Yes / Command centres have been piloted in some hospitals across the developed world in the last few years. Their impact on patient safety, however, has not been systematically studied. Hence, we aimed to investigate this. This is a retrospective population-based cohort study. Participants were patients who visited Bradford Royal Infirmary Hospital and Calderdale & Huddersfield hospitals between 1 January 2018 and 31 August 2021. A five-phase, interrupted time series, linear regression analysis was used. After introduction of a Command Centre, while mortality and readmissions marginally improved, there was no statistically significant impact on postoperative sepsis. In the intervention hospital, when compared with the preintervention period, mortality decreased by 1.4% (95% CI 0.8% to 1.9%), 1.5% (95% CI 0.9% to 2.1%), 1.3% (95% CI 0.7% to 1.8%) and 2.5% (95% CI 1.7% to 3.4%) during successive phases of the command centre programme, including roll-in and activation of the technology and preparatory quality improvement work. However, in the control site, compared with the baseline, the weekly mortality also decreased by 2.0% (95% CI 0.9 to 3.1), 2.3% (95% CI 1.1 to 3.5), 1.3% (95% CI 0.2 to 2.4), 3.1% (95% CI 1.4 to 4.8) for the respective intervention phases. No impact on any of the indicators was observed when only the software technology part of the Command Centre was considered. Implementation of a hospital Command Centre may have a marginal positive impact on patient safety when implemented as part of a broader hospital-wide improvement programme including colocation of operations and clinical leads in a central location. However, improvement in patient safety indicators was also observed for a comparable period in the control site. Further evaluative research into the impact of hospital command centres on a broader range of patient safety and other outcomes is warranted. / This research is supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC).

Il est préconisé de développer le climat de sécurité (CS) pour améliorer la sécurité des soins. Dans cette thèse, nous essaierons de préciser l’utilisation du concept de CS pour l’évaluation d'interventions d’amélioration de la sécurité des soins.Les objectifs des travaux présentés étaient d’élaborer un questionnaire de CS en français et d’évaluer l’impact de l’analyse de vignettes d’événements indésirables associés aux soins (EIAS) sur le CS d’unités de soins en milieu hospitalier.Ces travaux ont montré la faisabilité de mesurer le CS avec une version française du questionnaire américain, le Hospital Survey On Patient Safety Culture (HSOPSC). Ils ont permis de proposer une version française aux performances psychométriques suffisantes. Ils ont montré l’importance du rôle de l’encadrement, de l’organisation apprenante et du travail d’équipe entre services. La version française de l’HSOPSC a été utilisée pour évaluer l’effet de l’analyse de vignettes d’EIAS. Testée dans un essai contrôlé randomisé en clusters, cette intervention a amélioré les perceptions des professionnels sur l’organisation apprenante et l’amélioration continue, sans modifier les autres dimensions.Face à la difficulté de modifier dans un temps court l’ensemble des dimensions, le CS devrait être utilisé pour caractériser le contexte d'implémentation des interventions afin de les adapter et de mieux en comprendre l’impact, plutôt que pour servir de critère de résultat.Les pistes de recherche sont d’étudier la pérennité d’une intervention au-delà de son évaluation initiale au travers du maintien ou du développement de la culture de sécurité ; et d’étudier les perceptions des patients en matière de sécurité de soins / It is recommended to develop the safety climate (SC) to improve patient safety. In this thesis, we will try to clarify the use of the CS concept for the evaluation of interventions aiming to improve patient safety.The objectives of the articles presented were to develop a French version of a SC questionnaire and to assess the impact of a vignette-based analysis of adverse events (AEs) on the SC of care units.The studies demonstrated the feasibility of measuring the SC with a French version of the American questionnaire, the Hospital Survey On Patient Safety Culture (HSOPSC). They made it possible to propose a French version with sufficient psychometric performance. They showed the importance of the role of supervision, the organisational learning and teamwork between units. The French version of the HSOPSC was used to evaluate the effect of the vignette-based analysis of AEs. Tested in a randomized controlled cluster trial, this intervention improved professionals' perceptions of the organisational learning and continuous improvement, without modifying other dimensions.Given the difficulty of modifying all dimensions in a short period of time, SC should be used to characterize the context in which interventions are implemented in order to adapt them and better understand their impact, rather than being used as an outcome criterion.The research areas are to study the sustainability of an intervention beyond its initial evaluation through the maintenance or development of a safety culture; and to study patients' perceptions of care safety

Medication errors are the second most frequent cause of injury among all types of medical errors (Leape, et al., 1991). Of concern to nursing practice, medication administration errors (MAE) are second only to ordering errors (Bates, Cullen, et al., 1995). The introduction of information technology designed to promote safe medication practice, such as the Bar Code Medication Administration (BCMA) system, offers new opportunities for reducing MAE. BCMA was developed to improve patient safety, improve documentation of medication administration, decrease medication errors, and capture medication accountability data. The overall goal of this study was to evaluate the impact of BCMA on medication administration errors: wrong patient, medication, dose, time, and route. Rogers' (1995) theory, organizational diffusion of innovations, provided the study's framework.A descriptive comparative design examined incidence of MAEs before (Time 1) and after implementation (Time 2) of BCMA on eight units in one medical center. MAE incidence was calculated using MAE and patient-days data. Nurse adherence to BCMA usage procedure was assessed with a questionnaire created for the study.Findings indicated that total MAEs increased from Time 1 to Time 2, however, wrong patient and wrong dose errors decreased. There was a statistically significant (p < 0.05) increase in wrong route errors at Time 2. Comparing these findings with previous research demonstrated a diversity of methods, limiting conclusions. Nurse adherence findings indicated high overall adherence. However, completion of certain steps was hindered by software, equipment, or the work environment.Study findings were significant to nursing, informatics and patient safety research. Findings demonstrated the early state of BCMA research, added to knowledge about MAE detection methods, and brought a nursing perspective to information technology research on a process primarily within nursing purview. Implications for future research include improvement in MAE definitions and detection methods to support reliable data collection for research and quality improvement analysis. Also, sociotechnical theory recognizes health care as an interwoven, heterogeneous environment with complex roles and work practices, and may provide a more appropriate framework for evaluation of medication safety technology innovations than the linear model used in this study.

How clinicians detect and differentiate near misses from adverse events in health care is poorly understood. This study adopted a constructivist grounded theory approach and utilized document analysis and semi-structured interviews with 24 managers (middle and senior) and clinicians to examine the processes and factors associated with recognizing and recovering and learning from near misses in daily clinical practice. While safety science suggests that near misses are sources of learning to guide improvement efforts, the study identified how clinicians and managers cognitively downgrade and accept near misses as a routine part of daily practice. Such downgrading reduces the visibility of near misses and creates a paradoxical effect of promoting collective vigilance and increased safety while also encouraging violations in clinical practice. Three approaches to correcting and/or learning from near misses emerged: “doing a quick fix,” “going into the black hole,” and “closing off the swiss-cheese holes”; however, minimal organizational learning occurs. From these findings, two key paradoxes that undermine organization-level learning require further attention: (a) near misses are pervasive in everyday practice but many remain undetected and are missed learning opportunities, and (b) collective vigilance serves as both safety net and safety threat. Study findings suggest that organizational efforts are required to determine which near misses need to be reported. Organizations need to shift the culture from one of “doing a quick fix” to one that learns from near misses in daily practice; they should reinforce the benefits and reduce the risks of collective vigilance, and further encourage learning at the clinical microsystem level. Future research is required to provide insight into how individual, social, and organizational factors influence the recognition, recovery, and instructional value of near misses and safety threats in health care organizations’ daily practice.

Driven by research studies and national targets, sedation practices in Intensive care Units (ICU) are undergoing change. Traditionally, ventilated patients in ICUs were kept deeply sedated and only gradually ‘weaned off’ sedation. However, current evidence supports a more ‘wakeful’ patient with the introduction of ‘sedation holds’ encouraging them to regain consciousness (Kress et al. 2000). There is little research exploring ICU nurses’ assessment and management of sedation. Employing a Heideggerian, hermeneutic phenomenological approach to enquiry, the study sought to provide insights into the world of the critical care nurse, nursing with technology, and specifically their beliefs surrounding sedation practices and how organisational factors, knowledge and personal experiences influence their clinical decisions in the care of the ventilated patient. The setting was the Royal Infirmary of Edinburgh, ICU and the purposive sample consisted of 16 ICU nurses with diverse critical care nursing experience. Bedside interviews, utilising an aide memoir, elicited narratives about the nurses’ experiences of sedation practice and a novel sedation monitor (responsiveness). The phenomenological analysis drew upon a number of existing frameworks to guide enquiry. The researcher engaged with the ‘hermeneutic circle’, acknowledging her pre-understandings and using these as a platform to move between the whole of the research and the parts, the descriptions and narratives offered, to develop new knowledge. Themes emerged that demonstrated patients’ sedation status directly impacted upon the nurses’ ICU lived experiences and left them in a state of disequilibrium regarding the requirement to deliver research based care, the desire to deliver holistic care and the duty to deliver safe care. The nurses perceived sedation holds and ‘wakefulness’ as resulting in patient agitation and distress which affected patient safety and comfort. However, the nurses equally felt a pressure of obligation to the doctors to perform such evidence based sedation holds. They described the struggling to maintain patient safety and manage their own fears and anxieties and organisational constraints, whilst experiencing guilt, blame and failure associated with their behavioural discordance with the prescribed decisions and their own clinical decision making processes and strategies. Team work between the two professions and effective leadership is evidently less than ideal. Consequently the implementation of changes in sedation practice is failing to meet either the national targets or to respond to the nurses’ concerns regarding their patient’s short term wellbeing. On both counts this potentially impairs the pursuit of best practice.

In the Kingdom of Saudi Arabia, there has not been a systematic effort to evaluate the problems of medical error and patient safety as critical issues in healthcare organizational ethics. This dissertation aims to pursue the impact of the original IOM report on this crucial topic by adopting what have been done in the American healthcare system in order to gain insight for the Saudi Arabian healthcare system. This dissertation examines the functions of continuous quality improvement in the healthcare environment of Saudi Arabia through the lens of the organization’s moral agency. This dissertation identifies several areas in Saudi healthcare organizations that are in need of improvement. As a result, this paper makes several recommendations that systematically address patient safety and medical error so that the system can be free from adverse events and medical errors. This dissertation argues that Saudi healthcare organizations have an ethical responsibility to continuously improve the system of healthcare in order to enhance patients’ safety and to reduce medical errors. This dissertation also recommends that Saudi health organizations foster a culture of safety as part of their ethical responsibility toward the customers they serve. Therefore, Saudi healthcare organizations should have an active, anonymous, and confidential reporting system; an open communication and collaboration between healthcare professionals; and create a non-punitive system. In addition, this dissertation argues in favor of patients’ involvement in the treatment process, and for having an ethics committee in Saudi healthcare organizations. / McAnulty College and Graduate School of Liberal Arts; / Health Care Ethics / PhD; / Dissertation;

Background: Violations occur when individuals choose to bypass or deviate from procedures. Although violations are often not intended to cause harm, they are nevertheless breaches of the preferred way of working. Violations have been suggested to introduce risk into the environment by eroding the margin of safety. Therefore, violations are of potential concern to healthcare professionals that are responsible for patient safety. This thesis examines how and why violations occur in community pharmacies. Method: The research adopted a mixed methods approach to explore violations in community pharmacies and three studies were undertaken. The first study was a qualitative study that explored the views of management and frontline staff with regards to the prevailing safety culture in community pharmacies. The aim was to understand the context in which violations occur and to explore the goals that staff manage in practice. The second interview study explored how procedures are perceived in practice and the types of violations that occur in this setting. The third study utilised a survey based on the COM-B model that further explored the influence of capability, opportunity and motivation on violating behaviours. Results: Overall, findings demonstrated that numerous types of violations occur in community pharmacies. Mainly they occur either to ensure that timely patient care is provided or to ensure that productivity is maintained in practice. The safety culture study suggested that frontline staff and management have a different safety culture, with frontline staff reacting to risk in the moment and head office staff managing risk through the provision of multiple detailed procedures. The interviews suggested that procedures are useful for outlining what is expected of staff in practice; however they are not always possible to follow to the letter due to the complex working environment. The social norm within each pharmacy was suggested to influence violating behaviours, as was the professional judgement of the pharmacist. Violations were shown to be necessary for maintaining care at times, especially in exceptional circumstances. However, at times violations to maintain productivity did result in an increased risk to patient safety. The questionnaire study highlighted motivation, opportunity, length of experience, staff role and gender as influences on certain types of violations. Conclusions: The mixed methods utilised as part of this thesis revealed the types of violations that occur in community pharmacies and the reasons why pharmacists and support staff choose to violate. The findings led to recommendations for policymakers to evaluate how procedures are implemented in practice, to provide additional support for staff in practice through improved workflow, to provide patient safety specific training in pharmacies, to improve communication between frontline and head office staff and to educate pharmacy students regarding the possibility that they will need to violate procedures at times to manage the complex reality of working within community pharmacies.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

The U.S. Institute of Medicine estimates that there are 98,000 people died yearly from medical errors; approximate 20,000 people died from medical adverse events annually was estimated in Taiwan. All these reports indicate that the medical errors have great impact on patient safety. The hemodialysis population in Taiwan keeps increasing these years, and this means more attention should be paid to patient safety with the growing hemodialysis population. In 2005, Taiwan Joint Commission on Hospital Accreditation sets six goals for patient safety, general guidelines for healthcare facilities, and relative regulations are mostly on standard devices. This study tries to provide more possible root causes about patient safety at a hemodialysis center. Root cause analysis (RCA) has been greatly used in patient safety because latent factors can be determined by RCA. RCA was simulated in this study at a hemodialysis center. Firstly, a series of formal questions, developed by the U.S. Department of Veteran Affairs, were used to examine the current situation. The questions used are composed of six dimensions. Then, cause-effect-diagram was used to locate latent causes, and finally identified four dimensions. Research results are mainly summarized as human resource management issues, including two root causes of inadequate professional training and overwork. Adjusted job assignment and job content are also suggested in this study.

Objective: Today, many healthcare organizations have implemented health care reporting systems in the hope of learning from experience to prevent or reduce adverse events, medical errors or accidents. However, most applications have failed or not been implemented as predicted. This study presents an extended technology acceptance model (TAM) that integrates subjective norm, trust, and management support into the TAM to investigate what determines healthcare professional reporting system acceptance. Design: The proposed model was empirically tested using data collected from a survey in the hospital environment. The structural equation modeling technique was used to evaluate the causal model and confirmatory factor analysis was performed to examine the reliability and validity of the measurement model. Measurements: Questionnaire administered items measuring the behavioral intention to use the reporting system and five hypothesized antecedents. Results: Our findings indicated that all variables significantly affected healthcare professionals¡¦ behavioral intention to use the reporting system. Among them, the subjective norm had the most significant influence. Conclusion: The proposed model provides a means to understand what factors determine healthcare professional¡¦s behavioral intention to use a reporting system and how this may affect future use. In addition, antecedents to the behavioral intent can be used to predict reporting system acceptance in advance of system development.