Our research 1999 to 2007

CSRU has led patient safety research in the UK for over a decade. This section summarises some of our key research between 1997 and 2007.

 

Error Reduction in Healthcare

Funded by the Nuffield Trust.

In 1999 we published a protocol for the investigation and analysis of adverse events in acute settings for use by risk managers and others in the NHS. This is now in use both nationally and internationally. We are currently refining the protocol and modifying it for use in mental health and primary care domains. We have also recently reviewed accident investigation and analysis methodologies used in other high risk industries such as nuclear power, chemical and aviation. Industrial methods, unlike health service models, often contain a module on error reduction to facilitate organisational learning. As yet however none of the various healthcare incident investigation and analysis methods have developed to the point of providing solutions for the problems uncovered.

The next developmental step, addressed in the present proposal, is to specify error reduction methods at the conclusion of incident investigations. Linking specific error reduction techniques to the findings of investigations, rather than just making broad recommendations, would greatly increase the impact and value of such investigations. The principal aims of this project are:

• To review error reduction methods used in high-risk industries and assess their potential utility in healthcare;
• To review methods of error reduction in healthcare to determine the range and nature of available methods;
• To produce an error reduction module for use in conjunction with our protocol for investigation and analysis; and

• To pilot the error reduction process in a sample of investigations and case analyses.

 

Getting clinicians involved in assessing the quality of care in hospital practice

Over the past 10 years epidemiological studies, based on retrospective case record review, have revealed that about 10% patients admitted to hospital suffer an adverse event. These data stem from case record studies designed to explore clinical litigation in the USA . In Australia the methodology was adapted to explore quality in healthcare and this has been used in the UK , New Zealand , Denmark , France , Canada and other countries that have yet to publish the results of their studies.

Despite these reports little progress has been made in developing methods to improve the quality of hospital care. In part, this reflects the lack of structures for hospital clinicians to monitor the effects of medical management especially in non-specialist areas. Dr Berwick, Chairman and Chief Executive of the Institute of Healthcare improvement, believes that it will be costly to improve the situation and will require cultural changes. These changes will require new methods of training and support aiming to develop better teamwork between doctors and nurses; the re-designing of jobs; and massive technical changes especially in relation to computerisation.

In our research we have picked up on a lead from Dr Peter Simpson, Chairman of National Confidential Enquiry into Patient Outcomes and Deaths “If you want a hospital system that requires clinicians to change their practice it works best if it is clinically led” (. BMJ 2004; 328: 248.)

We have designed and run a clinician-led system to address errors in practice. This has now been used in several countries – most recently in India and Spain . Sisse Olsen has been co-opted on to a World Health Organisation committee concerned to improve the quality of hospital care across the world.

 

A Review of NHS Litigation Databases

Joint Project with University of Manchester Funded by the Department of Health.

Researchers and policy makers have been suggesting for sometime that analysis of negligence claims against the NHS may provide useful insights into the nature and cause of error. Previous information that can be obtained from British medico-legal cases is limited but there is a suggestion that there is considerable potential for the extraction of valuable information.

The Department of Health commissioned a consortium to undertake a research project aimed at examining whether and how information about claims for clinical negligence against the NHS could be used to learn lessons and bring about improvements in patient safety. The CSRU (Imperial College London) was part of the consortium, which was led by the University of Manchester.

The project findings have been published in a series of three reports, detailed below, and in a concise project summary Litigation project summary .

1. The epidemiology of error: an analysis of databases of clinical negligence litigation reports on the first phase of the project, in which the data from litigation databases was collated and used to examine the epidemiology of error and the quality and utility of that data in improving patient safety. Epidemiology of error
2. Learning from litigation: an analysis of claims for clinical negligence reports on the second phase of the project, in which a series of cases in four specialties were analysed using a structured process of claims review aiming at examining causation and contributory factors. It discusses the potential value of such claims reviews, and some of the problems and limitations involved in using them to examine patient safety issues. Learning from litigation
3. Case studies in litigation: claims reviews in four specialties contains the detailed reports on claims reviews in four specialties – primary care, general medicine and surgery; psychiatry; and obstetrics. In each case the reviewers report on the common characteristics and lessons learned from the case reviews, and on the process of review itself. Case study of litigation

  

Teamwork and Team Performance in the Operating Theatre

Team performance is increasingly recognised as an essential foundation of good surgical care and as a determinant of good surgical outcome. In order to understand team performance and to develop team training, reliable and valid measures of team performance are necessary. High reliability organisations such as aviation have highlighted the complexity of measuring team performance in dynamic multi-professional environments. Effective team coordination is underpinned by the understanding of each other's functional roles and objectives along with shared mental models. Interdisciplinary teamwork in surgery currently lacks models and objective measures of performance, important for assessment and formative feedback in practice and training and for developing surgical teams of the future. Furthermore restructuring of the workforce in healthcare has changed the traditional team approach necessitating increased awareness of individual members' responsibilities and limitations, especially during crises.

The aims of this project are the following:

1. To explore the discrepancies between expectations of team members and reality.
2. To develop and validate an observational assessment of teamwork designed to capture the essentials of the surgical process.
3. To develop and pilot a team training module using multi-disciplinary crisis scenarios in a simulated operating theatre environment to train surgical teams.
4. To develop and pilot a tool that assesses observable distractions in and interruptions to the surgical process.