The Warwick and Imperial Study of Reliability in healthcare (The WISER study)
Launched by the Health Foundation in October 2008, the Safer Clinical Systems (SCS) programme will test and demonstrate ways to improve healthcare systems or processes to improve patient safety. Experienced teams from five NHS sites are working together with expert advisers to co-design the initial phase of the programme. The WISER research was designed to run in parallel and to support the activities of the four sites participating in phase I of SCS, which runs until 2010.
Aim and objectives
The overall aims of the research are to describe the type, extent and causes of defects in healthcare system reliability that have the potential to cause patient harm, and to provide research support for the Health Foundation’s Safer Clinical Systems (SCS) programme.
Our objectives are to:
- Identify and document a selection of common but important processes within healthcare in which to explore defects in reliability
- Explore their nature, extent and variation, both within and between organisations
- Identify the systems factors involved
The study employs a mixed methods approach using both quantitative and qualitative methods. For each of the topics, data collection has taken place in three stages. These are:
- documentation of the processes involved
- measurement of reliability using quantitative data collection methods specific to each topic
- exploration of the causes of reliability failures using qualitative interviews with key staff at each organisation, using Vincent’s framework of factors that affect clinical practice for analysis.
The study was undertaken in seven NHS organisations. Three of these were participating in phase I of SCS; four were additional organisations selected to increase the breadth of the sample in terms of geographical spread and other characteristics. The five topics are:
- Providing information at the point of clinical decision making
- Prescribing for hospital inpatients
- Handover within acute medicine
- Providing equipment in the operating theatre
- Providing equipment for the insertion of intravenous lines
A significant proportion of the reliability failures identified by this research were associated with risks to patient safety. For example, we found 15% of outpatient appointments were affected by missing clinical information at our study sites. In 20% of these cases, the doctors involved judged the patients to be exposed to what the clinic doctors perceived as risk.
Fully reliable systems would function correctly under expected conditions. The four clinical systems for which reliability could be measured had an average failure rate of 13% - 19%.
Different organisations varied significantly in their reliability: problems such as faulty or missing equipment affected 37% of operations at one organisation but only 12% at another.
Across the five systems and organisations, unreliability was usually the result of the same factors. These included: a lack of feedback mechanisms for both individuals and systems; poor communication; and a widespread acceptance on the part of clinical staff that systems are going to be unreliable, and that this is not their responsibility.
The variation between and within organisations suggests that it is possible to create systems that have higher reliability.
Key project outputs
Peer-reviewed journal articles
- Franklin BD, Deelchand V, Cooke M, Holmes A, Vincent C. The safe insertion of peripheral intravenous catheters: a mixed methods descriptive study of the availability of the equipment needed. Antimicrobial Resistance and Infection Control. 2012; 1:15.
- Franklin BD, Reynolds M, Shebl N and Burnett S. Prescribing errors in hospital inpatients: a multi-centre study of their incidence, types and causes. Submitted to Postgraduate Medical Journal, Februay 2011.
- Burnett S, Deelchand V, Franklin BD, Moorthy K, Vincent C. Missing Clinical Information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care. Submitted to Health Services Research, January 2011
- Deelchand V, Cooke M, Holmes A, Franklin BD, Vincent C. Safe systems to support peripheral intravenous care bundle. Submitted to the Journal of Hospital Infection, February 2011
- Burnett S, Cooke M, Deelchand V, Franklin BD, Holmes A, Moorthy K, Savarit E, Sujan M, Vats A, Vincent C. How safe are clinical systems? Primary research into systems reliability within seven NHS organisations. Read the report here
- Report Summary of WISER was published and launched at the Patient Safety Congress 2010. A copy of the summary report is available on the Health Foundation web site here
Conference presentations and posters
- Burnett S, Deelchand V. Systems design and patient safety: Findings of the WISER (Warwick and Imperial study on reliability of healthcare systems) project. Oral presentation at Patient Safety Congress, May 2010, Birmingham, UK.
- Franklin BD, Reynolds M (2010). A comparative study of prescribing errors in three NHS organisations. Abstract presented at Royal Pharmaceutical Society Conference 5-6 September; London.
- The Warwick and Imperial Study of Reliability in Healthcare (the WISER study): A multi-centre study of healthcare process reliability. Poster presented at Patient Safety Congress (May 2010)
- A multi-centre study of prescribing errors in hospital inpatients. Poster presented at Patient Safety Congress (May 2010)
- A multi-centre study of missing clinical information in outpatient clinics in the UK. Poster presented at Patient Safety Congress (May 2010)
- A multi-centre study of handover within acute medicine. Poster presented at Patient Safety Congress (May 2010)
- A multi-centre study on safe systems for insertion of IV lines. Poster presented at Hospital Infection Society International Conference (Oct 2010)