how to communicate with patients and their carers who have been involved in a patient safety incident that led to moderate harm, severe harm or death.
AS A RESULT OF PROFESSIONAL, public and political pressure, the medical field is becoming increas... more AS A RESULT OF PROFESSIONAL, public and political pressure, the medical field is becoming increasingly aware of the need to understand the role played by human error in adverse events (ie near misses, critical incidents and deaths). In a recent edition of the British Medical ...
Patients, clinicians and managers all want to be reassured that their healthcare organisation is ... more Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. The Francis Inquiry report into patient treatment at the Mid Staffordshire NHS Foundation Trust set out 29 recommendations on measurement, more than on any other topic, and set the measurement of safety an absolute priority for healthcare organisations. The Berwick review found that most healthcare organisations at present have very little capacity to analyse, monitor or learn from safety and quality information. This paper summarises the findings of a more extensive report and proposes a framework which can ...
We demonstrate the use of dynamic longitudinal models to investigate error management in cardiac ... more We demonstrate the use of dynamic longitudinal models to investigate error management in cardiac surgery. Case study data were collected from a multicentre study of the neonatal arterial switch operation (ASO). Information on two types of negative events, or 'errors', observed during surgery, major and minor events, was extracted from case studies. Each event was judged to be recovered from (compensated) or not (uncompensated). The aim of the study was to model compensation given the occurrence of past events within a case. Two models were developed, one for the probability of compensating for a major event and a second model for the probability of compensating for a minor event. Analyses based on dynamic logistic regression models suggest that the total number of preceding minor events, irrespective of compensation status, is negatively related with the ability to compensate for major events. The alternative use of random effects models is investigated for comparison purposes.
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Papers by Jane Carthey