Patient safety in complex systems: developing and applying 'Safety II' in multidisciplinary care for younger people with eating disorders

复杂系统中的患者安全：在患有饮食失调的年轻人的多学科护理中开发和应用“安全 II”

• 批准号: 1913714
• 金额: --
• 依托单位: University of Warwick
• 依托单位国家: 英国
• 项目类别: Studentship
• 财政年份: 2017
• 资助国家: 英国
• 起止时间: 2017 至 无数据
• 项目状态: 已结题
• 来源: https://gtr.ukri.org/projects?ref=studentship-1913714
• 关键词: Patient; safety; complex; systems; developing

[...]Our field of study is youth mental health, specifically eating disorders amongst young people. It is estimated more than 1.6m people in the UK are affected by an eating disorder (www.jcpmh.info), although this is recognised as a conservative estimate since the problem is often hidden and there exists unmet need (some estimates put the number at 4m). The problem is not exclusive to, but much more prevalent among, teenage girls. There have been high profile inquiries into deaths of patients from eating disorders, such as that of Emma Carpenter, a 17 year-old in Nottingham, detailed in national press (Daily Mirror, 26 June 2015). Her death was ascribed to patient safety failure with poor co-ordination of care resultant from dissipated responsibility amongst organisations and professionals. The proposed PhD research is likely to have significant positive impact upon service delivery through working closely with service providers (specifically CWPT - see below), and then diffusing local evidence and practice through the NIHR £10m funded CLAHRC WM (clahrc-wm.nihr.ac.uk) and CLAHRC EM (clahrc-em.nihr.ac.uk), the former for which Currie is Deputy Director and Implementation Research Lead, the latter for which Martin is Deputy Implementation Research Lead. A notable characteristic of younger patients with eating disorders is the complexity of their care, and the duration of treatment over which various groups of professionals intervene. In circumstances such as this, patient safety can be conceptualised as a 'dynamic non-event', whereby in most cases of complex, long-term treatment and care, safe practices generate a constant and hence apparently uninteresting non-event outcome (Reason, 1997). Yet provision of such care is challenging because it requires effective coordination at interfaces across multiple organizations, in particular at transition points in order to mitigate risk and enable positive outcomes (Vincent & Amalberti, 2016). Indeed, poor transition between professionals and organisations is a common patient safety failure globally (Waring et al., 2015; Burgess & Currie, 2013). Further, care is likely delivered in a discontinuous way over time. A patient with a long-term condition may have intense periods of intervention, but these are punctuated by longer time periods where they manage their condition without recourse to clinical or other interventions. There have thus been calls for a more wide-ranging conceptualisation of harm and, correspondingly, safety: as a matter not just of avoidance of harmful events, but also relating to issues such as lost opportunities for better care and improved outcomes due to poor coordination, whether inside a hospital, or transition with primary care, or over a long period of time in the community (Vincent & Amalberti, 2016).In reconceptualising harm and safety in this way, the organisation and management of health care at the system level becomes foregrounded, but to date there has been limited research on organisational factors that enable safety across organisation and sector boundaries. This PhD seeks to address this lacuna, building on the insight that patient safety resides at all levels of healthcare systems and using a case study of the care of younger people with eating disorders to examine how safety is enacted, reproduced and coproduced at the interface between different professional and non-professional actors, including healthcare professionals, managers, administrators, patients and informal carers. It addresses issues such as accountability, the co-ordination of leadership across professional and managerial groups, and organisational culture (and particularly the encouragement of a 'just culture' or 'safety culture' which combines appropriate personal responsibility with recognition for the interdependencies upon which safety relies, and the need to prioritise learning over blame).[...]

[...]我们的研究领域是青少年心理健康，特别是年轻人的饮食失调。据估计，英国有超过 160 万人受到饮食失调的影响 (www.jcpmh.info)，尽管这被认为是保守估计，因为问题往往是隐藏的，并且存在未满足的需求（一些估计数字为 400 万人）。这个问题并非少女所独有，而且在少女中更为普遍。对饮食失调患者死亡事件进行了备受瞩目的调查，例如诺丁汉 17 岁的艾玛·卡彭特 (Emma Carpenter) 的死亡事件，国家媒体对此进行了详细报道（《每日镜报》，2015 年 6 月 26 日）。她的死亡归因于患者安全失败以及由于组织和专业人员之间的责任分散导致护理协调不力。拟议的博士研究可能会通过与服务提供商密切合作（特别是 CWPT - 见下文）对服务提供产生重大积极影响，然后通过 NIHR 1000 万英镑资助的 CLAHRC WM (clahrc-wm.nihr.ac.uk) 和 CLAHRC EM (clahrc-em.nihr.ac.uk) 传播当地证据和实践，Currie 是前者的副主任兼实施研究负责人， 马丁是后者的副实施研究负责人。患有饮食失调的年轻患者的一个显着特征是其护理的复杂性以及不同专业人士干预的治疗持续时间。在这种情况下，患者安全可以被概念化为“动态非事件”，在大多数复杂、长期治疗和护理的情况下，安全实践会产生恒定的、因此显然无趣的非事件结果（Reason，1997）。然而，提供此类护理具有挑战性，因为它需要跨多个组织的接口进行有效协调，特别是在过渡点，以减轻风险并实现积极成果（Vincent & Amalberti，2016）。事实上，专业人员和组织之间的过渡不力是全球范围内常见的患者安全失败问题（Waring 等人，2015 年；Burgess & Currie，2013 年）。此外，随着时间的推移，护理可能会以不连续的方式提供。患有长期疾病的患者可能会经历密集的干预期，但这些干预期会被更长的时间间隔所打断，他们在不求助于临床或其他干预措施的情况下控制自己的病情。因此，有人呼吁对伤害和相应的安全进行更广泛的概念化：这不仅是为了避免有害事件，还涉及到由于协调不善而失去获得更好护理和改善结果的机会等问题，无论是在医院内部，还是向初级保健过渡，还是在社区中长期存在（Vincent & Amalberti，2016）。以这种方式重新概念化伤害和安全，健康的组织和管理 系统层面的护理变得至关重要，但迄今为止，对跨组织和部门边界实现安全的组织因素的研究还很有限。本博士旨在解决这一缺陷，基于患者安全存在于医疗保健系统各个层面的见解，并利用对患有饮食失调的年轻人的护理案例研究来研究如何在不同专业和非专业参与者（包括医疗保健专业人员、经理、管理人员、患者和非正式护理人员）之间的界面上制定、复制和共同产生安全性。它解决了诸如问责制、跨专业和管理团体的领导协调以及组织文化等问题（特别是鼓励“公正文​​化”或“安全文化”，其中将适当的个人责任与对安全所依赖的相互依赖性的认识相结合，以及将学习优先于责备的需要）。[...]