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Introduction: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted., Objective: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research., Methods: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed., Results: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement . Most studies reported activities from multiple categories. Implementation factors included: c linical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation . Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread . Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities., Conclusions: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice., Competing Interests: Competing interests: All authors have completed the ICMJE form for disclosure of competing interests. JTO, ES, SH, HVW have been supported in their work on this paper by grants from the Research Council of Norway, the Western Norway Regional Health Authority, and the Bergen Hospital Trust. MH has been supported in her work on this paper by grants from the Research Council of Norway, and by employment as a researcher by the Fonna Hospital Trust. SH has headed the reference group for the Norwegian Patient Safety Campaign (2011–2014, honorary without payment), and is a paid member of the Regional Committee for Medical Ethics since 2021. PEA has coauthored this paper as part of his work at the Norwegian Centre for Antiobiotic Use in Hospitals, Haukeland University Hospital. He is also an editor of the national guidelines for antibiotic use in hospitals, member of the editorial board of the national guidelines for antibiotic use in primary care, and member of the national breakpoint committee, all without extra funding, as part of his ordinary work. NS has recieved consulting fees as director of London Safety and Training Solutions. RKL has coauthored this paper salaried as an academic librarian at the University of Bergen., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: 'Situation Awareness For Everyone' (SAFE) was a 3-year project which aimed to improve situation awareness in clinical teams in order to detect potential deterioration and other potential risks to children on hospital wards. The key intervention was the 'huddle', a structured case management discussion which is central to facilitating situation awareness. This study aimed to develop an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle., Methods: A cross-sectional observational design was used to psychometrically develop the 'Huddle Observation Tool' (HOT) over three phases using standardised psychometric methodology. Huddles were observed across four NHS paediatric wards participating in SAFE by five researchers; two wards within specialist children hospitals and two within district general hospitals, with location, number of beds and length of stay considered to make the sample as heterogeneous as possible. Inter-rater reliability was calculated using the weighted kappa and intraclass correlation coefficient., Results: Inter - rater reliability was acceptable for the collaborative culture (weighted kappa=0.32, 95% CI 0.17 to 0.42), environment items (weighted kappa=0.78, 95% CI 0.52 to 1) and total score (intraclass correlation coefficient=0.87, 95% CI 0.68 to 0.95). It was lower for the structure and risk management items, suggesting that these were more variable in how observers rated them. However, agreement on the global score for huddles was acceptable., Conclusion: We developed an observational assessment tool to assess the team processes occurring during huddles, including the effectiveness of the huddle. Future research should examine whether observational evaluations of huddles are associated with other indicators of safety on clinical wards (eg, safety climate and incidents of patient harm), and whether scores on the HOT are associated with improved situation awareness and reductions in deterioration and adverse events in clinical settings, such as inpatient wards., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To obtain a specialist-based consensus on the aims, format and function for MDT-driven care within an inflammatory bowel disease (IBD) service., Design: This was a prospective, multicentre study using a Delphi formal consensus-building methodology., Setting: Participants were recruited nationally across 13 centres from July to August 2014., Participants: 24 participants were included into the Delphi Specialist Consensus Panel. They included six consultant colorectal surgeons, six gastroenterologists, five consultant radiologists, three consultant histopathologists and 4 IBD nurse specialists., Interventions: Panellists ranked items on a Likert scale (1=not important to 5=very important). Items with a median score >3 were considered eligible for inclusion., Main Outcome Measures: Consensus was defined with an IQR ≤1. Consensus on categorical responses was defined by an agreement of >60%., Results: A consensus on items (median; IQR) that described the aims of the MDT-driven care that were considered very important included: advance patient care (5;5-5), provide multidisciplinary input for the patient's care plan (5;5-5), provide shared experience and expertise (5;5-5), improve patient outcome (5;5-5), deliver the best possible care for the patient (5;5-5) and to obtain consensus on management for a patient with IBD (5;4-5). A consensus for being a core MDT member was demonstrated for colorectal surgeons (24/24), radiologists (24/24), gastroenterologists (24/24), nurse specialists (24/24), dieticians (14/23), histopathologists (21/23) and coordinators (21/24)., Conclusions: This study has provided a consensus for proposed aims, overall design, format and function MDT-driven care within an IBD service. This can provide a focus for core members, and aid a contractual recognition to ensure attendance and proactive contribution., Competing Interests: Competing interests: NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisations globally. NS and JG deliver teaching and consultancy-based work on evaluating and improving MDT effectiveness and team processes for hospitals in the UK and internationally. The other authors have no conflicts to declare.

Background: Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care., Objective: To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role., Methods: After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised., Results: Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally., Conclusions: We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers-particularly middle managers-also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To elicit expert views to define the aims, optimal design, format and function of an inflammatory bowel disease (IBD) multidisciplinary team (MDT) with the overall purpose of enhancing the quality of MDT-driven care within an IBD service provision., Design: This study was a multicentre, prospective, qualitative study using a standard semistructured interview methodology., Participants: A multidisciplinary sample of 28 semistructured interviews of which there are six consultant colorectal surgeons, six IBD nurse specialists, seven consultant gastroenterologists, five consultant radiologists and four consultant histopathologists., Setting: Participants were recruited from 10 hospitals, which were a mixture of community hospitals and specialist IBD centres between June and October 2013., Results: Experts argued that the main goal of MDT-driven IBD care is to improve patient outcomes via sharing collective expertise in a formalised manner. Themes regarding the necessary requirements for an IBD MDT to occur included good attendance, proactive contribution, a need to define core members and appropriate and functional computer facilities. Emergent themes regarding the logistics of an effective IBD MDT included an eligibility criterion for case selection and discussion and appropriate scheduling. Themes regarding the overall design of the IBD MDT included a 'hub-and-spoke' model versus a 'single-centre' model., Conclusions: Defining key elements for an optimal design format for the IBD MDT is necessary to ensure quality of care and reduce variation in care standards. This study has produced a set of expert-based standards that can be used to structure the IBD MDT. These standards now require larger scale validation and consensus prior to becoming a practical guideline for the management of IBD care.

Background: Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study was to assess patients' views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in., Method: Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients' views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire., Results: 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly., Conclusions: It is feasible and instructive to capture patients' views of the delivery of safety improvements like the checklist. We have demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To develop, implement and evaluate a novel patient safety training programme for junior doctors across a Foundation School-'Lessons Learnt: Building a Safer Foundation'., Design, Setting and Participants: Prospective preintervention /postintervention study across 16 Foundation Programmes in North West England, UK. 1169 participants including all Foundation Programme Directors, Administrators, Foundation trainees and senior faculty., Interventions: Half-day stakeholder engagement event and faculty development through recruitment and training of local senior doctors. Foundation trainee-led monthly 60-min sessions integrated into compulsory Foundation teaching from January to July 2011 comprising case-based discussion and analysis of patient safety incidents encountered in practice, facilitated by trained faculty., Main Outcome Measures: Participants' satisfaction and Foundation trainees' patient safety knowledge, skills, attitudes and behavioural change., Results: Participants reported high levels of satisfaction with 'Lessons Learnt'. There was a significant improvement in trainees' objective patient safety knowledge scores (Meanpreintervention=51.1%, SD=17.3%; Meanpostintervention=57.6%, SD=20.1%, p<0.001); subjective knowledge ratings and patient safety skills. Trainees' perceived control and behavioural intentions regarding safety improved significantly postintervention. Feelings and personal beliefs about safety did not shift significantly. Trainees reported significantly more patient safety incidents in the 6 months following introduction of 'Lessons Learnt' (Meanpreintervention=0.67, SD=1.11; Meanpostintervention=1.18, SD=1.46, p<0.001). 32 quality improvement projects were initiated by trainees, spanning the development of novel clinical protocols; implementation of user-informed teaching and improved rota design, Conclusions: Patient safety training can be implemented and sustained to deliver significant improvements in patient safety knowledge, skills and behaviours of junior doctors-with potential for wider positive organisational impact. Medical education commissioners and providers could adopt and build upon the 'Lessons Learnt' approach as a springboard to promote medical engagement in quality and safety improvement.

Objectives: To develop, implement and evaluate a training programme for senior doctors to become faculty leaders for patient safety training., Methods: Senior doctors were recruited from across 20 hospitals in the North Western Deanery, England, UK. The intervention comprised a half-day course in patient safety theory, root cause analysis and small-group facilitation, following which participants were invited to sign up as faculty for a region-wide patient safety training programme for trainees 'Lessons Learnt'. Course evaluation comprised a prospective longitudinal study conducted in 2010-2012. Patient safety knowledge, attitudes and skills were evaluated pre and post course and retention further evaluated 8 months post course., Results: 216 senior doctors volunteered as faculty of whom 122 were appointed. Participants reported high levels of satisfaction with the course. Objective scores of patient safety knowledge significantly improved immediately post course (MedianPre course=70%, MedianPost course=80%, p<0.001) and were sustained at 8 months (Median8 month post course=90%). Similarly, measures of attitudes and self-reported safety skills also significantly improved post course and were sustained. Upon completion of the course, 88/122 (72%) participants facilitated 213 'Lessons Learnt' sessions from January 2011 to July 2012 (mean 2, range 1-8 sessions per faculty member). Trainee satisfaction with faculty was high., Conclusions: There is considerable appetite for senior doctors to engage with training in patient safety as teachers and learners. Training senior doctors in patient safety is feasible, acceptable and effective as a means of building capacity and capability for delivering training in this rapidly emerging field.

Simulation-based training for healthcare providers is well established as a viable, efficacious training tool, particularly for the training of non-technical team-working skills. These skills are known to be critical to effective teamwork, and important in the prevention of error and adverse events in hospitals. However, simulation suites are costly to develop and releasing staff to attend training is often difficult. These factors may restrict access to simulation training. We discuss our experiences of 'in situ' simulation for unannounced cardiac arrest training when the training is taken to the clinical environment. This has the benefit of decreasing required resources, increasing realism and affordability, and widening multidisciplinary team participation, thus enabling assessment and training of non-technical team-working skills in real clinical teams. While there are practical considerations of delivering training in the clinical environment, we feel there are many potential benefits compared with other forms of simulation training. We are able to tailor the training to the needs of the location, enabling staff to see a scenario that is relevant to their practice. This is particularly useful for staff who have less exposure to cardiac arrest events, such as radiology staff. We also describe the important benefit of risk assessment for a clinical environment. During our simulations we have identified a number of issues that, had they occurred during a real resuscitation attempt, may have led to patient harm or patient death. For these reasons we feel in situ simulation should be considered by every hospital as part of a patient safety initiative.

Background and Objectives: Effective communication is imperative to safe surgical practice. Previous studies have typically focused upon the operating theatre. This study aimed to explore the communication and information transfer failures across the entire surgical care pathway., Methods: Using a qualitative approach, semi-structured interviews were conducted with 18 members of the multidisciplinary team (seven surgeons, five anaesthetists and six nurses) in an acute National Health Service trust. Participants' views regarding information transfer and communication failures at each phase of care, their causes, effects and potential interventions were explored. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Sampling ceased when categorical and theoretical saturation was achieved., Results: Preoperatively, lack of communication between anaesthetists and surgeons was the most common problem (13/18 participants). Incomplete handover from the ward to theatre (12/18) and theatre to recovery (15/18) were other key problems. Work environment, lack of protocols and primitive forms of information transfer were reported as the most common cause of failures. Participants reported that these failures led to increased morbidity and mortality. Healthcare staff were strongly supportive of the view that standardisation and systematisation of communication processes was essential to improve patient safety., Conclusions: This study suggests communication failures occur across the entire continuum of care and the participants opined that it could have a potentially serious impact on patient safety. This data can be used to plan interventions targeted at the entire surgical pathway so as to improve the quality of care at all stages of the patient's journey.

Background: Subjective workload in healthcare employees is suspected to be important for the performance and safety of healthcare delivery. This study investigates associations between workflow interruptions and hospital doctors' capability to manage their perceived workload in a safe and efficient manner., Aim: To examine the relationship of observed workflow interruptions with hospital doctors' perceived workload during day clinical shifts., Methods: A prospective study of 43 full shift observations with 29 doctors working in internal medicine and surgical specialties. Workflow interruptions were assessed via observation using a previously validated observation instrument. Doctors assessed their workload twice throughout their day shift using three items of the validated NASA-Task Load Index (NASA-TLX; mental demands, effort, frustration)., Results: Hospital doctors were on average disrupted 3.66 times per hour. Most frequent were interruptions by nursing staff, telephone/beeper interruptions and by fellow doctors. Senior doctors reported higher workload than their junior colleagues. Overall workflow interruptions were significantly related to doctors' workload (β = 0.22; p = 0.03). Further analyses revealed that doctors' workload was associated particularly with interruptions by nursing personnel (β = 0.23; p = 0.03)., Conclusions: Frequent workflow interruptions may be linked with increased workload in doctors. Healthcare environments need to be better designed to reduce unnecessary interruptions and distractions so that hospital doctors can manage clinical work efficiently and safely.

Aim: Team performance is important in multidisciplinary teams (MDTs), but no tools exist for assessment. Our objective was to construct a robust tool for scientific assessment of MDT performance., Materials and Methods: An observational tool was developed to assess performance in MDTs. Behaviours were scored on Likert scales, with objective anchors. Five MDT meetings (112 cases) were observed by a surgeon and a psychologist. The presentation of case history, radiological and pathological information, chair's effectiveness, and contributions to decision-making of surgeons, oncologists, radiologists, pathologists and clinical nurse specialists (CNSs) are analysed via descriptive statistics, a comparison of average scores (Mann-Whitney U) to test interobserver agreement and intraclass correlation coefficients (ICCs) to further assess interobserver agreement and learning curves., Results: Contributions of surgeons, chair's effectiveness, presentation of case history and radiological information were rated above average (p ≤ 0.001). Contributions of histopathologists and CNS were rated below average (p ≤ 0.001), and others average. The interobserver agreement was high (ICC = 0.70+) for presentation of radiological information, and contribution of oncologists, radiologists, pathologists and CNSs; adequate for case history presentation (ICC = 0.68) and contribution of surgeons (ICC = 0.69); moderate for chairperson (ICC = 0.52); and poor for pathological information (ICC = 0.31). Average differences were found only for case-history presentation (p ≤ 0.001). ICCs improved significantly in assessment of case history, and Oncologists, and ICCs were consistently high for CNS, Radiologists, and Histopathologists., Conclusions: Scientific observational metrics can be reliably used by medical and non-medical observers in cancer MDTs. Such robust assessment tools provide part of a toolkit for team evaluation and enhancement.

OBJECTIVES (1) To identify a range of safety skills (attributes of a safe practitioner) relevant across clinical specialities. 2) To obtain the views of clinicians regarding their importance and trainability. DESIGN We used a survey and focus group of 10 patient safety experts to extract a list of safety skills. 50 experienced clinicians rated the skills in terms of importance and trainability in an electronic questionnaire. SETTING A Clinical Safety Research Unit and its associated NHS Trust, within an Academic Health Science Centre. RESULTS 73 skills, in 18 broad categories, were identified from the focus group and survey. The majority of clinicians felt the skills were important (most important: technical skills (98%), crisis management (98%), honesty (97.5%); least important: open-mindedness (82%), patient awareness/empathy (81.7%), humility (81.2%)). There was less agreement about trainability (16/18 categories were felt to be trainable; most trainable: technical skills (98%), anticipation/preparedness (84%), organisational skills/efficiency (83%); least trainable: conscientiousness (56%), humility (40%), open-mindedness (30%)). More surgeons than physicians felt that team awareness and crisis management skills were trainable (p=0.0099, p=0.025, respectively). CONCLUSIONS We have identified a preliminary set of safety skills, which with further refinement could form the template for the development of a formal taxonomy of the qualities and attributes of the safe practitioner. Experts and practitioners agree about the importance of the individual skills. The fact that the majority of these were felt by experienced cross-speciality clinicians to be trainable is encouraging in terms of the possibility of developing generic safety curricula.

Background: Despite growing recognition internationally that patients can help to promote their own safety, little evidence exists on how willing patients are to take on an active role., Objectives: To investigate medical and surgical patients' perceived willingness to participate in different safety-related behaviours and the potential impact of doctors'/nurses' encouragement on patients' willingness levels., Design: Cross-sectional exploratory study using a survey that addressed willingness to participate in different behaviours recommended by current patient safety initiatives. Interactional behaviours (asking factual or challenging questions, notifying doctors or nurses of errors or problems) and non-interactional behaviours (choosing a hospital based on the safety record, bringing medicines and a list of allergies into hospital, and reporting an error to a national reporting system) were assessed., Participants: 80 medical and surgical patients from an inner city London teaching hospital. Findings Patients' perceived willingness to participate was affected (p<0.05) by the action required by the patient and (for interactional behaviours) whether the patient was engaging in the specific action with a doctor or nurse. Patients were less willing to participate in challenging behaviours. Doctors' and nurses' encouragement appeared to increase patient-reported willingness to ask challenging questions, but no other consistent findings were observed., Conclusion: Patients do not view involvement in a range of safety-related behaviours uniformly. Particular efforts are needed to encourage patients to participate in novel or challenging behaviours as these are behaviours where patients appear less inclined to take on an active role.