Cox C, Hughes H, Nicholls J. Patient safety: emerging applications of safety science. Bridgwater: Class Professional Publishing; 2024
Before we get into the main section of this book, we are presented with a very comprehensive list of the 35 contributors to this publication. Having read through each bibliography, I have to say this book could have easily been kin to ‘War and Peace’, rather than the modest 170 pages it actually is. There are a variety of professions and areas of expertise, ranging from managerial positions within the NHS, education, the military and private international businesses. In short, the expectation for the content of this book is high judged on the caliber of these individuals.
Change management
After a brief introduction, we are provided with an in-depth analysis of change management. This is primarily text supported by a few tables covering models and theories around leadership and change, such as ‘Kotter's Eight-Step Change Model’ and ‘Roger's Diffusion of Innovation Theory’. The leadership principles are cleverly linked to patient safety, which covers all levels in an organisation, from executive to individual workforce level.
Case studies
The following chapters see the introduction of case studies, which focus on specific topics such as learning from never-events or a thematic review of a root cause analysis. These are real-life examples collected from varying NHS organisations. The balance has been struck well in terms of keeping the case studies succinct, yet not losing the detail required to provide the reader with an understanding of the case.
Patient perspective
Another excellent tool to support the narrative is the use of presenting a patient's lived experience perspective. This really helps hang some of the theories and tools on and keeps the reader focused on the impact incidents can have on patients and families. This message becomes even more powerful by the author simply adding a photo of the individual who has been affected.
Safety II
By chapter 5 the reader should have a good understanding of the background to the Patient Safety Incident Response Framework (PSIRF). This knowledge will help navigate the chapter on Safety-II. As the author states, ‘Safety-II is not well understood by healthcare staff’ and I would whole heartedly agree. Many frontline clinicians go about their day-to-day duties without considering the work that may have gone on to ensure their guidelines or protocols have been through a PSIRF process.
After action reviews
We know that much of our clinical practice originated in the military. This extends into the next subject covered in chapter 6, after action reviews (AARs). I have specifically focused on this topic as I feel this is arguably the most relevant to the practising paramedic. If you have attended a significant incident, you were likely asked to take part in a hot debrief. Depending on your organisation, the person conducting the debrief, and the nature of the incident, I would suspect that these hot debriefs have varied in content, length and outcome. There are several hot debrief tools used in practice and, in my experience, many are conducted with no tool, guidance or training. This chapter covers the background, theory and concepts of the AAR, which can be used as a tool to complete a hot debrief.
When things go wrong
The final four chapters cover a human factor-informed system approach called ‘Walk-Through-Talk-Through (WT3)’, ‘AcciMaps’, ‘Transformative Simulation’, and ‘Thematic Reviews’. These chapters cover a mixture of models, methods and theories, which can assist in the learning that needs to happen when things go wrong. The topics give a real appreciation of how complex this process really is.
In summary
It is likely that a lot of the content of this book will be new to a frontline paramedic. However, a number of helpful techniques run through the book to aid the reader, such as real-life case studies, a list of 81 abbreviations, and short, sub-headed topics, which helps break the subject matter down. This will allow the frontline paramedic to understand the importance of learning from patient safety incidents.
Three Key Takeaways
- Presentation of real-life case studies allows the reader to relate many of the theories and concepts directly to patient care
- The use of the After Action Review (AAR) as a hot debrief tool can be useful to promote learning from an incident
- Patient safety incidents are relevant to all clinicians; understanding the importance of learning from incidents will encourage both the organisation and individual to engage in the process