Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia

Quantifying Use of a Health Virtual Community of Practice for General Practitioners' Continuing Professional Development: A Novel Methodology and Pilot Evaluation

Background

Health care practitioners (HPs), in particular general practitioners (GPs), are increasingly adopting Web-based social media platforms for continuing professional development (CPD). As GPs are restricted by time, distance, and demanding workloads, a health virtual community of practice (HVCoP) is an ideal solution to replace face-to-face CPD with Web-based CPD. However, barriers such as time and work schedules may limit participation in an HVCoP. Furthermore, it is difficult to gauge whether GPs engage actively or passively in HVCoP knowledge-acquisition for Web-based CPD, as GPs’ competencies are usually measured with pre- and posttests.

Objective

This study investigated a method for measuring the engagement features needed for an HVCoP (the Community Fracture Capture [CFC] Learning Hub) for learning and knowledge sharing among GPs for their CPD activity.

Methods

A prototype CFC Learning Hub was developed using an Igloo Web-based social media software platform and involved a convenience sample of GPs interested in bone health topics. This Hub, a secure Web-based community site, included 2 key components: an online discussion forum and a knowledge repository (the Knowledge Hub). The discussion forum contained anonymized case studies (contributed by GP participants) and topical discussions (topics that were not case studies). Using 2 complementary tools (Google Analytics and Igloo Statistical Tool), we characterized individual participating GPs’ engagement with the Hub. We measured the GP participants’ behavior by quantifying the number of online sessions of the participants, activities undertaken within these online sessions, written posts made per learning topic, and their time spent per topic. We calculated time spent in both active and passive engagement for each topic.

Results

Seven GPs participated in the CFC Learning Hub HVCoP from September to November 2017. The complementary tools successfully captured the GP participants’ engagement in the Hub. GPs were more active in topics in the discussion forum that had direct clinical application as opposed to didactic, evidence-based discussion topics (ie, topical discussions). From our knowledge hub, About Osteoporosis and Prevention were the most engaging topics, whereas shared decision making was the least active topic.

Conclusions

We showcased a novel complementary analysis method that allowed us to quantify the CFC Learning Hub’s usage data into (1) sessions, (2) activities, (3) active or passive time spent, and (4) posts made to evaluate the potential engagement features needed for an HVCoP focused on GP participants’ CPD process. Our design and evaluation methods for ongoing use and engagement in this Hub may be useful to evaluate future learning and knowledge-sharing projects for GPs and may allow for extension to other HPs’ environments. However, owing to the limited number of GP participants in this study, we suggest that further research with a larger cohort should be performed to validate and extend these findings.

Critical incidents, including cardiac arrest, associated with pediatric anesthesia at a tertiary teaching children's hospital

BACKGROUND

Analysis of critical incidents provides valuable information to improve the quality and safety of patient care. This study identified and analyzed pediatric anesthesia-related critical incidents including cardiac arrests in a tertiary teaching children's hospital.

METHODS

All pediatric anesthesia-related critical incidents reported in a voluntary departmental reporting system between January 2008 and August 2013 were included in the analysis. A critical incident was defined as (i) any incident that altered patients' vital signs and affected the management of patients while they were under the care of an anesthesiologist, and (ii) human factor: where patient injury or accidents were as a result of human error. Changes in vital signs that recovered spontaneously were excluded.

RESULTS

During the 6-year study period, a total of 229 critical incidents were reported from 49,373 anesthetic procedures. The most frequently reported incidents were associated with the respiratory system (55%), with tracheal tube-related events accounting for 40.9% of respiratory incidents followed by laryngospasm (17.3% of respiratory incidents). Cardiac arrest occurred in 42 cases in this study (8.5 cases per 10,000 anesthetics). Cardiovascular problems were the major causes of cardiac arrest (66.7%), and incidents of cardiogenic shock and hemorrhage/hypotension contributed equally to the cardiac arrest induced by cardiovascular problems (each 16.7%). Human factor-related events accounted for 58.5% of all critical incidents of which 53.7% were respiratory events.

CONCLUSION

Despite recent improvements in safety of pediatric anesthesia, many preventable factors still remain that can lead to critical incidents.

National critical incident reporting systems relevant to anaesthesia: a European survey

BACKGROUND

Critical incident reporting is a key tool in the promotion of patient safety in anaesthesia.

METHODS

We surveyed representatives of national incident reporting systems in six European countries, inviting information on scope and organization, and intelligence on factors determining success and failure.

RESULTS

Some systems are government-run and nationally conceived; others started out as small, specialty-focused initiatives, which have since acquired a national reach. However, both national co-ordination and specialty enthusiasts seem to be necessary for an optimally functioning system. The role of reporting culture, definitional issues, and dissemination is discussed.

CONCLUSIONS

We make recommendations for others intending to start new systems and speculate on the prospects for sharing patient safety lessons relevant to anaesthesia at European level.

General practice training and virtual communities of practice - a review of the literature

BACKGROUND

Good General Practice is essential for an effective health system. Good General Practice training is essential to sustain the workforce, however training for General Practice can be hampered by a number of pressures, including professional, structural and social isolation. General Practice trainees may be under more pressure than fully registered General Practitioners, and yet isolation can lead doctors to reduce hours and move away from rural practice. Virtual communities of practice (VCoPs) in business have been shown to be effective in improving knowledge sharing, thus reducing professional and structural isolation. This literature review will critically examine the current evidence relevant to virtual communities of practice in General Practice training, identify evidence-based principles that might guide their construction and suggest further avenues for research.

METHODS

Major online databases Scopus, Psychlit and Pubmed were searched for the terms "Community of Practice" (CoP) AND (Online OR Virtual OR Electronic) AND (health OR healthcare OR medicine OR "Allied Health"). Only peer-reviewed journal articles in English were selected. A total of 76 articles were identified, with 23 meeting the inclusion criteria. There were no studies on CoP or VCoP in General Practice training. The review was structured using a framework of six themes for establishing communities of practice, derived from a key study from the business literature. This framework has been used to analyse the literature to determine whether similar themes are present in the health literature and to identify evidence in support of virtual communities of practice for General Practice training.

RESULTS

The framework developed by Probst is mirrored in the health literature, albeit with some variations. In particular the roles of facilitator or moderator and leader whilst overlapping, are different. VCoPs are usually collaborations between stakeholders rather than single company VCoPs. Specific goals are important, but in specialised health fields sometimes less important than in business. Boundary spanning can involve the interactions of different professional groups, as well as using external experts seen in business VCoPs. There was less use of measurement in health VCoPs. Environments must be supportive as well as risk free. Additional findings were that ease of use of technology is paramount and it is desirable for VCoPs to blend online and face-to-face involvement.

CONCLUSIONS

The business themes of leadership, sponsorship, objectives and goals, boundary spanning, risk-free environment and measurements become, in the health literature, facilitation, champion and support, objectives and goals, a broad church, supportive environment, measurement benchmarking and feedback, and technology and community.General Practice training is under pressure from isolation and virtual communities of practice may be a way of overcoming isolation. The health literature supports, with some variation, the business CoP framework developed by Probst. Further research is needed to clarify whether this framework is an effective method of health VCoP development and if these VCoPs overcome isolation and thus improve rural retention of General Practice registrars.

How and why are communities of practice established in the healthcare sector? A systematic review of the literature

Background

Communities of Practice (CoPs) are promoted in the healthcare sector as a means of generating and sharing knowledge and improving organisational performance. However CoPs vary considerably in the way they are structured and operate in the sector. If CoPs are to be cultivated to benefit healthcare organisations, there is a need to examine and understand their application to date. To this end, a systematic review of the literature on CoPs was conducted, to examine how and why CoPs have been established and whether they have been shown to improve healthcare practice.

Methods

Peer-reviewed empirical research papers on CoPs in the healthcare sector were identified by searching electronic health-databases. Information on the purpose of establishing CoPs, their composition, methods by which members communicate and share information or knowledge, and research methods used to examine effectiveness was extracted and reviewed. Also examined was evidence of whether or not CoPs led to a change in healthcare practice.

Results

Thirty-one primary research papers and two systematic reviews were identified and reviewed in detail. There was a trend from descriptive to evaluative research. The focus of CoPs in earlier publications was on learning and exchanging information and knowledge, whereas in more recently published research, CoPs were used more as a tool to improve clinical practice and to facilitate the implementation of evidence-based practice. Means by which members communicated with each other varied, but in none of the primary research studies was the method of communication examined in terms of the CoP achieving its objectives. Researchers are increasing their efforts to assess the effectiveness of CoPs in healthcare, however the interventions have been complex and multifaceted, making it difficult to directly attribute the change to the CoP.

Conclusions

In keeping with Wenger and colleagues' description, CoPs in the healthcare sector vary in form and purpose. While researchers are increasing their efforts to examine the impact of CoPs in healthcare, cultivating CoPs to improve healthcare performance requires a greater understanding of how to establish and support CoPs to maximise their potential to improve healthcare.

An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006-2008

OBJECTIVES/AIMS

We aimed to identify and analyze critical incidents relating to pediatric anesthesia from the National Reporting and Learning System (NRLS) in England and Wales.

BACKGROUND

Critical incident reporting plays a key role in learning from problems and so enhancing patient safety. There has been no previous analysis of pediatric anesthetic incidents in the NRLS.

METHODS

We obtained potentially relevant records from the UK National Patient Safety Agency. Eligible incidents were classified according to patient age, degree of harm sustained, and clinical category.

RESULTS

A total of 606 incidents met the inclusion criteria. Six deaths were reported and 48 incidents resulted in severe harm. In many reports, sufficient detail was lacking for a full understanding of what had happened. However, the broad focus of the NRLS revealed a wide spectrum of clinical and organizational incidents relating to pediatric anesthesia. Medication issues predominated (35.6%), notably inadvertent duplication of dosing in operating theater and ward. Airway/ventilation incidents formed 18.8% of the total, cardiovascular incidents 5.9%, and equipment-related incidents (failure or unavailability) 15.7%. Communication and organizational problems made up 8.6% of reports.

CONCLUSIONS

We make a number of recommendations for practice. In addition, anesthetists should be encouraged to take ownership and contribute high-quality descriptions of incidents to national systems.

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*

Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system's own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient's airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment. You can respond to this article at http://www.anaesthesiacorrespondence.com.

The geography of patient safety: a topical analysis of sterility

Many studies on patient safety are geared towards prevention of adverse events by eliminating causes of error. In this article, I argue that patient safety research needs to widen its analytical scope and include causes of strength as well. This change of focus enables me to ask other questions, like why don't things go wrong more often? Or, what is the significance of time and space for patient safety? The focal point of this article is on the spatial dimension of patient safety. To gain insight into the 'geography' of patient safety and perform a topical analysis, I will focus on one specific kind of space (sterile space), one specific medical procedure (insertion of an intravenous line) and one specific medical ward (neonatology). Based on ethnographic data from research in the Netherlands, I demonstrate how spatial arrangements produce sterility and how sterility work produces spatial orders at the same time. Detailed analysis shows how a sterile line insertion involves the convergence of spatially distributed resources, relocations of the field of activity, an assemblage of an infrastructure of attention, a specific compositional order of materials, and the scaling down of one's degree of mobility. Sterility, I will argue, turns out to be a product of spatial orderings. Simultaneously, sterility work generates particular spatial orders, like open and restricted areas, by producing buffers and boundaries. However, the spatial order of sterility intersects with the spatial order of other lines of activity. Insight into the normative structure of these co-existing spatial orders turns out to be crucial for patient safety. By analyzing processes of spatial fine-tuning in everyday practice, it becomes possible to identify spatial competences and circumstances that enable staff members to provide safe health care. As such, a topical analysis offers an alternative perspective of patient safety, one that takes into account its spatial dimension.