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Journal article
Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study
BMJ Open, Vol.14(7), pp.1-9
2024
PMID: 38969384
Abstract
Introduction
At least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm (‘adverse events’). When a patient is seriously harmed, an investigation or review is undertaken to reduce the risk of further incidents occurring. Despite 20 years of investigations into adverse events in healthcare, few evaluations provide evidence of their quality and effectiveness in reducing preventable harm.
This study aims to develop consistent, informed and robust best practice guidance, at state and national levels, that will improve the response, learning and health system improvements arising from adverse events.
Methods and analysis
The setting will be healthcare organisations in Australian public health systems in the states of New South Wales, Queensland, Victoria and the Australian Capital Territory. We will apply a multistage mixed-methods research design with evaluation and in-situ feasibility testing. This will include literature reviews (stage 1), an assessment of the quality of 300 adverse event investigation reports from participating hospitals (stage 2), and a policy/procedure document review from participating hospitals (stage 3) as well as focus groups and interviews on perspectives and experiences of investigations with healthcare staff and consumers (stage 4). After triangulating results from stages 1–4, we will then codesign tools and guidance for the conduct of investigations with staff and consumers (stage 5) and conduct feasibility testing on the guidance (stage 6). Participants will include healthcare safety systems policymakers and staff (n=120–255) who commission, undertake or review investigations and consumers (n=20–32) who have been impacted by adverse events.
Ethics and dissemination
Ethics approval has been granted by the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH02007 and 2023/ETH02341).The research findings will be incorporated into best practice guidance, published in international and national journals and disseminated through conferences.
Details
- Title
- Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study
- Authors
- Peter D Hibbert (Corresponding Author) - Macquarie UniversityLouise Raggett - Macquarie UniversityCharlotte J Molloy - Macquarie UniversityJohanna Westbrook - Macquarie UniversityFarah Magrabi - Macquarie UniversityVirginia Mumford - Macquarie UniversityRobyn Clay-Williams - Macquarie UniversityRaghu Lingam - UNSW SydneyPaul M Salmon - University of the Sunshine Coast, Queensland, Centre for Human Factors and Systems ScienceSandy Middleton - Australian Catholic UniversityMike Roberts - Safer Care VictoriaPatricia Bradd - Clinical Excellence CommissionSteven Bowden - Clinical Excellence CommissionKathleen Ryan - North Mid Coast Local Health DistrictMark Zacka - Northern Sydney Local Health DistrictKirstine Sketcher-Baker - Queensland HealthAndy Phillips - Safer Care VictoriaLanii Birks - Safer Care VictoriaDinesh K Arya - Act HealthCatherine Trevorrow - Act HealthSuchit Handa - ACSQHGirish Swaminathan - ACSQHAndrew Carson-Stevens - Cardiff UniversitySiri Wiig - University of StavangerCarl de Wet - South West Hospital and Health Service (Australia)Elizabeth E Austin - Macquarie UniversityBrona Nic Giolla Easpaig - Charles Darwin UniversityYing Wang - Macquarie UniversityGaston Arnolda - Macquarie UniversityGregory M Peterson - University of TasmaniaJeffrey Braithwaite - Macquarie University
- Publication details
- BMJ Open, Vol.14(7), pp.1-9
- Publisher
- BMJ Group
- Date published
- 2024
- DOI
- 10.1136/bmjopen-2024-085854
- ISSN
- 2044-6055
- PMID
- 38969384
- Copyright note
- © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made.
- Grant note
- The grant has been funded by the Clinical Excellence Commission (NSW), Clinical Excellence Queensland, Safer Care Victoria, and ACT Health.
- Organisation Unit
- Centre for Human Factors and Systems Science
- Language
- English
- Record Identifier
- 991048275302621
- Output Type
- Journal article
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