Improving the impact of patient safety incident reporting systems through healthcare professional digitally enabled networks: a novel patient safety strategy
Creators: name: Faquer Manhaes, Marcos
Publisher: name: Imperial College London
Year: 2021

description: Considered a cornerstone of patient safety improvement efforts, incident reporting systems which capture information about hazards and adverse events in order to learn lessons that will help prevent harm or the recurrence of similar events, have been developed in several countries over the past two decades(1, 2). The UK National Reporting and Learning System (NRLS), developed by the UK National Patient Safety Agency and launched in 2003, was the world’s first national system of its kind(3), and is the world’s largest dedicated data source supporting the identification of risks and development of initiatives to prevent harm to patients(4). A crucial part of a reporting and learning system is its capability to provide effective feedback from safety reporting and learning systems - including corrective actions – and to improve safety and addressing specific systems’ vulnerabilities. However, limited evidence exists concerning the issue of effective forms and mechanisms for providing safety feedback within healthcare(5). The rapid scientific and technological advances observed in recent years, in particular the development of digital applications that make the most of the intrinsic advantages of web networks, consuming and remixing data from multiple sources, including individual users through an architecture of participation, encapsulated under the term Web 2.0 (6), opened up opportunities for new forms of communication and knowledge formation, allowed relationship creating between users from distinct backgrounds and geographical areas, and resulted in a tenacious, pervasive and potentially influential social structure, able to facilitate information flow and promote behaviour change. These digitally enabled networks (DENs) are currently used among health professionals in front line clinical practice, in professional collaborations, in education and training, and in disseminating information and expanding professional connections(7). The impact of use of DENs by healthcare professionals on patient safety warrant further investigation. This thesis addresses the question, can a novel learning model to feed back, using healthcare professional digitally enabled networks, increase the effectiveness of national patient safety reporting systems? In order to collate existing information and augment the knowledge base available to support a response, this work ascertains national patient safety reporting systems latest developments and current challenges; explores healthcare professionals perspectives, experiences and preferences in relation to such systems, their feedback and available mechanisms and characteristics to feed back; and proposes a novel and inclusive framework to feed back which makes use of healthcare professional (HCP) digitally enabled networks (DENs). First, this work systematically appraises available evidence upon the development, evolution, use and reported shortfalls of national patient safety incident reporting systems, identifying current knowledge gaps, most perceived weaknesses and potential opportunities to increase their effectiveness. This substantiates the paucity of evidence on understanding front line healthcare staff behaviours, needs, preferences and motivations in relation to patient safety incident reporting systems. And, in addition, it acknowledges the impact of modern ways to communicate, access and consume information, on people’s social and professional interactions, learning and development. Furthermore, this work assesses the evidence of use of HCP DENs in patient safety improvement initiatives, identifying healthcare settings and patient safety topics of prevalence, and DENs features reported to potentially providing most opportunities or challenges to the development of patient safety interventions that objective capitalising on HCP DENs. This work then using a set of surveys tailored to different healthcare staff population segments, leverages and discusses patient safety reporting systems and feedback stakeholders’ perspectives and concerns to form a set of requirements to support the development of a new national reporting systems and feedback framework. Based on the empirical data which were collected and evaluated in this research, alongside a series of policy recommendations in relation to national reporting systems, a new safety action and learning from incident reporting feedback framework is proposed for the UK healthcare system – the NHS. The new framework employs the use of established healthcare professional digitally enabled networks to promote and facilitate information sharing and engagement with safety feedback amongst front line staff. This research contributes to the evidence base upon which the development of a new Learn From Patient Safety Events (LFPSE) – formally known as Patient Safety Incident Management System (PSIMS), is built.