2021_Book_TextbookOfPatientSafetyAndClin

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12 From Theory to Real-World Integration: Implementation Science and Beyond 153 potential for introducing error. These principles and values are again consistent both with the participatory ergonomics principles and with recent calls for transdisciplinary teams focused on engaging with all relevant stakeholders. It is therefore clear that HFE is a salient discipline for the problems faced by the healthcare system relating to patient safety. The application of the HFE participatory approach within healthcare has been extensively researched with Hignett et al. (2005) illustrating the numerous benefits associated with such an approach. Within the context of this book chapter, the ability of participatory ergonomics tactics to promote transdisciplinarity in team characteristics [47], is also an important consideration [46]. This is vital as earlier aspects of this chapter highlight the increasing need for transdisciplinary team collaboration for solving complex healthcare and patient safety issues. Unfortunately, currently HFE is only well established in the West and has little traction in many countries in the Global South (see Thatcher and Todd 2019 for further details [46]). Furthermore, when there are multinational transdisciplinary teams working in healthcare in emerging economies, the nature of the collaboration is typically poor; this is in spite of good practice frameworks existing. Schneider and Maleka (2018) and Hedt- Gauthier et al. (2018) have both illustrated the problematic nature of these relationships in healthcare. These problems are not isolated to healthcare settings, with Thatcher and Todd (2019) that it is necessary to foster respectful progress through a program of action that acknowledges the lessons that the people of the Global South can teach the North. 12.3 Way Forward 12.3.1 International Ergonomics Association General Framework Model International Ergonomics Association in response the problems identified above has developed a General Framework Model that is focused on using the values of HFE to guide their interactions and collaborative development efforts in LMICs. Evidence of patient safety interventions have been mainly based on high cost projects in HICs. This evidence needs translation and adaptation when developed for LMICs. Human Factors and Ergonomics (HFE) and in particular the IEA General Framework Model are the suggested research approaches to adapt tools to the context within which they will be applied. Indeed Thatcher and Todd (2019) recently argued that training and implementation models must focus on up skilling local capacity allowing LIC and LMIC countries to solve their own problems, thus recognizing the emergent characteristics of patient safety issues and the emergent nature of organizational culture. The IEA approach is consistent with this and is underpinned by several philosophical standpoints published in the international development standing committee of the IEA triennial report from 2018. These focus on: 1 An engagement with, and understanding of, how knowledge and technology are effectively diffused across countries. That is, diffusion occurs within sociotechnical systems and as such should be negotiated, enabled, and diffused (Greenhalgh et al. 2004) 2 Using the relationship between stakeholders, emergence and networks as promoted by Wheatley and Frieze to promote the development of communities of good practice and then translate these into systems of influence 3 Closer alignment and integration of science and practice The IEA general framework model was developed based on the aforementioned principles and focused on the provision of a participatory framework to facilitate the systematic design of HFE- related projects. The GFM outlined in Fig. 12.1 although presented in an eight step model is in fact a highly iterative process, as the characteristics at one step are made explicit they may require the reexamination of previous steps. For example as the understanding of who stakeholders are (step 4) and what the relationships are between stakeholders (step 5) is devel-
154 G. Dagliana et al. Fast Track - Instinctive, Experience-based, Focusing on Particular Aspects - Procedural for analytical approach Project (s) 1. Identify A Value Added Topic 2. Capture Project Outlines 3. Identify Needs Support Systemic HFF Design Discover Shared Objectives & Goals Participatory Ideas Generator Share Ideas & Understandings Comprehensive & Balanced Projects Uplift HFE Influences Provide Accountability Base 8. Specify Project Proposals 7. Develop Strategies 6. Identify Potential Benefits 4. Identify Stakeholders 5. Identify Stakeholder Relationship Fig. 12.1 International Ergonomics Association model for the promotion of collaboration across multiple stakeholders within a system oped so the understanding of what a value-added topic is (step 1) and what the actual needs are (step 3) may need to be refined. Through this iterative process, the various stakeholders within the system are able to discover shared objectives and goals, and consequently collaborate in the generation of ideas on the solutions to be implemented within the constraints of system they are attempting to shape. The framework therefore promotes an interrogation of the social characteristics of the system (through a detailed examination of the various stakeholders and their relationships to each other) and how the technical aspects of the system can be aligned with the strengths and weaknesses of various stakeholders through the development of benefits and implementation strategies. The framework also promotes the use of contextually appropriate tools and methods at each step that meet the requirements of elucidating the necessary information. For example, in more advanced systems the initial steps (1–3) can be facilitated through the use of existing HFE tools such as cognitive work analysis, while in less mature systems alternative tools may be more appropriate. As mentioned in Sect. 12.2.2 and as emerged from the overview on barriers and facilitating factors that can influence the positive results of an improvement project, context, and its actors (stakeholders) represent the main elements to take into account when designing and implementing solutions. This requires an appreciation of both the social and technical components of the system within which the improvement project is to take place. Therefore, just understanding the context is not sufficient for the success of interventions that aim at creating a long-lasting behavioral change that become part of the cultural heritage of a specific system and a shared and recognized attitude. In order to make this cultural change lasting over time, it has to be embedded in the system, it need to be thought of, designed, and implemented by actors that participate in the system, that are part of the system and that are recognized as to be parts of that systems. Furthermore, the emerging characteristics of safety and culture need to be taken into account, and those that remain within the system once the improvement project is complete need to be empowered
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Textbook of Patient Safety and Clin
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Liam Donaldson • Walter Ricciardi
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Foreword As a member of the 17th le
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Preface Despite the extensive atten
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Acknowledgements The volume editors
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xii Contents 11 Adverse Event Inves
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Part I Introduction
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4 explain how to prepare and update
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6 considered preventable) [11]. Fur
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8 W. Ricciardi and F. Cascini the l
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10 W. Ricciardi and F. Cascini inte
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12 maximized or perhaps even realiz
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14 steps in obtaining, managing, an
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16 quality improvement methodologie
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18 99. Morciano C, et al. Policies
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20 Reason travelled the world makin
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22 For each hospital unit, other do
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24 As head of clinical risk managem
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26 R. Tartaglia Table 2.1 Differenc
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28 R. Tartaglia Open Access This ch
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30 otherwise efficient brains lead
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32 • A routine violation is basic
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34 Table 3.1 Framework of contribut
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36 H. Higham and C. Vincent The con
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38 H. Higham and C. Vincent recogni
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40 H. Higham and C. Vincent Table 3
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42 assessment and prevention was no
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44 of human error, 2nd: 1983: Bella
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46 ment of theories on how to deliv
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48 all times, not only when there i
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50 healthcare, pursued by enthusias
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52 15. National Academies of Scienc
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54 In this chapter, I will reflect
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56 hospital, there may be 50 indivi
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58 medicals, these are part of the
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60 facility and could therefore bec
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62 health. It is hoped that the Che
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64 Medication Without Harm, invites
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66 21. World Alliance for Patient S
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68 death of my late husband, Pat, f
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70 S. Sheridan et al. test. A separ
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72 enced some kind of harm due to h
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74 S. Sheridan et al. member of The
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76 6.7.1 Example: Canada 6.7.1.1 Wo
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78 All stakeholders must accept, va
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Human Factors and Ergonomics in Hea
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7 Human Factors and Ergonomics in H
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Patient Safety in the World Neelam
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8 Patient Safety in the World 95 8.
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8 Patient Safety in the World adopt
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Infection Prevention and Control An
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Page 125 and 126: The Patient Journey Elena Beleffi,
Page 127 and 128: 10 The Patient Journey 119 End of e
Page 129 and 130: 10 The Patient Journey 121 Fig. 10.
Page 131 and 132: 10 The Patient Journey advocates) i
Page 133 and 134: 10 The Patient Journey Table 10.2 T
Page 135 and 136: 10 The Patient Journey 7. Internati
Page 137 and 138: 130 from these interactions that pe
Page 139 and 140: 132 Data integration is certainly t
Page 141 and 142: 134 organizational processes, such
Page 143 and 144: 136 Table 11.3 Scheme of contributo
Page 145 and 146: 138 tocol requires one or more exte
Page 147 and 148: 140 system failure. Quantification
Page 149 and 150: 142 8. Carayon P, editor. Handbook
Page 151 and 152: 144 similar industries, in terms of
Page 153 and 154: 146 (2002) argue is a more effectiv
Page 155 and 156: 148 for research in patient safety
Page 157 and 158: 150 hospital in Kenya with focus on
Page 159: 152 Haines et al. (2002) proposed a
Page 163 and 164: 156 G. Dagliana et al. 11. Jha AK,
Page 165 and 166: Part III Patient Safety in the Main
Page 167 and 168: 162 development of new receptor ant
Page 169 and 170: 164 Physician burnout and the psych
Page 171 and 172: 166 S. Damiani et al. Fig. 13.1 In
Page 173 and 174: 168 mortality and has rapidly becom
Page 175 and 176: 170 ing to patient safety and share
Page 177 and 178: 172 ability to cope with the workin
Page 179 and 180: 174 2. Vlayen A, Verelst S, Bekkeri
Page 181 and 182: Safe Surgery Saves Lives Francesco
Page 183 and 184: 14 Safe Surgery Saves Lives manner
Page 185 and 186: 14 Safe Surgery Saves Lives not yet
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Page 189 and 190: 14 Safe Surgery Saves Lives 14.15.1
Page 191 and 192: 14 Safe Surgery Saves Lives • Tea
Page 193 and 194: Emergency Department Clinical Risk
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Page 209 and 210: 206 • Pragmatic: in a healthcare
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208 Risks associated with pregravid
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210 Table 16.1 Common and Recurrent
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212 improved clinical surveillance
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214 (only IM wards or all medical w
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216 M. L. Regina et al. Table 17.1
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218 Table 17.2 Types and preventabi
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220 nicians were certain resulted w
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224 Table 17.6 “Debiasing questio
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226 in care. At a minimum, medicati
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228 cation rates there substantiall
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230 well-structured, concise, focus
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232 M. L. Regina et al. Fig. 17.3 W
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236 Table 17.14 Risk factors for as
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238 Table 17.16 Common risk factors
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240 In patients with kidney disease
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242 Table 17.19 Clinical response t
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244 stones. Giordano’s test posit
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246 in practice. Swiss Med Wkly. 20
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248 procedures done by general inte
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250 tion: a systematic review and m
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252 162. Improvement IfH. What is a
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254 and therapeutic strategies, all
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256 direct effect of radiotherapy o
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258 obtaining treatment consent and
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260 A. Marcolongo et al. Table 18.1
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262 A. Marcolongo et al. Toxicities
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264 nies that are aimed at building
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266 A. Marcolongo et al. tissues. B
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268 and breast cancer) and can be r
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270 happened during the first three
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272 40. World Health Organization (
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Patient Safety in Orthopedics and T
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19 Patient Safety in Orthopedics an
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Patient Safety and Risk Management
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20 Patient Safety and Risk Manageme
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Patient Safety in Pediatrics Sara A
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21 Patient Safety in Pediatrics eve
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21 Patient Safety in Pediatrics of
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21 Patient Safety in Pediatrics Cri
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21 Patient Safety in Pediatrics of
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Patient Safety in Radiology Mahdieh
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22 Patient Safety in Radiology The
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22 Patient Safety in Radiology indu
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22 Patient Safety in Radiology CA a
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22 Patient Safety in Radiology Refe
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Organ Donor Risk Stratification in
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23 Organ Donor Risk Stratification
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23 Organ Donor Risk Stratification
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326 M. Plebani et al. Fig. 24.1 The
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328 ical laboratory and the definit
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330 • Findings of external accred
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332 M. Plebani et al. Fig. 24.2 Mod
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334 laboratory medicine professiona
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336 (WHO) website on the incidence
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338 54. Magnezi R, Hemi A, Hemi R.
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340 In 2010 this condition represen
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342 which should be slightly smalle
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344 needed by the pulse waveform to
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346 washed properly prior to steril
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348 ocular reaction without infecti
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350 large retrospective cohort stud
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352 • Lack of appropriate skills.
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354 scription [126]. Furthermore, a
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356 time and knowledge to young doc
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358 48. Barry P, Gettinby G, Lees F
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360 implant versus intravitreal ant
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Part IV Healthcare Organization
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366 causes of safety incidents and
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368 • Human factors such as teamw
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370 access to the Emergency Room. F
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372 that many doctors simply choose
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374 E. Alti and A. Mereu Open Acces
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376 components (people, technology,
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378 J. Braithwaite et al. Hence, cl
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380 stakeholders to figure out how
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382 J. Braithwaite et al. Clinician
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384 27.5.3 Social Networks in a War
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386 J. Braithwaite et al. Fig. 27.9
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388 representations the essential l
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390 21. Pomare C, Churruca K, Ellis
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Measuring Clinical Workflow to Impr
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28 Measuring Clinical Workflow to I
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Shiftwork Organization Giovanni Cos
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29 Shiftwork Organization influenci
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29 Shiftwork Organization Many epid
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29 Shiftwork Organization quences o
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29 Shiftwork Organization in shift
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Non-technical Skills in Healthcare
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30 Non-technical Skills in Healthca
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Medication Safety Hooi Cheng Soon,
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31 Medication Safety • Be familia
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31 Medication Safety 439 Table 31.1
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31 Medication Safety to be made bet
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31 Medication Safety medication reg
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31 Medication Safety and contexts,
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31 Medication Safety quently when m
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31 Medication Safety 31.5 Final Rec
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31 Medication Safety 451 ity and im
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31 Medication Safety 453 Open Acces
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456 studies in recent years have hi
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458 F. Ranzani and O. Parlangeli in
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460 Any difficulty encountered by t
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462 32.4.2 The Usability Assessment
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464 23. Parlangeli O, Mengoni G, Gu
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466 S. Ushiro et al. No-fault compe
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468 33.2 The Meaning of “No-Fault
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470 S. Ushiro et al. figure of 2.3
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472 S. Ushiro et al. Childbirth fac
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474 • When cerebral palsy is caus
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476 (c) (d) (e) (f) (g) (h) (i) (j)
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478 115 bpm to 80 bpm and complete
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480 • It is desirable that system
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482 cific monitoring procedures (1)
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484 Res. 2019;45(3):493-513. https:
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486 19. In the most severe cases, t
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488 Phases 3 and 4, strong emphasis
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490 Phases 5 and 6 focus is on the
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492 during a pandemic to promote tr
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494 M. Tanzini et al. the mother, p
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496 All four abilities are necessar
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