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Learning from significant medical events: a systematic review

Tristan Price, Rebecca Baines, Martin Marshall, Niall Cameron, Marie Bryce, Julian Archer

Abstract


Rationale, aims and objectives: Learning from significant medical events is a core component of quality and safety practice in healthcare worldwide and is a key component of efforts to increase the person-centeredness of clinical service. However, the evidence that analysis of, or reflection on, significant events has a positive impact on subsequent doctor performance is relatively sparse. This review aims to explore the impact of undertaking significant event analysis on medical performance.

Method: A systematic review using the following databases: PubMed, EMBASE, Medline, PsycINFO and the Cochrane Collaboration Library. Citation searches were carried out on included studies. Impact was defined according to a modified adaptation of the Kirkpatrick evaluation model. The selection and quality appraisal of studies was conducted by 2 reviewers, independently and blinded. Data were extracted from included studies related to: study type and location, population, methodology and intervention type.

Results: Six papers met the inclusion criteria for this review. Of these: one reported learners’ reaction (Kirkpatrick 1); 2 reported modified attitudes (modified Kirkpatrick 2a); 5 reported the acquisition of knowledge (modified Kirkpatrick level 2b) and all 6 identified reported changes in behaviour (modified Kirkpatrick level 3a). Significant event analysis is reported to identify gaps in knowledge, improve teamwork and communication and encourage reflection leading to improvements in practice. Time, resources and team dynamics were identified as factors that impacted on the effectiveness of significant event analysis. Significant event analysis may benefit from suspending existing hierarchies during the process itself and external facilitation.

Conclusion: There is a lack of high quality evidence within the existing literature to ascertain the effectiveness of significant event analysis in the medical context. Existing studies are largely based on self-reported measures, which may reinforce the importance of the discursive process for practitioners. Future research could be directed at identifying the pedagogical processes that effect changes in performance as a result of engaging in significant event analysis, leading to substantial increase in the person-centeredness of clinical care.

Keywords


Continuing medical education, doctor performance, incident reporting, medical education and training, medical performance, quality improvement, revalidation, root cause analysis, significant event analysis, systematic review regulation

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References


McKay, J., Bowie, P., Murray, L. & Lough, M. (2008). Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study. Quality and Safety in Health Care 17 (5) 339-345.

Mitchell, I., Schuster, A., Smith, K., Pronovost, P. & Wu, A. (2015). Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. BMJ Quality & Safety 25 (2) 92-99.

Kohn, L., Corrigan, J. & Donaldson, M. (2000). To err is human: building a safer healthcare system. Washington DC: National Academies Press.

Macrae, C. (2015). The problem with incident reporting. BMJ Quality & Safety 25 (2) 71-75.

Doupi, P. (2009). National reporting systems for patient safety incidents: a review of the situation in Europe. Raportti/Terveyden ja hyvinvoinnin laitos (THL) = Report/National Institute for Health and Welfare: 13/2009.

Braithwaite, J., Westbrook, M.T., Mallock, N.A., Travaglia, J.F. & Iedema, R.A. (2006). Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Quality and Safety in Health Care 15 (6) 393-399.

Bowie, P., Pope, L. & Lough, M. (2008). A review of the current evidence base for significant event analysis. Journal of Evaluation in Clinical Practice 14 (4) 520-536.

Pringle, M., Bradley, C., Carmichael, C., Wallis, H. & Moore, A. (1995). Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care. Occasional Paper Royal College of General Practitioners (70) i-viii 1-71.

Stavropoulou, C., Doherty, C. & Tosey, P. (2015). How Effective Are Incident‐Reporting Systems for Improving Patient Safety? A Systematic Literature Review. The Milbank Quarterly 93 (4) 826-866.

Archer, J. & de Bere, S.R. (2013). The United Kingdom's experience with and future plans for revalidation. Journal of Continuing Education in the Health Professions 33, S48-53.

Archer, J., Pitt, R., Nunn, S. & Regan de Bere, S. (2015). The evidence and options for revalidation in the Australian context. Canberra, ACT: Medical Board of Australia.

Leistikow, I., Mulder, S., Vesseur, J. & Robben, P. (2016). Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Quality & Safety 26 (3) 252-256.

Bowie, P., McNaughton, E., Bruce, D., Holly, D., Forrest, E., Macleod, M., et al. (2016). Enhancing the Effectiveness of Significant Event Analysis: Exploring Personal Impact and Applying Systems Thinking in Primary Care. Journal of Continuing Education in the Health Professions 36 (3) 195-205.

Dodds, A. & Kodate, N. (2012). Understanding institutional conversion: the case of the National Reporting and Learning System. Journal of Public Policy 32 (2) 117-139.

Mahajan, R. (2010). Critical incident reporting and learning. British Journal of Anaesthesia 105 (1) 69-75.

Moher, D., Liberati, A., Tetzlaff, J. & Altman, D.G. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Medicine 151 (4) 264-269.

Khan, K.S., Ter Riet, G., Glanville, J., Sowden, A.J. & Kleijnen, J. (2001). Undertaking systematic reviews of research on effectiveness: CRD's guidance for carrying out or commissioning reviews. York: NHS Centre for Reviews and Dissemination.

Sampson, M., McGowan, J., Cogo, E., Grimshaw, J., Moher, D. & Lefebvre, C. (2009). An evidence-based practice guideline for the peer review of electronic search strategies. Journal of Clinical Epidemiology 62 (9) 944-952.

Mourad, O., Hossam, H., Zbys, F. & Elmagarmid, A. (2016). Rayyan - a web and mobile app for systematic reviews. Systematic Reviews 5 (1) 210.

Barr, H., Freeth, D., Hammick, M. & Koppel, I.S.R. (2000). Evaluations of Interprofessional Education: A United Kingdom Review of Health and Social Care. London: CAPE.

Overeem, K., Lombarts, M., Arah, O.A., Klazinga, N.S., Grol, R.P. & Wollersheim, H.C. (2010). Three methods of multi-source feedback compared: a plea for narrative comments and coworkers’ perspectives. Medical Teacher 32 (2) 141-147.

Barr, H., Freeth, D., Hammick, M., Koppel, I. & Reeves, S. (2000). Evaluations of interprofessional education. London: United Kingdom Review of Health and Social Care.

Critical Appraisal Skills Programme CASP (Qualitative Research) Checklist. Online 2017.

Critical Appraisal Skills Programme CASP (Systematic Review) Checklist. Online 2017.

Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., et al. (2006). Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme Version 1. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.178.3100&rep=rep1&type=pdf.

Fereday, J. & Muir-Cochrane, E. (2006). Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods 5 (1) 80-92.

Thomas, J. & Harden, A. (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology 8 (1) 1-10.

de Wet, C., Bradley, N. & Bowie, P. (2011). Significant event analysis: a comparative study of knowledge, process and attitudes in primary care. Journal of Evaluation in Clinical Practice 17 (6) 1207-1215.

McKay, J., Bradley, N., Lough, M. & Bowie, P. (2009). A review of significant events analysed in general practice: implications for the quality and safety of patient care. BMC Family Practice 10 (1) 61.

Rea, D. & Griffiths, S. (2016). Patient safety in primary care: incident reporting and significant event reviews in British general practice. Health & Social Care in the Community 24 (4) 411-419.

Abdi, Z. & Ravaghi, H. (2017). Implementing root cause analysis in Iranian hospitals: challenges and benefits. The International Journal of Health Planning and Management 32 (2) 147-162.

Kantelhardt, P., Müller, M., Giese, A., Rohde, V. & Kantelhardt, S. (2011). Implementation of a critical incident reporting system in a neurosurgical department. Central European Neurosurgery 72 (1) 15-21.

Wallace, L.M., Boxall, M., Spurgeon, P. & Barwell, F. (2007). Organizational interventions to promote risk management in primary care: the experience in Warwickshire, England. Health Services Management Research 20 (2) 84-93.

Bowie, P., Skinner, J. & de Wet, C. (2013). Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes. BMC Health Services Research 13 (1) 50.

Nicolini, D., Waring, J. & Mengis, J. (2011). The challenges of undertaking root cause analysis in health care: a qualitative study. Journal of Health Services Research & Policy 16 (Supplement 1) 34-41.

Elder, N.C., Graham, D., Brandt, E. & Hickner, J. (2007). Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN). Journal of the American Board of Family Medicine 20 (2) 115-123.

Ivers, N., Jamtvedt, G., Flottorp, S., Young, J.M., Odgaard‐Jensen, J., French, S.D., O'Brien, M.A., Johansen, M., Grimshaw, J. & Oxman, A.D. (2012). Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews (6):CD000259.

Cox, S.J. & Holden, J.D. (2007). A retrospective review of significant events reported in one district in 2004-2005. British Journal of General Practice 57 (542) 732-736.

Bruster, B.G. & Peterson, B.R. (2013). Using critical incidents in teaching to promote reflective practice. Reflective Practice 14 (2) 170-182.

Bolsin, S., Colson, M., Patrick, A., Creati, B. & Bent, P. (2010). Critical incident reporting and learning. British Journal of Anaesthesia 105 (5) 698.

Adrian, R. (2015). The UK general election: a manifesto for health. Lancet 385 (9971) 829.

Vincent, C.A. (2004). Analysis of clinical incidents: a window on the system not a search for root causes. Quality and Safety in Health Care 13 (4) 242.

Bushe, G.R. & Marshak, R.J. (2009). Revisioning Organization Development: Diagnostic and Dialogic Premises and Patterns of Practice. Journal of Applied Behavioral Science 45 (3) 348-368.

McNab, D., McKay, J. & Bowie, P. (2017). Evaluation of a Primary Care Safety Improvement Intervention using Enhanced Significant Event Analysis in a Regional Scottish Health Board. Quality in Primary Care 25 (3) 148-156.




DOI: https://doi.org/10.5750/ejpch.v7i2.1637

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