Thursday 11 April 2024 | 11:00-12:15

Format: Presentation

Stream: Safety

Content filters: Co-presented with patients, service users or carers; Features discussion of community led projects, including those outside of health and care

Maarten van der Laan University Medical Center Groningen, The Netherlands (Chair)

PART 1: Combining Safety Science with a compassionate approach to learn from a recurrent serious incident

Our department wanted to produce a meaningful response to a tragic event of misdiagnosis of acute aortic dissection (AAD). We engaged multidisciplinary stakeholders, including a national charity, and implemented systemic and educational interventions using a Human Factors approach.

A significant and sustained increase in the number of CT Aortograms (CTA) performed with a significant reduction in duration from initial medical assessment to scan request has been achieved, evidence that a structured and compassionate incident investigation strategy is the way to effect lasting organisational change.

As a result of this session, participants will be able to:

• Use the stories of those with lived experience to communicate their vision


• Create psychological safety in their organisation


• Take a systems approach to understand a complex problem


• Create an alertness to rare but dangerous events


• Use simple data to demonstrate improvements over time


• Implement a similar programme

Augustine Smithies Hull University Teaching Hospitals NHS Trust, England

Catherine Fowler The Aortic Dissection Charitable Trust, England

Graham Cooper The Aortic Dissection Charitable Trust, England

 

PART 2: Improvement through reflection: learning from performance variability in perioperative sentinel events

Hospitals work tirelessly to enhance patient safety and reduce the occurrence of preventable harm or loss of life. While significant progress has been made, such sentinel events (SEs) present unique challenges.

In our quest for continuous improvement, we turn our attention to a crucial factor: performance variability (PV). PV encompasses the variations in performance influenced by environmental, organisational, and job-related factors, as well as individual characteristics. While addressing PV can be complex, it is a critical aspect of our journey to enhance patient care. We will explore the pivotal role of PV in perioperative SEs and uncover why PV should be an integral part of our SE improvement efforts.

As a result of this session, participants will be able to:

• Understand performance variability, its effect on care safety, and the different factors shaping performance


• Analyse how performance variability is included in analysis reports and improvement measures, as well as current pitfalls in the analysis


• Know what to focus on to effectively include performance variability in the analysis report and improvement measures, making it a target of intervention

Iris Reijmerink University Medical Centre Groningen, Netherlands

Jop Groeneweg TU Delft, The Netherlands