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

[...]我们的研究领域是年轻人的心理健康，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)，尽管这被认为是一个保守的估计，因为这个问题往往是隐藏的，而且存在未得到满足的需求(一些估计数字为400万)。这个问题并不是少女独有的，而是在少女中更为普遍。对饮食失调患者的死亡进行了高调调查，例如诺丁汉17岁的艾玛·卡彭特，全国媒体详细报道了这一事件(《每日镜报》，2015年6月26日)。她的死亡被归因于患者安全失误，以及组织和专业人员之间责任分散导致的护理协调不力。拟议的博士研究很可能通过与服务提供商(特别是CWPT-见下文)密切合作，然后通过NIHR GB 1000万资助的CLAHRC WM(CLAHRC-wm.nihr.ac.uk)和CLAHRC EM(CLAHRC-em.nihr.ac.uk)传播当地证据和实践，前者由Currie担任副主任和实施研究主管，后者由Martin担任实施研究副主管。患有饮食障碍的年轻患者的一个显著特征是他们的护理复杂，以及各种专业团体干预的治疗持续时间。在这样的情况下，患者的安全可以被概念化为“动态的非事件”，在大多数复杂的、长期的治疗和护理的情况下，安全的做法产生一个恒定的、因此明显无趣的非事件结果(Reason，1997)。然而，提供这种护理具有挑战性，因为它需要在多个组织的接口上进行有效协调，特别是在过渡点，以便降低风险并取得积极成果(文森特和阿马尔贝蒂，2016)。事实上，专业人员和组织之间的糟糕过渡是全球常见的患者安全故障(Wling等人，2015；Burgess&Currie，2013)。此外，随着时间的推移，护理可能会以一种不连续的方式提供。患有长期疾病的患者可能会有激烈的干预期，但这些期间会被较长的时间段打断，他们在不求助于临床或其他干预的情况下管理自己的情况。因此，有人呼吁对伤害和相应的安全进行更广泛的概念化：不仅是为了避免有害事件，而且还涉及由于协调不力而失去更好护理和改善结果的机会等问题，无论是在医院内，还是与初级保健过渡，或在社区中长期如此(文森特和阿马尔伯蒂，2016)。通过以这种方式重新概念化伤害和安全，系统层面的卫生保健的组织和管理成为前台，但迄今为止，关于使安全能够跨越组织和部门边界的组织因素的研究有限。这一博士学位试图解决这一缺陷，基于患者安全驻留在医疗体系的各个层面，并使用对患有饮食障碍的年轻人的护理的案例研究，来检验安全是如何在不同的专业和非专业行为者之间的界面上颁布、复制和共同产生的，这些行为者包括医疗保健专业人员、经理、行政人员、患者和非正式护理人员。它涉及问责制、跨专业和管理团队的领导力协调以及组织文化(尤其是鼓励“公正文化”或“安全文化”，这种文化将适当的个人责任与对安全所依赖的相互依赖的认识相结合，以及需要优先于学习而不是指责)。

[...]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).[...]