The Warwick and Imperial Study of Reliability in healthcare (The WISER study)

Project summary

Background

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:

1. Identify and document a selection of common but important processes within healthcare in which to explore defects in reliability
2. Explore their nature, extent and variation, both within and between organisations
3. Identify the systems factors involved

Methods

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:

1. documentation of the processes involved
2. measurement of reliability using quantitative data collection methods specific to each topic
3. 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:

1. Providing information at the point of clinical decision making
2. Prescribing for hospital inpatients
3. Handover within acute medicine
4. Providing equipment in the operating theatre
5. Providing equipment for the insertion of intravenous lines

Results

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.