2021_Book_TextbookOfPatientSafetyAndClin

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27 Complexity Science as a Frame for Understanding the Management and Delivery of High Quality… 381 to the patient, to meso-level studies, to those attempting to influence macro, systems-wide change. The studies are of a group of carers alongside action researchers seeking to improve the way they deliver services to patients with a single clinical condition (our Lynch syndrome study) [38]; an investigation of a coal-face solution to deteriorating patients in acute settings (research on Medical Emergency Teams) [39– 41]; studies of departmental decision-making, communication and teamwork (social networks in a ward and an emergency department) [42, 43]; an examination of social processes in aggregate, with aligned clinicians, scientists and researchers creating a learning community (Australian Genomics) [44, 45]; and a systemslevel enquiry into patient safety (the Deepening our Understanding of Quality in Australia research programme) [46]. 27.5.1 The Lynch Syndrome Study The complexities of work or organisational processes are not always evident at the start of a quality improvement project. An initial or superficial view will end up missing the underlying interdependencies, social processes and emergent behaviours which need to be explored and understood. One way of proceeding is to identify and visualise the focal process as they manifest (work-as-done), rather than as it is believed they manifest (work-as-imagined) [47]. Only then can we design useful interventions. By talking through the steps of how things usually go, and questioning why they are done that way, underlying complexities can be revealed. One of our projects aimed to increase the referral rates of patients with cancer that receive a high-risk result from a screening test [38, 48, 49]. When we initially scoped the project and reviewed the guidelines, it was easy to imagine the system that the clinicians were working in as a relatively simple, linear process of: 1. Screening tests carried out to assess the risk of the cancer being hereditary. 2. Results reported as high or low risk. 3. People with a high-risk result were referred to the genetic service (Fig. 27.5). It took nine iterations across multiple consultations between the stakeholders involved (surgeons, medical and radiation oncologists, pathologists and genetic specialists) and the research team to develop a process map that was agreed upon as depicting ‘referral as done’ [38] as seen in Fig. 27.6. The number of factors influencing whether a high-risk result triggered a referral or not was surprising to all participants in the study. Factors included reluctance to initially overwhelm patients with a ‘new’ issue (‘The results arrive in the first days post-op when the patient is dealing with pain, incontinence and fear of the cancer returning’), failure to remember to refer later, practical issues (‘Referral forms are never available’, ‘There’s nowhere in the electronic medical record to record if a referral has been made’), lack of consensus on roles (‘It’s not my role to refer, just report’), and confusion (‘I’m not exactly sure what the report means. Do I refer or not?’). A suite of interventions was developed to effect changes in practices. By mapping the multiplicity of issues arising from the complexity of the context, and presenting them, we allowed Screen High risk Refer Fig. 27.5 Linear conceptualisation of clinical work amongst Lynch Syndrome clinicians: referral as imagined. (Authors’ simplification extracted from Taylor N, Long JC, Debono D, Williams R, Salisbury E, O’Neill S, Eykman E, Braithwaite J & Chin M. (2016) Achieving behaviour change for detection of Lynch syndrome using the Theoretical Domains Framework Implementation (TDFI) approach: a study protocol. BMC Health Services Research 16:89)
382 J. Braithwaite et al. Clinicians thought there would be around 15-20 patients Screening test 16 + 119 Clinicians thought there may be some patients who would attend private clinics High risk Refer to genetics service? Yes Patient agrees to referral 2 Low risk No NO REFERRAL 14 Clinicians thought only 1 or 2 would be missed Clinicians thought there may be some patients who would not attend 0 Referral to a private clinic or another public genetics service Not seen No 0 Yes Referral made to HCC Yes Patient attends appointment at HCC 2
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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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9 Infection Prevention and Control
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The Patient Journey Elena Beleffi,
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10 The Patient Journey 119 End of e
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10 The Patient Journey 121 Fig. 10.
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10 The Patient Journey advocates) i
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10 The Patient Journey Table 10.2 T
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10 The Patient Journey 7. Internati
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130 from these interactions that pe
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132 Data integration is certainly t
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134 organizational processes, such
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136 Table 11.3 Scheme of contributo
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138 tocol requires one or more exte
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140 system failure. Quantification
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142 8. Carayon P, editor. Handbook
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144 similar industries, in terms of
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146 (2002) argue is a more effectiv
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148 for research in patient safety
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150 hospital in Kenya with focus on
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152 Haines et al. (2002) proposed a
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154 G. Dagliana et al. Fast Track -
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156 G. Dagliana et al. 11. Jha AK,
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Part III Patient Safety in the Main
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162 development of new receptor ant
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164 Physician burnout and the psych
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166 S. Damiani et al. Fig. 13.1 In
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168 mortality and has rapidly becom
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170 ing to patient safety and share
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172 ability to cope with the workin
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174 2. Vlayen A, Verelst S, Bekkeri
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Safe Surgery Saves Lives Francesco
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14 Safe Surgery Saves Lives manner
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14 Safe Surgery Saves Lives not yet
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14 Safe Surgery Saves Lives In a su
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14 Safe Surgery Saves Lives 14.15.1
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14 Safe Surgery Saves Lives • Tea
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Emergency Department Clinical Risk
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15 Emergency Department Clinical Ri
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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
Page 329 and 330: 328 ical laboratory and the definit
Page 331 and 332: 330 • Findings of external accred
Page 333 and 334: 332 M. Plebani et al. Fig. 24.2 Mod
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Page 339 and 340: 338 54. Magnezi R, Hemi A, Hemi R.
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Page 355 and 356: 354 scription [126]. Furthermore, a
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Page 359 and 360: 358 48. Barry P, Gettinby G, Lees F
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Page 363 and 364: Part IV Healthcare Organization
Page 365 and 366: 366 causes of safety incidents and
Page 367 and 368: 368 • Human factors such as teamw
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Page 373 and 374: 374 E. Alti and A. Mereu Open Acces
Page 375 and 376: 376 components (people, technology,
Page 377 and 378: 378 J. Braithwaite et al. Hence, cl
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Page 383 and 384: 384 27.5.3 Social Networks in a War
Page 385 and 386: 386 J. Braithwaite et al. Fig. 27.9
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Page 391 and 392: Measuring Clinical Workflow to Impr
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Page 401 and 402: Shiftwork Organization Giovanni Cos
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Page 411 and 412: 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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