Theme 2 - Safer Organisations is led by Prof Cecilia Vendrola and Prof Ramani Moonesinghe.

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Learning from episodes of avoidable harm, and understanding how good care is delivered, are both critically important features of a learning healthcare system. While individual healthcare professionals may or may not learn from their own and/or others' experience, organisational learning is also an important and under-recognised feature of safer healthcare systems. This theme focuses on improving organisational learning, patient safety and culture. Initially, we are focusing on three main programmes of work. 

 

Study 1: An ethnographic study of the impact of the NAP6 recommendations on practice

 

Many reports of this type are written, often with many hundreds of recommendations, but there is much less understanding about whether or not they may a lasting improvement to patient safety and quality of care. Understanding the impact of such reports requires both an understanding of how care is delivered, and also an appreciation of the learning culture of an organisation.

 

Our first project provides an in-depth exploration of the impact of the national recommendations developed through the 6th National Audit Project (NAP6) of the Royal College of Anaesthetists (RCoA) for life-threatening anaphylaxis. The aims of the project are:

 

1. Explore staff perceptions of recommendations

2. Identify if the recommendations were translated into practice

3. Describe the perceived impact of the recommendations

4. Identify the factors that acted as barriers and enablers in the translation of the recommendations into changes in practice

5. Explore any lessons that can be learned for the development of future NAP recommendations or national-level recommendations developed from other data sources.

 

Study 2: Learning from patient safety events (in NAP7)

 

Our second project uses the qualitative data generated in the RCoA National Audit Project (NAP7) on perioperative cardiac arrest to explore how organisations and individual clinicians learn and are (or should be) supported after patient safety events. The study aims include:

 

1. Explore variation in the support offered to staff

2. Explore the processes currently used for organisational learning

3. Explore the impact of different training models on staff’s ability to deal with adverse events. 

4. Use this project to develop a methodological approach for the analysis of large qualitative datasets.

 

The first output with findings from this study can be found here. This project has allowed us to generate a model using Big Qual Data Methods that is currently being used in Study 3. 

 

Study 3: How can we use Big Qual Data Methods to analyse large scale qual/free-text data to understand reporting challenges in Maternity Patient Safety incidents?

 

This project will explore whether thematic and sentiment analysis of maternity care data using Big Qual Methods can help identify patterns of good and harmful practices in a timely way. The study will use thematic analysis and sentiment analysis (iterative process-learn as go along) using Infranodus and Caplena and ongoing human annotation. Output from the data analysis using these methods will feed the Large Language Model (LLM).

 

PhD studentship: Safe Organisations – Digital Sociology Approaches in Patient Safety Research

 

A PhD student is joining our team to collaborate on a series of projects using digital sociological and big qualitative data methodologies to explore aspects of patient safety using Electronic Health Record (EHR) datasets and other EPIC data. This work will contribute to the development of an analytical and predictive AI model that can understand the language and sentiment involved in the free-text reporting of adverse patient safety events – with the aim of identifying key topics of concern and focusing effective support in key areas where support may be needed.