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Transcript of Framing and Measuring Patient Safety Dr Jeanette Jackson ([email protected])[email protected]...
![Page 1: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/1.jpg)
Framing and Measuring Patient Safety
Dr Jeanette Jackson
This SPSRN work is funded by
![Page 2: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/2.jpg)
Outline
Introduction
Objectives
Framing Patient Safety Research
1. Examples of Industry Models for Safety Research
2. Examples of Patient Safety Models
3. Multilevel Framework of Patient Safety Research
Measuring Patient Safety Research
![Page 3: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/3.jpg)
Introduction
• Effective management of patient safety in healthcare requires:
1. an understanding of the causes of adverse events and related outcomes
2. a capacity to measure adverse events and their causes as well as related outcomes at different levels (individual, unit, organization, industry, national, international)
• Measurement of industry safety status is achieved by a range of methods based on key performance indicators for risk factors and safety events as well as leading indicators for safety (including causes like cultural factors)
![Page 4: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/4.jpg)
Objectives
1. To propose a causal framework for patient safety outcomes
2. To review possible methods for the relevant variables in each component of the framework with particular reference to acute hospitals
![Page 5: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/5.jpg)
Framing Patient Safety Research
Examples of Industry Models for Safety Research:
1) ‘Swiss Cheese’ model of accident causation (Reason, 1997)
DANGERSome ‘holes’due to active
failures
Other ‘holes’due to latent conditions
Defences in depth
DANGERDANGERSome ‘holes’due to active
failures
Other ‘holes’due to latent conditions
Defences in depth
![Page 6: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/6.jpg)
Framing Patient Safety Research
Examples of Industry Models for Safety Research:
1) ‘Swiss Cheese’ model of accident causation (Reason, 1997)
2) Vincent et al. (2000): Reason’s model within the healthcare setting
![Page 7: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/7.jpg)
Framing Patient Safety Research
Examples of Industry Models for Safety Research:
1) ‘Swiss Cheese’ model of accident causation (Reason, 1997)
2) Vincent et al. (2000): Reason’s model within the healthcare setting
3) Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep)
![Page 8: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/8.jpg)
External Influences
Organization Intervening Behaviours Outcomes
National Culture
Economic
Regulator
Government Targets
Safety Culture
Leadership
HR Practices
Safety ManagementPractices
Motivation
Wellbeing Morale
Knowledge
Safe
Compliance
Reporting
Speaking Up
Unsafe
Risk taking
Risk breaking
Plant/Worker Safety
Patient Safety
Framing Patient Safety Research
3) Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep)
![Page 9: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/9.jpg)
Framing Patient Safety Research
Examples of Industry Models for Safety Research:
1) ‘Swiss Cheese’ model of accident causation (Reason, 1997)
2) Vincent et al. (2000): Reason’s model within the healthcare setting
3) Factors influencing safety behaviours and safety outcomes at different levels of analysis (Flin, in prep)
4) Threat and Error model (Helmreich, 2000)
![Page 10: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/10.jpg)
Framing Patient Safety Research
4) Threat and Error model (Helmreich, 2000)
![Page 11: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/11.jpg)
Framing Patient Safety Research
Examples of Patient Safety Models:
1) Generic Reference Model (GRM, Runciman et al., 2006)
![Page 12: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/12.jpg)
![Page 13: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/13.jpg)
Framing Patient Safety Research
Examples of Patient Safety Models:
1) Generic Reference Model (GRM, Runciman et al., 2006)
2) Conceptual Framework for the International Classification for Patient Safety (ICPS, WHO Drafting Group of the Project to Develop the International Classification for Patient Safety, 2008)
![Page 14: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/14.jpg)
Contributing Factors/Hazards
Patient Characteristics
Ameliorating Actions
System Resilience (Proactive & Reactive Risk Assessment)
Clinically meaningful, recognizable categories for incident identification & retrieval
Descriptive information
Organizational Outcomes
Detection
Mitigating Factors
Actions Taken to
Reduce Risk or Harm
Actio
ns
T
aken to
R
edu
ce R
isk or
Harm
Incident Characteristics
Patient Outcomes
IncidentIncident Type
Influences Informs
Influences
Influences
Informs
Informs
Informs Informs
Informs Informs
![Page 15: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/15.jpg)
Framing Patient Safety Research
Examples of Patient Safety Models:
1) Generic Reference Model (GRM, Runciman et al., 2006)
2) Conceptual Framework for the International Classification for Patient Safety (ICPS, WHO Drafting Group of the Project to Develop the International Classification for Patient Safety, 2008)
3) Donabedian’s (1966) ‘triad’ of structure, process and outcome
4) Brown et al.’s (2008) adaptation of Donabedian’s ‘triad’
![Page 16: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/16.jpg)
Framing Patient Safety Research
4) Brown et al.’s (2008) adaptation of Donabedian’s ‘triad’
Structure Patient OutcomesClinical Processes
- Error
Fidelity
Management Processes
Fidelity
Intervening Variables
e.g. morale, culture
Generic Intervention
Specific Intervention Throughput
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Framing Patient Safety Research
Multilevel Framework of Patient Safety Research (Jackson & Flin, in prep):
Organizational Factors
Unit Management
WorkerBehaviours
Outcomes
Individual Differences
• Based on the causal chain and different levels of analysis (i.e., individual, team, unit, and organisational) proposed by industrial and patient safety models
• Applies within an organisation even though external factors such as government and regulators responsibilities exist outside an organisation
![Page 18: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/18.jpg)
Measuring Patient Safety Research
Medical records
Incident reporting systems
Prospective analysis tools
Questionnaires
Direct observations and video techniques
Interviews
Simulations
Claims and complaints
Shift reporting
Autopsy reports
Checklists and audits
![Page 19: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/19.jpg)
Measuring Patient Safety Research
Method
Component
Organizational Factors
Unit Management
Worker Behaviours
Individual Differences
Outcomes
Medical records
Questionnaires
Claims and Complaints
![Page 20: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/20.jpg)
Measuring Patient Safety Research
Medical records
• ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003)
![Page 21: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/21.jpg)
Measuring Patient Safety Research
Method
ComponentOrganizational
FactorsUnit
ManagementWorker
BehavioursIndividual
DifferencesOutcomes
Medical records
x
![Page 22: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/22.jpg)
Measuring Patient Safety Research
Medical records
• ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003)
Questionnaires
• Provide information about people’s knowledge, beliefs, attitudes and behaviours
• Wide range of questionnaires including instruments measuring Safety Culture Safety improvement requires a culture of the healthcare system that is
not regarded as a potential risk factor threatening the patient
![Page 23: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/23.jpg)
Measuring Patient Safety Research
Method
ComponentOrganizational
FactorsUnit
ManagementWorker
BehavioursIndividual
DifferencesOutcomes
Medical records
x
Questionnaires x x x x x
![Page 24: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/24.jpg)
Measuring Patient Safety Research
Medical records
• ‘Triggers’ to measure patient harm to identify adverse events in medical records (Rozich et al., 2003)
Questionnaires
• Provide information about people’s knowledge, beliefs, attitudes and behaviours
• Wide range of questionnaires including instruments measuring Safety Culture Safety improvement requires a culture of the healthcare system that is
not regarded as a potential risk factor threatening the patient
Claims and complaints
• Incidence data, experience with intervention programmes, starting point for reviews of patient safety data and activities
![Page 25: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/25.jpg)
Measuring Patient Safety Research
Method
Component
Organizational Factors
Unit Management
Worker Behaviours
Individual Differences
Outcomes
Medical records
x
Questionnaires x x x x x
Claims and Complaints
x x x
![Page 28: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/28.jpg)
Organizational Factors: include stressors on the system Available resources (e.g., staffing, equipment) Responsibilities of the senior management (e.g., setting standards and goals within the organisation)
Unit Management: Wide range of behaviours that influence outcomes (e.g., planning, delegating, scheduling, providing training and supervision, leadership, communication, decision making)
Worker Behaviours: Reporting at unit / team level Safety participation / compliance at individual level Non-technical skills (e.g., teamwork, speaking up)
Outcomes: Wide range of outcomes affecting the patient (e.g., infections, surgical incidents, adverse drug events) and the worker (e.g., injuries)
Individual Differences: possible mediators e.g., motivation, knowledge, fatigue, burnout
Organizational Factors
Unit Management
WorkerBehaviours
Outcomes
Individual Differences
![Page 29: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/29.jpg)
Method
ComponentOrganizational
FactorsUnit
ManagementWorker
BehavioursIndividual
DifferencesOutcomes
Incident reporting systems
Prospective analysis tools
Direct observations and video techniques
Interviews
Simulations
Shift reporting
Autopsy reports
Checklists and audits
![Page 30: Framing and Measuring Patient Safety Dr Jeanette Jackson (j.jackson@abdn.ac.uk)j.jackson@abdn.ac.uk This SPSRN work is funded by.](https://reader036.fdocuments.net/reader036/viewer/2022070407/56649e375503460f94b274b6/html5/thumbnails/30.jpg)
Method
ComponentOrganizational
FactorsUnit
ManagementWorker
BehavioursIndividual
DifferencesOutcomes
Incident reporting systems
x x x
Prospective analysis tools
x x x x x
Direct observations and video techniques
x x x x x
Interviews x x x
Simulations x
Shift reporting x
Autopsy reports
x
Checklists and audits
x