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Objective: To study experiences of women who gave birth in maternity units that have implemented a 'care bundle' quality improvement initiative to reduce obstetric anal sphincter injury (OASI) and associated morbidity., Design: Postnatal electronic questionnaire., Setting: Twenty-nine maternity units across England, Scotland and Wales., Population: Women with live vaginal births., Methods: Descriptive statistics for quantitative results. Analysis of free-text responses informed by framework method., Main Outcome Measures: Experience with components of the care bundle: information provision, manual perineal protection (MPP) and post-birth rectal examination., Results: In this study, 1208 women completed the survey: 684 (56.6%) said they received antenatal information about perineal health, 377 (31.2%) recalled MPP, and 664 (55.0%) recalled rectal examination. Of the 684 women who said they received antenatal information, 595 (87.0%) agreed that the information was easy to understand, and 423 (61.8%) agreed that it helped them to make their own choices to reduce their OASI risk. One hundred and fifty-four (22.5%) agreed that the information made them fearful about giving birth vaginally. Of the 377 women who recalled MPP, 203 (53.9%) felt it provided them with support, and another 97 (25.7%) did not mind the sensation. Of the 664 women who recalled rectal examination, 281 (42.3%) did not mind the exam, and another 335 (50.5%) felt it was uncomfortable but understood its importance. Free-text responses aligned with quantitative results., Conclusions: Many women did not recall MPP or rectal examination. The reported experiences for those who recalled these components do not support concerns that the OASI care bundle has negative effects on women's experiences., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date., (© 2023 Association of Anaesthetists.)

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia., (© 2023 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates., Design: Multicentre stepped-wedge cluster design., Setting: Sixteen maternity units located in four regions across England, Scotland and Wales., Population: Women with singleton live births between October 2016 and March 2018., Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth)., Main Outcome Measures: Obstetric anal sphincter injury in singleton live vaginal births., Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period., Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth., Tweetable Abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use., (© 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Rationale, Aims and Objectives: Acute myocardial infarctions (MIs) or heart attacks are the result of a complete or an incomplete occlusion of the lumen of the coronary artery with a thrombus. Prompt diagnosis and early coronary intervention results in maximum myocardial salvage, hence time to treat is of the essence. Adequate, accurate and complete information is vital during the early stages of admission of an MI patient and can impact significantly on the quality and safety of patient care. This study aimed to record how clinical information between different clinical teams during the journey of a patient in the MI care pathway is captured and to review the flow of information within this care pathway., Method: A prospective, descriptive, structured observational study to assess (i) current clinical information systems (CIS) utilization and (ii) real-time information availability within an acute cardiac care setting was carried out. Completeness and availability of patient information capture across four key stages of the MI care pathway were assessed prospectively., Results: Thirteen separate information systems were utilized during the four phases of the MI pathway. Observations revealed fragmented CIS utilization, with users accessing an average of six systems to gain a complete set of patient information. Data capture was found to vary between each pathway stage and in both patient cohort risk groupings. The highest level of information completeness (100%) was observed only in the discharge stage of the MI care pathway. The lowest level of information completeness (58%) was observed in the admission stage., Conclusion: The study highlights fragmentation, CIS duplication, and discrepancies in the current clinical information capture and data transfer across the MI care pathway in an acute cardiac care setting. The development of an integrated and user-friendly electronic data capture and transfer system would reduce duplication and would facilitate efficient and complete information provision at the point of care., (© 2012 John Wiley & Sons Ltd.)

Objective: To investigate hospital patients' reports of undesirable events in their health care., Design: Cross-sectional mixed methods design., Participants: A total of 80 medical and surgical patients (mean age 58, 56 male)., Intervention: Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed., Main Outcome Measures: Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care., Results: In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system., Conclusion: Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety., (© 2012 John Wiley & Sons Ltd.)

Rationale, Aims and Objectives: Patients can play an important role in reducing health care harm. Finding strategies to encourage patients to take on an active role in issues related to the quality and safety of their care is therefore essential. The aim of this study was to examine patients' and health care professionals' attitudes towards a video aimed at promoting patient involvement in safety-related behaviours., Method: A within-subjects design was used where participants were required to complete a questionnaire pre and post screening of a patient safety video. Participants are 201 patients aged 19-103 years (mean 52) and 95 health care professionals aged 23-48 years (mean 32). Main outcome measures include (i) patients' willingness to participate and perceived importance in participating in safety-related behaviours; and (ii) health care professionals' willingness to support patient involvement., Results: After watching the video patients elicited more positive attitudes towards asking doctors and nurses if they had washed their hands and notifying them about issues to do with personal hygiene. No significant effects were observed in relation to patients notifying staff if they have not received their medication or if they were in pain or feeling unwell. In relation to health care professionals, doctors and nurses were more willing to support patient involvement in asking about hand hygiene after they had watched the video., Conclusion: Video may be effective at changing patients' and health care professionals' attitudes towards patient involvement in some, but not all safety-related behaviours. Our findings suggest video may be most effective at encouraging involvement in behaviours patients are less inclined to participate in and health care professionals are less willing to support., (© 2011 Blackwell Publishing Ltd.)

Objectives/hypothesis: To assess the face and construct validity of two assessment tools for a microlaryngoscopy simulator-a Checklist Assessment for Microlaryngeal Surgery and Global Rating Assessment for Microlaryngeal Surgery., Study Design: Blinded experimental simulator-based study., Methods: There were 15 candidates divided into a novice (≤50 procedures performed) or experienced (>50 procedures) group depending on their previous microlaryngoscopy experience. Each candidate undertook a 10-minute simulation of a microlaryngoscopy and excision biopsy, and two blinded experts rated their performance live on each of the two assessment tools. To assess face validity, each candidate subsequently completed a questionnaire about the simulator., Results: The model demonstrated good face validity across all levels of experience. The global rating assessment demonstrated excellent interrater reliability (0.9) compared to the checklist assessment (0.7). The checklist assessment was able to differentiate experienced and novice candidates and therefore demonstrated construct validity. The global rating tool, however, was unable to differentiate candidates. There was a significant correlation between the two assessment tools (correlation coefficient = 0.624)., Conclusions: This study is the first reported study of a high-fidelity microlaryngoscopy simulator with task-specific rating tools. Use of these tools is recommended within otolaryngology training programs, with the global rating assessment for use as a frequently used feedback tool, and the checklist assessment as a confirmatory evaluation of competency at transitions of professional training., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

This article addresses key questions frequently asked by researchers conducting systematic reviews in patient safety. This discipline is relatively young, and asks complex questions about complex aspects of health care delivery and experience, therefore its studies are typically methodologically heterogeneous, non-randomized and complex; but content rich and highly relevant to practice. Systematic reviews are increasingly necessary to drive forward practice and research in this area, but the data do not always lend themselves to 'standard' review methodologies. This accessible 'how-to' article demonstrates that data diversity need not preclude high-quality systematic reviews. It draws together information from published guidelines and experience within our multidisciplinary patient safety research group to provide entry-level advice for the clinician-researcher new to systematic reviewing, to non-biomedical research data or to both. It offers entry-level advice, illustrated with detailed practical examples, on defining a research question, creating a comprehensive search strategy, selecting articles for inclusion, assessing study quality, extracting data, synthesizing data and evaluating the impact of your review. The article concludes with a comment on the vital role of robust systematic reviews in the continuing advancement of the patient safety field., (© 2010 Blackwell Publishing Ltd.)

Background and Aims: In the UK, cancer care is managed via multidisciplinary teams (MDT). Core members of these teams are typically surgeons, oncologists, radiologists, pathologists and clinical nurse specialists (with other health care professionals potentially present). Good teamwork, including team communication and leadership, has been shown to be a prerequisite for safe care delivery in other health care contexts, but cancer MDT team working processes are yet to be fully explored. This study aimed to assess the self-perceived contribution of oncologists to MDTs, with emphasis on their potential role as team leaders., Methods: Data were collected at the British Uro-oncology Group 6th Annual Meeting (Sep 11-12 2009, York, UK). Respondents completed various items related to their perceived contribution to MDTs, aspects of current and potential MDT leadership, team decision making in these meetings, and also demographic information., Results: Seventy-seven oncologists attended the meeting, of whom 61 fully completed the survey (response rate 79%). Oncologists reported that their contribution to the MDT discussion carries equal weight to those of surgeons, radiologists and pathologists. Whereas 83% of respondents reported that MDT chairmanship could rotate, only 39% reported that it does in their own MDTs. More than 90% of respondents thought that oncologists (clinical or medical) could chair these meetings, but only 25% of them had ever chaired their own MDT., Conclusions: Despite a high level of contribution to MDTs and the respect of their colleagues, oncologists are not taking leadership roles within MDTs at the level that they expect. This study raises the question of whether a re-evaluation the leadership of MDTs is required with clinicians from a variety of specialities being given opportunities to develop skills necessary to lead cancer MDTs and improve team performance and ultimately cancer care., (© 2010 Blackwell Publishing Ltd.)

Rationale, Aims and Objectives: Diagnostic errors and delays carry potentially grave consequences for patients and feature prominently in studies of adverse events in health care. Diagnostic errors present a particular challenge for error/incident reporting systems because they involve clinical reasoning and are difficult to define precisely. The aim of the present study was to investigate what insights can be gained about diagnostic error from an incident reporting system., Methods: Diagnostic errors reported to the UK's National Reporting and Learning System (NRLS) between November 2003 and October 2005 were investigated. We analysed reported level of harm to the patient and incident location and we compared diagnostic with non-diagnostic incidents. We also assessed the quality of reporting in a subset of reports associated with a patient's death., Results: Of 316,589 incidents reported in the period under investigation, 1674 were diagnostic (0.5%). Diagnostic incidents were more likely than other incidents to be associated with moderate or severe harm, or a patient's death and were more likely to occur in a hospital emergency department than other incidents. Diagnostic incidents in emergency departments were more likely to be associated with greater harm than similar incidents in wards. Observed reporting quality (detail; clarity) was very variable., Conclusion: These findings replicate findings from studies in emergency departments and suggest that reporting systems have a role to play in understanding diagnostic errors alongside other sources of error analysis. Accurate and complete reporting of adequate volume enhances the potential contribution of an incident reporting system to understanding diagnostic error., (© 2010 Blackwell Publishing Ltd.)

Objectives: Emotional intelligence (EI) involves the perception, processing, regulation and management of emotions. This article aims to systematically review the evidence for EI in medicine through the context of the Accreditation Council for Graduate Medical Education (ACGME) competencies., Methods: MEDLINE, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched for English-language articles published between January 1980 and March 2009. The grey literature was also searched and experts in the field contacted for additional studies. Two independent reviewers selected articles which reported empirical research studies about clinicians or medical students. Conceptual articles and opinion pieces and commentaries were excluded. Information about the measure used to assess EI, the study parameter or domain, and the educational or clinical outcome (with specific relation to the ACGME competencies) was extracted., Results: The literature search identified 485 citations. An abstract review led to the retrieval of 24 articles for full-text assessment, of which 16 articles were included in the final review. Eleven studies focused on postgraduates, four on undergraduates and one on medical school applicants. Six out of seven studies found women to have higher EI than men. Higher EI was reported to positively contribute to the doctor-patient relationship (three studies), increased empathy (five studies), teamwork and communication skills (six studies), and stress management, organisational commitment and leadership (three studies)., Conclusions: Measures of EI correlate with many of the competencies that modern medical curricula seek to deliver. Further research is required to determine whether training can improve EI and thus augment educational and clinical outcomes.

Rationale, Aims and Objectives: Current evidence suggests that hospital inpatient identification wristbands are not used optimally. Here we report a project by the National Patient Safety Agency (NPSA) to inform guidance development to hospitals regarding wristband specifications., Method: A survey assessed (i) the information on wristbands; (ii) the processes of issuing/checking/applying wristbands onto patients; (iii) the types/designs of wristbands (including colour-coding); and (iv) the main problems faced by staff face in relation to wristbanding patients., Results: Responses from 166 staff members from 62 hospitals in England and Wales were collected. Information: most participants reported using the patients' first and last names, their date of birth and their local hospital number. The National Health Service (NHS) number, which is a unique identifier for each patient, is used by 37% of the respondents. Issuing process: wristbands are issued on admission or at Emergency Departments. Trained or untrained staff are involved in issuing/checking/applying wristbands onto patients, without significant problems. Colour-coding: 29/36 multiple-respondent hospitals and 15/16 single-respondent hospitals use colour-coded wristbands to indicate special patient status (e.g. allergies). Colour-coding is not used consistently: four colours are used to signal risk of fall; red is used to signal at least 10 different statuses/risks., Conclusion: The NPSA recommends that wristbands should include patient's last and first name, date of birth and NHS number. They should be printed/written in black against white background. Only red colour should be used to signal special patient status. These recommendations are consistent with current developments in patient identification, and will be evaluated.

Rationale, Aims and Objectives: Wristbands are essential for accurate patient identification. Some evidence suggests that missing wristbands is not an infrequent occurrence in acute hospitals. The National Patient Safety Agency (NPSA) has developed guidance on patient identification for hospitals in England and Wales. Here we report an evaluation of the uptake of the guidance., Method: The evaluation was designed as a 'pre-post' intervention survey. Fifty hospitals (response rate 67%) responded to the 'pre-guidance' part and 40 hospitals (response rate 43%) responded to the 'post-guidance' part., Results: The majority of the hospitals use wristbands to identify inpatients. Fifty-eight per cent of the hospitals in the 'pre-guidance' survey and 50% of them in the 'post-guidance' survey reported not having a patient identification policy before receiving the guidance. Only one hospital reported not having developed such a policy in the 'post-guidance' survey. Ninety-eight per cent of the hospitals reported that their policies are consistent with the guidance. Relevant training to staff is provided in about a quarter of the organizations, both before and after the guidance. Problems in implementing the guidance were reported by 23% of the hospitals, and included difficulties with staff or patient attitudes, or with the guidance itself, or difficulty to identify a lead staff member., Conclusion: Overall, implementation of NPSA guidance regarding inpatient identification was satisfactory. The reported problems should be taken into account, as they likely apply to a range of patient safety interventions. Limitations of evaluating intervention uptake, rather than efficacy, and relying on self-report are discussed.

In clinical trials, it is common practice to follow up significant interactions between the factors under investigation with subgroup analyses. Such analyses pose at least two analytical and interpretational challenges. The first challenge is that performing multiple subgroup analyses increases the likelihood of obtaining spuriously significant results. This has been acknowledged and relevant guidance exists in the medical literature. The second challenge is that the effects that are obtained at the level of subgroup are composite. This has yet to be fully acknowledged and discussed in the context of medical research. This paper aims to fill this lacuna. Using a simple additive model, we use recent findings from the CHARISMA trial on the efficacy of clopidogrel in addition to aspirin in the treatment of patients at risk for atherothrombotic events to demonstrate quantitatively the composition of effects at the level of subgroups. In the simplest case of a design involving an interaction (two crossed factors, with two levels each, i.e. a 2 x 2 design), effects at the level of subgroup consist of influences that stem (i) from the incidence of the measured outcome in the study population as a whole; (ii) from the factor of interest (e.g. treatment vs. placebo); (iii) from the second factor (e.g. patient group membership); (iv) from the interaction between the two factors; and (v) from random error in the measured outcome. The value of the approach illustrated here is that it is generalizable to any research design irrespective of its complexity and that it prompts clinicians to consider the multiple causality underlying medical research findings.

Rationale and Aims: Research suggests that there are problems of communication effectiveness in surgery. Here we describe the content, initiators and recipients of communications that intrude or interfere with individual surgical cases. We also consider the level at which the surgical team and its team members are distracted by these case-irrelevant communications (CICs)., Methods: Two psychologist observers sampled 48 general surgery procedures and they recorded the initiator and the recipient of CIC events, their content and the level of observable distraction that they caused., Results: Irrelevant comments and queries (i.e. 'small-talk') accounted for half of the observed CICs. From the remaining CICs that we observed, most were related to the organization and administration of the case-list, to operating theatre provisions and to teaching junior staff. Surgeons initiated a third of the observed CICs, while receiving two thirds of them. External staff visiting the operating theatre initiated the most distracting communications. The CICs addressed to surgeons introduced significantly less distraction to the operating theatre than those addressed to anaesthetists and nurses., Conclusions: Some of the observed CICs contributed to the administration of the operating theatre case-list. Nonetheless, this communication can interfere with highly sensitive work. More effectively co-ordinated communication could reduce this interference. More research should assess the communication effectiveness and the impact of CICs on task performance in the operating theatre.

When people miss a good bargain, they are less likely to take a subsequent one that is not as good. This phenomenon is termed inaction inertia. Two regret-based explanations of it have been proposed. According to one, people anticipate that buying the item will lead to regret because it will remind them that they missed a better opportunity to buy it. According to the other, the regret people experience when missing a bargain, together with a subjective devaluation of the item resulting from that, produces inaction inertia. In two studies, we assessed experienced regret, anticipated regret, subjective valuation (SV) of the bargain and likelihood of purchase. Our findings provide grounds for reconciling the above accounts. The former is more appropriate when the difference between the previous and subsequent bargain is large, and the latter is more appropriate when it is smaller. Furthermore, our findings suggest that previous accounts of inaction inertia are incomplete. Whereas subjective value and regret considerations jointly determine purchase likelihood when no previous opportunity has been missed, regret considerations are the sole determinant of this likelihood when such an opportunity has been missed. Inaction inertia arises at least partly because considering regret turns attention away from the financial advantages of taking the bargain.

Rationale: The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team., Method: We used concepts from the team performance and team mental models literature to assess OT professionals' perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams' performance., Results: Team structure: OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles: OT professionals tended to overrate their own understanding of their colleagues' role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance: OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement., Conclusions: The OT environment need not be as cohesive as previously assumed--a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety.