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Objectives To codesign safety-netting strategies for primary and emergency care settings by integrating the experiences and ideas of patients, carers and clinicians. Design A codesign process involving two focus group discussions, eight individual interviews and five workshops. All sessions were audio recorded and transcribed verbatim. Data were analysed using qualitative content analysis and reported using the Consolidated criteria for Reporting Qualitative research guidelines. Setting Primary and emergency care in Sweden, focusing on the Stockholm region. Participants 7 (5 women) individuals with patient expertise, 1 (man) individual with carer expertise, 18 (12 women) individuals with clinical expertise. Results Three main categories reflecting strategies for applying safety-netting were developed: first, conveying safety-netting advice, which involves understanding patient concerns, tailoring communication and using appropriate modalities for communicating; second, ensuring common understanding, which involves summarising information, asking a teach-back question and anticipating questions post consultation; and third, supporting safety-netting behaviour, which involves facilitating reconsultation, helping patients and carers to navigate the health system and explaining the care context and its purpose. Conclusions Our study highlights the collaborative nature of safety-netting, engaging both the clinician and patient, sometimes supported by carers, in an iterative process. Adding to previous research, our study also emphasises the importance of anticipating postconsultation inquiries and facilitating reconsultation.

Hospitals work to provide quality, safety, and availability to patients with a wide variety of care needs, which makes efficient prioritisation and resource utilisation essential. Anticipation of each patients' trajectory, while monitoring available resources across the hospital, are major challenges for patient flow management. This study focuses on how hospital patient flow management is realised in situ with the help of concepts from cognitive systems engineering. Five semi-structured interviews with high level managers and shadowing observations of seven full work-shifts with management teams were conducted, to explore how patient flow is coordinated and communicated across the hospital. The data has been analysed using qualitative content analysis. The results describe patient flow management using an adapted Extended Control Model (ECOM) and reveal how authority and information might be better placed closer to clinical work for increased efficiency of patient flow. Practitioner summary: This study describes how a large tertiary paediatric hospital's patient flow management functions. The results offer a new understanding of how patient flow management is communicated and coordinated across organisational levels of the hospital and how authority and information might be better placed closer to clinical work for increased efficiency.

Overdiagnosis and overtreatment receive increasing attention. More than 20 percent of health expenditure is without patient benefit, so-called low-value care. Several national and international initiatives have been launched to minimize low-value care. Arguably, the most widely spread initiative is Choosing Wisely. First launched by the American Board of Internal Medicine in 2012, this campaign has spread to more than 20 countries. The Swedish Society of Medicine has identified low-value care as a significant problem in Swedish health care and has established a working group to investigate if and how a campaign based on Choosing Wisely would be feasible in Sweden. Here, the working group reports on the history of Choosing Wisely, identifies potential challenges for deimplementation generally and in the Swedish context specifically., Överdiagnostik och överbehandling har uppmärksammats allt mer både i Sverige och internationellt [1], framför allt på grund av stigande vårdkostnader [2]. Noggranna beräkningar från USA visar att 20‒30 procent av sjukvårdsutgifterna går till åtgärder utan patientnytta [3]. Liknande resultat rapporteras från and­ra utvecklade länder [4], och även i Sverige går sjukvårdsutgifter till åtgärder som saknar patientnytta [2]. Förutom ökande kostnader leder överdiagnostik och överbehandling, så kallad lågvärdevård (low-value care), till undanträngningseffekter och risk för patientskada [5]. Behovet av att minska åtgärder med liten, tveksam eller ingen patientnytta har blivit ännu tydligare under coronapandemin [6]. »Choosing wisely« är en internationell kampanj som syftar till att identifiera åtgärder i sjukvården som saknar patientnytta och underlätta utmönstringen av dem. Kampanjen lanserades av American Board of Internal Medicine 2012 [7] och är i dag spridd till fler än 20 länder [8]. Sverige har ännu inte startat någon formell kampanj, även om Choosing wisely beskrevs i Läkartidningen redan 2013 [9].

INTRODUCTION: Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care. OBJECTIVE: To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process. METHODS: Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool. RESULTS: High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia. CONCLUSION: The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity

Background Chronic care involves multiple activities that can be performed by individuals and healthcare staff as well as by other actors and artifacts, such as eHealth services. Thus, chronic care management can be viewed as a system where the individual interacts with people and eHealth services performing activities to maintain or improve health and functioning, called co-care. Yet, the system perspective is not reflected in concepts such as person-centered care and shared decision making. This limits the understanding of individuals’ global experience of chronic care management and subsequently the ability to optimize chronic care. The aim of this study was threefold: (1) to propose a theory-based operationalization of co-care for chronic care management, (2) to develop a scale to measure co-care as a distributed system of activities, and (3) to evaluate the scale’s psychometric properties. With the theory of distributed cognition as a theoretical underpinning, co-care was operationalized along three dimensions: experience of activities, needs support, and goal orientation. Methods Informed by the literature on patient experiences and work psychology, a scale denoted Distribution of Co-Care Activities (DoCCA) was developed with the three conceptualized dimensions, the activities dimension consisting of three sub-factors: demands, unnecessary tasks, and role clarity. It was tested with 113 primary care patients with chronic conditions in Sweden at two time points. Results A confirmatory factor analysis showed support for a second-order model with the three conceptualized dimensions, with activities further divided into the three sub-factors. Cronbach’s alpha values indicated a good to excellent reliability of the subscales, and correlations across time points with panel data indicated satisfactory test-retest reliability. Convergent, concurrent and predictive validity of the scale were, overall, satisfactory. Conclusions The psychometric evaluation supports a mod

Objectives The work context of the operating room (OR) is considered complex and dynamic with high cognitive demands. A multidimensional view of the complete preoperative and intraoperative work process of the surgical team in the OR has been sparsely described. The aim of this study was to describe the type and frequency of tasks, multitasking, interruptions and their causes during surgical procedures from a multidimensional perspective on the surgical team in the OR. Design Prospective observational study using the Work Observation Method By Activity Timing tool. Setting An OR department at a county hospital in Sweden. Participants OR nurses (ORNs) (n=10), registered nurse anaesthetists (RNAs) (n=8) and surgeons (n=9). Results The type, frequency and time spent on specific tasks, multitasking and interruptions were measured. From a multidimensional view, the surgical team performed 64 tasks per hour. Communication represented almost half (45.7%) of all observed tasks. Concerning task time, direct care dominated the surgeons' and ORNs' intraoperative time, while in RNAs' work, it was intra-indirect care. In total, 48.2% of time was spent in multitasking and was most often observed in ORNs' and surgeons' work during communication. Interruptions occurred 3.0 per hour, and the largest proportion, 26.7%, was related to equipment. Interruptions were most commonly followed by professional communication. Conclusions The surgical team constantly dealt with multitasking and interruptions, both with potential impact on workflow and patient safety. Interruptions were commonly followed by professional communication, which may reflect the interactions and constant adaptations in a complex adaptive system. Future research should focus on understanding the complexity within the system, on the design of different work processes and on how teams meet the challenges of a complex adaptive system. Trial registration number 2016/264.

Outcomes of care for various diseases and urgent conditions in an emergency department are dependent on balancing the patient’s need and available resources through management and coordination under often rapidly changing preconditions. However, although it is central to resilient operations, decision-making in dynamic resource management is rarely visible to managers. Sometimes the identification of successful strategies is apparent only through adverse event reports. A simulation game could be helpful for the acquisition of non-technical skills in addressing operational conundrums that could threaten the defence ability of a paediatric emergency department under care production pressures. This contribution presents a Sandtable serious logistical game of the care production system and, in particular, proposes its scoring mechanism, which was tested in a set of logistical experiments. The results show that through gamification, participants were challenged in terms of their intrinsic self-interest when it came to approaching the work. More importantly, the proposed extrinsic reward system allows all parallel functional roles to be equally rewarded as the game evolves. Anticipatory human resource management is identified as a successful strategy for achieving a sustainable working environment if the organizational resilience is confronted with patient inflow surges during the busiest hours of the busiest day., QC 20191121

Objectives Trauma is the leading cause of death in children. The lack of an accepted definition of what constitutes a high-quality stabilisation of a traumatically injured child has limited the evaluation of direct interventions in simulation-based education and service-delivery models to improve trauma care. The aim of this study was to create a framework that delineates quality by exploring the perceptions of the multi-disciplinary team providing and improving this initial care. Methods Interviews were conducted with 36 experienced UK trauma team members and governance administrators (clinical directors to executive board level), from three standard UK trauma units. This study used a phenomenographic approach to explore the relationships and hierarchy between the contrasting perceptions of quality and evaluation of quality in this acute context. Results The findings show that defining quality is a more complex concept than simple proxy measurements, such as time to CT scanning. They also show that the concept of quality requires the consideration of a spectrum of perspectives that range from the simple to the more sophisticated. This study highlights the importance of teamwork, individualised perspectives and the culture of care provision, when describing quality. A novel framework to delineate quality is presented, comprising System, Team, Process, Individual, Data and Culture. Conclusions This study has created a framework of understanding of acute paediatric trauma care quality and its measurement from the perspectives of team members and administrators. A framework and future tools to capture and disseminate the System, Team, Process, Individual, Data and Culture perspectives of the quality of trauma stabilisations could be a key advance in the care of severely injured children.

BACKGROUND: There has been a theoretical debate as to which retrospective record review method is the most valid, reliable, cost efficient and feasible for detecting adverse events. The aim of the present study was to evaluate the feasibility and capability of two common retrospective record review methods, the "Harvard Medical Practice Study" method and the "Global Trigger Tool" in detecting adverse events in adult orthopaedic inpatients. METHODS: We performed a three-stage structured retrospective record review process in a random sample of 350 orthopaedic admissions during 2009 at a Swedish university hospital. Two teams comprised each of a registered nurse and two physicians were assigned, one to each method. All records were primarily reviewed by registered nurses. Records containing a potential adverse event were forwarded to physicians for review in stage 2. Physicians made an independent review regarding, for example, healthcare causation, preventability and severity. In the third review stage all adverse events that were found with the two methods together were compared and all discrepancies after review stage 2 were analysed. Events that had not been identified by one of the methods in the first two review stages were reviewed by the respective physicians. RESULTS: Altogether, 160 different adverse events were identified in 105 (30.0%) of the 350 records with both methods combined. The "Harvard Medical Practice Study" method identified 155 of the 160 (96.9%, 95% CI: 92.9-99.0) adverse events in 104 (29.7%) records compared with 137 (85.6%, 95% CI: 79.2-90.7) adverse events in 98 (28.0%) records using the "Global Trigger Tool". Adverse events "causing harm without permanent disability" accounted for most of the observed difference. The overall positive predictive value for criteria and triggers using the "Harvard Medical Practice Study" method and the "Global Trigger Tool" was 40.3% and 30.4%, respectively. CONCLUSIONS: More adverse events were identified u

Background: While there is growing awareness of quality problems in healthcare systems, it remains uncertain how best to accomplish and sustain improvement over time. Objective: To report on the design and application of quality improvement theme months in orthopaedic nursing, and evaluate the impact on pressure ulcer as an example. Design: Retrospective mixed method case study with time series diagrams. Setting: An orthopaedic department at a Swedish university hospital. Method: The interventions were led by nursing teams and focused on one improvement theme at a time in two-month cycles, hence the term 'improvement theme months'. These included defined objectives, easy-to-use follow-up measurement, education, changes to daily routines, "reminder months" and data feedback. The study draws on retrospective record data regarding one of the theme topics, pressure ulcer risk assessment and prevalence, in 2281 orthopaedic admissions during January 2007-October 2010 through point prevalence measurement one-day per month. Data were analysed in time series diagrams and through comparison to annual point prevalence data from mandatory county council-wide measurements prior to, during and after interventions from 2003 to 2010. By using document analysis we reviewed concurrent initiatives at different levels in the healthcare organisation and related them to the improvement theme months and their impact. Results: The 46 monthly point prevalence samples ranged from 28 to 66 admissions. Substantial improvements were found in risk assessment rates for pressure ulcers both in the longitudinal follow-up (p<0.001) and in the annual county council-wide measurements. A reduction in pressure ulcer rate was observed in the annual county council-wide measurements. In the longitudinal data, wider variation in the pressure ulcer rate was seen (p<0.067); however, there was a significant decrease in pressure ulcer rates during the final ten-month period in 2010, compared to the baseli

Ej belagd 20190322

Ej belagd 20190322

Background and aim: The Institute of Medicine report, To err is human, heightened attention to safety and quality performance in healthcare. This has led to demands on healthcare systems to collect data on safety and quality performance. Patient safety improvement requires learning at many levels in the system leading to changes in organizational structure and processes along many dimensions. Safety information systems support learning about the performance of a system by collecting, analyzing, and providing feedback of data. Other industries have come further than healthcare in measuring safety performance as well as in identifying industry specific knowledge about sources of vulnerabilities and hazards. In healthcare, evidence based measures are being developed such as incident reporting systems, medical chart reviews, patient safety indicators and malpractice claims data. The Swedish patient insurance claims database is a source of data on safety performance that has not yet been systematically studied. The aim of this thesis is to assess the potential contribution of patient injury claims have in supporting organizational learning in improving patient safety and to present a framework for the management of patient safety information in healthcare. Principal findings: Patient injury claims are, by themselves, not sufficient to serve as a sensor for vulnerabilities in healthcare. They do, however, provide a broad national source of patient generated information on negative outcomes of care which complements other healthcare generated reporting systems (Study I-II). Swedish healthcare leaders have a relatively high awareness of patient safety and give it high priority. However, few healthcare organizations actively involve patients in improving safety (Study III). Based on the assumption that analogies to known phenomena promote learning, the preservation of genomic integrity was presented as a model to describe different sources of variability, applicable also to

QC 20210119