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），尽管这被认为是一个保守的估计，因为这个问题往往是隐藏的，而且存在未满足的需求（一些估计数字为400万）。这个问题并非少女独有，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的调查，比如诺丁汉17岁的艾玛·卡彭特（Emma Carpenter）的死亡，全国媒体对此进行了详细报道（《每日镜报》，2015年6月26日）。她的死亡是由于组织和专业人员之间的责任分散导致的患者安全失败和护理协调不力。拟议的博士研究可能会通过与服务提供者（特别是CWPT -见下文）密切合作，然后通过国家卫生研究院资助的1000万英镑CLAHRC WM （CLAHRC WM .nihr.ac.uk）和CLAHRC EM （CLAHRC EM .nihr.ac）传播当地的证据和实践，对服务提供产生重大的积极影响。Currie是前者的副主任和执行研究负责人，Martin是后者的执行研究副负责人。年轻饮食失调患者的一个显著特征是其护理的复杂性，以及各种专业人员干预治疗的持续时间。在这种情况下，患者安全可以被概念化为“动态非事件”，因此在大多数复杂的长期治疗和护理案例中，安全做法会产生恒定的，因此显然是无趣的非事件结果（Reason, 1997）。然而，提供这样的护理是具有挑战性的，因为它需要在多个组织的接口上进行有效的协调，特别是在过渡点，以减轻风险并实现积极的结果（Vincent & Amalberti, 2016）。事实上，专业人员和组织之间的不良过渡是全球常见的患者安全失败（Waring et al., 2015; Burgess & Currie, 2013）。此外，随着时间的推移，护理可能以不连续的方式提供。患有长期疾病的患者可能需要高强度的干预，但这些干预会被更长的时间所打断，在这段时间里，他们可以在不诉诸临床或其他干预的情况下控制自己的病情。因此，人们呼吁对伤害和相应的安全进行更广泛的概念化：这不仅是避免有害事件的问题，而且还涉及由于协调不良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，还是向初级保健过渡，还是在社区中长期（Vincent & Amalberti, 2016）。在以这种方式重新定义危害和安全时，系统层面的卫生保健组织和管理变得很有前景，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有限。本博士旨在解决这一空白，以患者安全存在于各级医疗保健系统的见解为基础，并通过对患有饮食失调的年轻人的护理案例研究，研究如何在不同专业和非专业行为者（包括医疗保健专业人员、管理人员、管理人员、患者和非正式护理人员）之间制定、复制和共同生产安全。它解决了诸如问责制、跨专业和管理团队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”，这种文化将适当的个人责任与对安全所依赖的相互依赖性的认识结合起来，并且需要优先考虑学习而不是责备）。

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