Preliminary adaptation of the systems thinking for everyday work cue card set in a US healthcare system: a pragmatic and participatory co-design approach.

INTRODUCTION: Healthcare is a highly complex adaptive system, requiring a systems approach to understand its behaviour better. We adapt the Systems Thinking for Everyday Work (STEW) cue cards, initially introduced as a systems approach tool in the UK, in a US healthcare system as part of a study investigating the feasibility of a systems thinking approach for front-line workers. METHODS: The original STEW cards were adapted using consensus-building methods with front-line staff and safety leaders. RESULTS: Each card was examined for relevance, applicability, language and aesthetics (colour, style, visual cues and size). Two sets of cards were created due to the recognition that systems thinking was relatively new in healthcare and that the successful use of the principles on the cards would need initial facilitation to ensure their effective application. Six principles were agreed on and are presented in the cards: Your System outlines the need to agree that problems belong to a system and that the system must be defined. Viewpoints ensure that multiple voices are heard within the discussion. Work Condition highlights the resources, constraints and barriers that exist in the system and contribute to the system's functions. Interactions ask participants to understand how parts of the system interact to perform the work. Performance guides users to understand how work can be performed daily. Finally, Understanding seeks to promote a just cultural environment of appreciating that people do what makes sense to them. The two final sets of cards were scored using a content validity survey, with a final score of 1. CONCLUSIONS: The cards provide an easy-to-use guide to help users understand the system being studied, learn from problems encountered and understand the everyday work involved in providing excellent care. The cards offer a practical 'systems approach' for use within complex healthcare systems.

Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.

OBJECTIVES: The objective of this scoping review is to map methods used to study medication safety following electronic health record (EHR) implementation. Patterns and methodological gaps can provide insight for future research design. MATERIALS AND METHODS: We used the Joanna Briggs Institute scoping review methodology and a custom data extraction table to summarize the following data: (1) study demographics (year, country, setting); (2) study design, study period, data sources, and measures; (3) analysis strategy; (4) identified limitations or recommendations; (5) quality appraisal; and (6) if a Safety-I or Safety-II perspective was employed. RESULTS: We screened 5879 articles. One hundred and fifteen articles met our inclusion criteria and were assessed for eligibility by full-text review. Twenty-seven articles were eligible for extraction. DISCUSSION AND CONCLUSION: We found little consistency in how medication safety following EHR implementation was studied. Three study designs, 7 study settings, and 10 data sources were used across 27 articles. None of the articles shared the same combination of design, data sources, study periods, and research settings. Outcome measures were neither defined nor measured consistently. It may be difficult for researchers to aggregate and synthesize medication safety findings following EHR implementation research. All studies but one used a Safety-I perspective to study medication safety. We offer a conceptual model to support a more consistent approach to studying medication safety following EHR implementation.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. METHODS: We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript. RESULTS: We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose. CONCLUSIONS: We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Mapping Processes in the Emergency Department Using the Functional Resonance Analysis Method.

Emergency departments (EDs) are dynamic, complex, and demanding environments. Introducing changes that lead to improvements in EDs can be challenging owing to the high staff turnover and mix, high patient volume with different needs, and being the front door to the hospital for the sickest patients. Quality improvement is a methodology applied routinely in EDs to instigate change to improve several outcomes such as waiting times, time to definitive treatment, and patient safety. Introducing the changes needed to transform the system in this way is seldom straightforward with the risk of "not seeing the forest for the trees" when attempting to change the system. In this article, we demonstrate how the functional resonance analysis method can be used to capture the experiences and perceptions of frontline staff to identify the key functions in the system (the trees), to understand the interactions and dependencies between them to make up the ED ecosystem ("the forest") and to support quality improvement planning, identifying priorities and patient safety risks.

A qualitative study of organisational resilience in care homes in Scotland.

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory.

OBJECTIVE: To develop mid-range programme theory from perceptions and experiences of out-of-hours community palliative care, accounting for human factors design issues that might be influencing system performance for achieving desirable outcomes through quality improvement. SETTING: Community providers and users of out-of-hours palliative care. PARTICIPANTS: 17 stakeholders participated in a workshop event. DESIGN: In the UK, around 30% of people receiving palliative care have contact with out-of-hours services. Interactions between emotions, cognition, tasks, technology and behaviours must be considered to improve safety. After sharing experiences, participants were presented with analyses of 1072 National Reporting and Learning System incident reports. Discussion was orientated to consider priorities for change. Discussions were audio-recorded and transcribed verbatim by the study team. Event artefacts, for example, sticky notes, flip chart lists and participant notes, were retained for analysis. Two researchers independently identified context-mechanism-outcome configurations using realist approaches before studying the inter-relation of configurations to build a mid-range theory. This was critically appraised using an established human factors framework called Systems Engineering Initiative for Patient Safety (SEIPS). RESULTS: Complex interacting configurations explain relational human-mediated outcomes where cycles of thought and behaviour are refined and replicated according to prior experiences. Five such configurations were identified: (1) prioritisation; (2) emotional labour; (3) complicated/complex systems; (4a) system inadequacies and (4b) differential attention and weighing of risks by organisations; (5) learning. Underpinning all these configurations was a sixth: (6a) trust and access to expertise; and (6b) isolation at night. By developing a mid-range programme theory, we have created a framework with international relevance for guiding quality improvement work in similar modern health systems. CONCLUSIONS: Meta-cognition, emotional intelligence, and informal learning will either overcome system limitations or overwhelm system safeguards. Integration of human-centred co-design principles and informal learning theory into quality improvement may improve results.

A systems analysis of the COVID-19 pandemic response in the United Kingdom - Part 1 - The overall context.

The most common reaction to suggesting that we could learn valuable lessons from the way the current pandemic has been/ is being handled, is to discourage the attempt; as it is suggested that it can all be done more accurately and authoritatively after the inevitable Public Inquiry (Slater, 2019). On the other hand, a more constructive approach, is to capture and understand the work that was actually done.This would include normal activities, as well as positive adaptations to challenges and failures that may have occurred. Such an approach aimed at improving what worked, rather than blaming people for what went wrong, has the potential to contribute more successfully to controlling the consequences of the current crisis. Such an approach should thus be aimed at detecting and feeding back lessons from emerging and probably unexpected behaviours and helping to design the system to adapt better to counter the effects. The science and discipline of Human Factors (HF) promotes system resilience. This can be defined as an organisation's ability to adjust its functioning before, during or after significant disturbances (such as a pandemic), enabling adaptation and operation under both anticipated and unanticipated circumstances. A "functional" approach methodology enables the identification of where the system and its various interdependent functions (an activity or set of activities that are required to give a certain output), could be improved and strengthened; if not immediately, at least for the future. Along these lines, suggestions for adding key resilience functions are additionally identified and outlined. The application and insights gained from this functional approach to the 2015 MERS-Cov pandemic in South Korea has been seen as contributing substantially to the effective response to the current crisis in that country (Min, submitted for publication). In this paper, we present an overarching framework for a series of projects that are planned to carry out focussed systems-based analysis to generate learning from key aspects of the COVID-19 pandemic response in the United Kingdom.

The contribution of human factors and ergonomics to the design and delivery of safe future healthcare.

Human factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, we set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. We consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care.

BACKGROUND: The COVID-19 pandemic has resulted in the rapid reorganisation of health and social care services. Patients are already at significant risk of healthcare-associated harm and the wholesale disruption to service delivery during the pandemic stood to heighten those risks. OBJECTIVES: We explored the type and nature of patient safety incidents in French primary care settings during the COVID-19 first wave to make tentative recommendations for improvement. METHODS: A national patient safety incident reporting survey was distributed to General Practitioners (GPs) in France on 28 April 2020. Reports were coded using a classification system aligned to the WHO International Classification for Patient Safety (incident types, contributing factors, incident outcomes and severity of harm). Analysis involved data coding, processing, iterative generation of data summaries using descriptive statistical analysis. Clinicaltrials.gov: NCT04346121. RESULTS: Of 132 incidents, 58 (44%) related to delayed diagnosis, assessments and referrals. Cancellations of appointments, hospitalisations or procedures was reported in 22 (17%) of these incidents. Home confinement-related incidents accounted for 13 (10%) reports and inappropriate medication stopping for five (4%). Patients delayed attending or did not consult their general practitioner or other healthcare providers due to their fear of contracting COVID-19 infection at an in-person visit in 26 (10%) incidents or fear of burdening their GPs in eight (3%) incidents. CONCLUSION: Constraints from the first wave of the COVID-19 pandemic have contributed to patient safety incidents during non-COVID-19 care. Lessons from these incidents pinpoint where primary care services in France can focus resources to design safer systems for patients.

Preliminary case report study of training and support needed to conduct bowtie analysis in healthcare.

BACKGROUND: There is limited engagement in healthcare with the kinds of proactive approaches to risk assessment used in other industries. Bowtie analysis (BTA) has previously been shown to have potential as a straightforward approach to proactively assessing risk in healthcare. The visual nature of BTA diagrams can aid communication of the essential elements of a complex risk management system. The aim of this small case report study was to investigate the training and support likely to be needed for existing healthcare professionals to conduct BTA in compliance with recognised industry best-practice. METHOD: Of 17 volunteers who attended training, 3 completed an analysis of significant healthcare risks in the study period: misadministration of gentamicin; unknown development of acute kidney injury and disposal of medical devices containing patient identifiable information (PII). Subjective assessments of the quality of the analyses were made against indicators of BTA best-practice. RESULTS: Use of the BTA method led to a deeper understanding of the issues and a more thorough understanding of the risks and what was needed to control them than would have been the case if 'normal practice' had been followed. Classroom-based training supported by written guidance; however, do not appear adequate to support development of competence to carry out a quality BTA in a healthcare setting. CONCLUSIONS: BTA seems to have potential though further evaluation of its application and utility is necessary. The most cost-effective and productive approach is likely to be to train a small number of people to develop deeper skills and experience in BTA. In addition to training and user guidance, the opportunity to facilitate at least one analysis, with some specialist/trainer support, appears to be essential in developing BTA competence.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

WHY IS THE AREA IMPORTANT?: A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable. WHAT IS ALREADY KNOWN AND GAPS IN KNOWLEDGE?: We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. FUTURE AREAS FOR ADVANCING RESEARCH AND PRACTICE: Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Will the COVID-19 pandemic transform infection prevention and control in surgery? Seeking leverage points for organizational learning.

BACKGROUND: In response to the coronavirus disease of 2019 (COVID-19) pandemic, healthcare systems worldwide have stepped up their infection prevention and control efforts in order to reduce the spread of the infection. Behaviours, such as hand hygiene, screening and cohorting of patients, and the appropriate use of antibiotics have long been recommended in surgery, but their implementation has often been patchy. METHODS: The current crisis presents an opportunity to learn about how to improve infection prevention and control and surveillance (IPCS) behaviours. The improvements made were mainly informal, quick and stemming from the frontline rather than originating from formal organizational structures. The adaptations made and the expertise acquired have the potential for triggering deeper learning and to create enduring improvements in the routine identification and management of infections relating to surgery. RESULTS: This paper aims to illustrate how adopting a human factors and ergonomics perspective can provide insights into how clinical work systems have been adapted and reconfigured in order to keep patients and staff safe. CONCLUSION: For achieving sustainable change in IPCS practices in surgery during COVID-19 and beyond we need to enhance organizational learning potentials.

Human factors/ergonomics to support the design and testing of rapidly manufactured ventilators in the UK during the COVID-19 pandemic.

BACKGROUND: This paper describes a rapid response project from the Chartered Institute of Ergonomics & Human Factors (CIEHF) to support the design, development, usability testing and operation of new ventilators as part of the UK response during the COVID-19 pandemic. METHOD: A five-step approach was taken to (1) assess the COVID-19 situation and decide to formulate a response; (2) mobilise and coordinate Human Factors/Ergonomics (HFE) specialists; (3) ideate, with HFE specialists collaborating to identify, analyse the issues and opportunities, and develop strategies, plans and processes; (4) generate outputs and solutions; and (5) respond to the COVID-19 situation via targeted support and guidance. RESULTS: The response for the rapidly manufactured ventilator systems (RMVS) has been used to influence both strategy and practice to address concerns about changing safety standards and the detailed design procedure with RMVS manufacturers. CONCLUSION: The documents are part of a wider collection of HFE advice which is available on the CIEHF COVID-19 website (https://covid19.ergonomics.org.uk/).

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare.

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment.

BACKGROUND: Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context. METHODS: A multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and 'experts' to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented. RESULTS: A redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%-98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%). CONCLUSIONS: The checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.

Multi-method evaluation of a national clinical fellowship programme to build leadership capacity for quality improvement.

BACKGROUND: This paper reports the results of the evaluation of the Scottish Quality and Safety Fellowship (SQSF)-a 10-month, lead-level international educational programme established in 2008 with the overarching aim of developing clinicians with advanced quality improvement knowledge, technical ability and essential leadership skills. The evaluation explores four levels of educational and practice outcomes associated with (1) the reaction of fellows to SQSF participation, (2) learning gained, (3) subsequent behaviour changes and (4) the overall impact on national and international level capability and capacity building. METHODS: A theory-informed multi-method design was applied using (1) a search and review of the SQSF organisational database to tabulate personal, professional and demographic characteristics; (2) semi-structured telephone interviews with 16 participants using purposive and self-selected sampling; and (3) a cross-sectional online evaluation survey across all 10 cohorts involving 222 fellows RESULTS: SQSF was positively perceived as a high-quality learning experience containing a well-balanced mix of theory and practice, with a majority of respondents reporting career changing benefits. Most participants reported improved social, behavioural and emotional skills, knowledge and attitudes and, with sustained support of their host organisations, were able to apply and share learning in their workplace. The impact of the SQSF on a wider national and international level capability and capacity was both mediated and moderated by a wide range of interrelated contextual factors. CONCLUSIONS: This multi-method evaluation demonstrates that SQSF has achieved significant positive outcomes for the great majority of participants. Some tentative recommendations are provided with the aim of further enhancing fellowship content, delivery, transfer and future evaluations of wider impacts at regional, national and international health system levels.

Development and application of 'systems thinking' principles for quality improvement.

INTRODUCTION: 'Systems thinking' is often recommended in healthcare to support quality and safety activities but a shared understanding of this concept and purposeful guidance on its application are limited. Healthcare systems have been described as complex where human adaptation to localised circumstances is often necessary to achieve success. Principles for managing and improving system safety developed by the European Organisation for the Safety of Air Navigation (EUROCONTROL; a European intergovernmental air navigation organisation) incorporate a 'Safety-II systems approach' to promote understanding of how safety may be achieved in complex work systems. We aimed to adapt and contextualise the core principles of this systems approach and demonstrate the application in a healthcare setting. METHODS: The original EUROCONTROL principles were adapted using consensus-building methods with front-line staff and national safety leaders. RESULTS: Six interrelated principles for healthcare were agreed. The foundation concept acknowledges that 'most healthcare problems and solutions belong to the system'. Principle 1 outlines the need to seek multiple perspectives to understand system safety. Principle 2 prompts us to consider the influence of prevailing work conditions-demand, capacity, resources and constraints. Principle 3 stresses the importance of analysing interactions and work flow within the system. Principle 4 encourages us to attempt to understand why professional decisions made sense at the time and principle 5 prompts us to explore everyday work including the adjustments made to achieve success in changing system conditions.A case study is used to demonstrate the application in an analysis of a system and in the subsequent improvement intervention design. CONCLUSIONS: Application of the adapted principles underpins, and is characteristic of, a holistic systems approach and may aid care team and organisational system understanding and improvement.

Preliminary Adaptation, Development, and Testing of a Team Sports Model to Improve Briefing and Debriefing in Neonatal Resuscitation.

Briefing in team sports has been shown to benefit both performance and confidence among team members. The neonatal resuscitation team shares similarities with sports teams, where task performance includes rapid decision-making skills within dynamic situations, alongside unpredictable circumstances. AIM: We aimed to determine the effect of a team sports briefing model on the neonatal resuscitation team. Method: We adapted and redesigned a team sports briefing and debriefing model and related protocol and tested them with a neonatal resuscitation team in a U.K. university teaching hospital. RESULTS: The team's confidence and perceptions around these 2 aspects of resuscitation were studied along with frequency of task execution before and after a teaching intervention about the sports teams' approach to briefing and the introduction of a 7-point checklist. In 20 preintervention observations of 13 key tasks, areas for improvement in how neonatal intensive care unit (NICU) staff prepared for deliveries and potential resuscitations were found such as in "discussing potential deliveries that day" (n = 10, 50%), "identifying roles within the resus team that shift" (n = 5, 20%), and announcing when and where a debrief would occur (n = 0, 0%). Postintervention, the NICU team's mean task completion increased significantly from 9.23 (SD = 6.34) to 18.0 (SD = 1.83), a statistically meaningful difference of 8.77 (95% CI, 4.99-12.55; P < 0.001). CONCLUSION: Together with increased levels of confidence and efficiency reported postintervention, this provides some evidence that a brief-debrief process based on how sports team's approach pregame situations could be potentially transferable and beneficial to NICU team performance.

Evaluation of a simulation-based Risk Management and Communication Masterclass to reduce the risk of complaints, medicolegal and dentolegal claims.

Objectives: To understand clinicians' experiences, learning and professional impacts following participation in a Risk Management and Communication Masterclass (RMCM) designed and delivered by Medical Protection Society. To identify the course's strengths and areas for enhancement. Design: Mixed method study including semistructured telephone interviews. Interviews were conducted between October and December 2017, 6-30 months after course participation. Data were subjected to a thematic analysis. Quantitative analysis of participants' feedback ratings (n=486) on RMCMs delivered between December 2014 and May 2017 was also undertaken. Setting: RMCMs were delivered to Doctors and Dentists based in the UK and Ireland and South Africa. Participants: A sample of 12 volunteer doctors (Obstetricians/Gynaecologists, Orthopaedic/Spinal Surgeons, General Surgeons, Paediatricians, General Practitioners) and dentists chosen to represent different clinical specialities accepted the invitation to participate. Results: Study participants reported examples of person-centred communication skills such as empathy, shared-decision making and managing patient expectations in their workplaces following participation in the RMCM. Many clinicians gave examples describing how they used the communication models they learned when back at work. They also demonstrated a better understanding of the motivations for patients to complain or claim. RMCM course participants' high feedback ratings provided further evidence that the course was valuable and met learning objectives. Conclusions: It may prove difficult to demonstrate quantitatively that liability improves as a direct result of risk management and communications training. Our results on other dimensions (reactions, learning, behaviour change and impact) suggest that the RMCM has a positive and durable effect based on participant feedback.

Incidence of Wrong-Site Surgery List Errors for a 2-Year Period in a Single National Health Service Board.

INTRODUCTION: Wrong-site/side surgical "never events" continue to cause considerable harm to patients, healthcare professionals, and organizations within the United Kingdom. Incidence has remained static despite the mandatory introduction of surgical checklists. Operating theater list errors have been identified as a regular contributor to these never events. The aims of the study were to identify and to learn from the incidence of wrong-site/side list errors in a single National Health Service board. METHODS: The study was conducted in a single National Health Service board serving a population of approximately 300,000. All theater teams systematically recorded errors identified at the morning theater brief or checklist pause as part of a board-wide quality improvement project. Data were reviewed for a 2-year period from May 2013 to April 2015, and all episodes of wrong-site/side list errors were identified for analysis. RESULTS: No episodes of wrong-site/side surgery were recorded for the study period. A total of 86 wrong-site/side list errors were identified in 29,480 cases (0.29%). There was considerable variation in incidence between surgical specialties with ophthalmology recording the largest proportion of errors per number of surgical cases performed (1 in 87 cases) and gynecology recording the smallest proportion (1 in 2671 cases). The commonest errors to occur were "wrong-side" list errors (62/86, 72.1%). DISCUSSION: This is the first study to identify incidence of wrong-site/site list errors in the United Kingdom. Reducing list errors should form part of a wider risk reduction strategy to reduce wrong-site/side never events. Human factors barrier management analysis may help identify the most effective checks and controls to reduce list errors incidence, whereas resilience engineering approaches should help develop understanding of how to best capture and neutralize errors.