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The COVID-19 pandemic's effects on people's lives and society induced a need for rapid individual and collective sensemaking, including communication forums enabling stakeholders in the health ecosystem to share information, solve problems, and learn. This study specifically focused on the needs of the patients and family caregivers living with cystic fibrosis (CF) or primary ciliary dyskinesia (PCD), conditions that lead to chronic infections and inflammation in the airways. We explored how CF and PCD patients, family caregivers, and clinicians collectively received, processed, and used information about COVID-19 to facilitate self-care and health care decisions at the beginning of the pandemic. We applied macrocognitive theory to analyze qualitatively the questions and answers exchanged in a series of six webinars facilitated by a CF learning network at the beginning of the pandemic (March - April 2020). We identified three macrocognitive functions: sensemaking, decision-making, and replanning. We further generated nine themes: (a) understanding the nature of COVID-19, (b) exploring self-care needs and possibilities, (c) understanding health care possibilities, (d) making decisions about prevention and testing, (e) managing COVID-19 within families, (f) adjusting planned care, (g) replanning chronic care management, (h) defining COVID-19 health care strategies, and (i) refining health care policies. The exchange of questions and answers played a central role in facilitating important cognitive processes, which enabled a rapid anticipation of needs and adaptation of services to support patients, family caregivers, and clinicians during the COVID-19 pandemic.

Background Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident. Methods A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering. Results Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented. Conclusions Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

AIM: To explore the incidence and characteristics of inpatient neonatal adverse events in a Swedish setting. METHODS: A retrospective record review, using a trigger tool, performed by registered nurses and a neonatologist, at a University Hospital. The identified adverse events were categorised by, for example, preventability, severity and time of occurrence. RESULTS: A random selection of 150 admissions representing 3531 patient days were reviewed (mean [SD] birthweight 2620 [1120]g). Three hundred sixty adverse events were identified in 78(52.0%) infants and 305(84.7%) of these were assessed as being preventable. The overall adverse event rate was 240 per 100 admissions and 102.0 per 1000 patient days. Preterm infants had a higher rate than term infants (353 versus 79 per 100 admissions, p=0.001), however with regard to the length of stay, the rates were similar. Most adverse events were temporary and less severe (n=338/360, 93.9%) and the most common type involved harm to skin, tissue or blood vessels (n=163/360, 45.3%). Forty percent (n=145) of adverse events occurred within the first week of admission. CONCLUSION: Adverse events were common in neonatal care and many occurred during the first days of treatment. Characterisation of adverse events may provide focus areas for improvements in patient safety.

Objectives With ever increasingly complex healthcare settings, technology enhanced simulation (TES) is well positioned to explore all perspectives to enhance patient safety and patient outcomes. Analysis from a Safety-II stance requires identification of human adjustments in daily work that are key to maintaining safety. The aim of this paper is to describe an approach to explore the consequences of human variability from a Safety-II perspective and describe the added value of this to TES. Methods The reader is guided through a novel application of functional resonance analysis methodology (FRAM), a method to analyse how a system or activity is affected by human variability, to explore human adaptations observed in in situ simulations (ISS). The structured applicability of this novel approach to TES is described by application to empirical data from the standardised ISS management of paediatric time critical head injuries (TCHI). Results A case series is presented to illustrate the step-wise observation of key timings during ISSs, the construction of FRAM models and the visualisation of the propagation of human adaptations through the FRAM models. The key functions/actions that ensure the propagation are visible, as are the sequelae of the adaptations. Conclusions The approach as described in this paper is a first step to illuminating how to explore, analyse and observe the consequences of positive and negative human adaptations within simulated complex systems. This provides TES with a structured methodology to visualise and reflect upon both Safety-I and Safety-II perspectives to enhance patient safety and patient outcomes.

Objective To (1) validate and (2) display initial results of surveys to health care professionals and patients on the importance and mitigation of specified risks for diagnostic and medication errors. Design For validation, psychometric properties were analysed by assessment of construct validity and internal consistency by factor analysis. Non-parametric analyses were used concerning areas of risk, and top ranking of solutions were reported descriptively. Setting Primary health care in Sweden. Participants Health care professionals (HCPs); including physicians, nurses and practice managers, as well as patients who had experienced diagnostic or medication errors. Main outcome measures Psychometric properties of the surveys. Median ratings for risks and top rankings of solutions for professionals and patients. Results There were 939 respondents to the HCP survey. Construct validity resulted in a model with four dimensions: Patient-provider level; Support systems for every day clinical work; Shared information and cooperation between different caregivers; Risks in the environment. Internal consistency was acceptable with Cronbach’s α values above 0.7. Confirmatory factor analysis generally showed an acceptable fit. Initial results from the professionals showed the importance of continuity of care, a nationwide on-line medical platform and cooperation in transfer of care. The patient survey could not be validated because of low response rate. Conclusion The HCP survey showed some contradicting results regarding model fit and may be tentatively acceptable but validity needs further study. HCP survey answers indicated that relational continuity of care and a nationwide on-line medical platform are highly valued.Current awareness Health care professionals and patients are rather untapped sources of knowledge regarding patient safety in primary health care Main statements Validation is performed on a new survey capturing rating of risks and solutions. The validation of the health care professional survey is tentatively acceptable. Survey answers indicate that health care professionals’ and patients’ perspectives are complementary.

Chronic care management is dependent on productive interactions between patients and healthcare professionals. Digital health technologies (eHealth) open up new possibilities for improving the quality of care, but there is a limited understanding of what productive interactions entail. This study explores characteristics of productive interactions to support self-care and healthcare in the context of eHealth use in diabetes care. We collected qualitative data based on interviews with nurses and responses to open-ended survey questions from patients, prior to and post using an eHealth service for self-monitoring and digital communication. We found that eHealth’s influence on productive interactions was characterized by unconstrained access, health parameter surveillance, and data-driven feedback, with implications for self-care and healthcare. Our findings indicate that eHealth perforates the boundaries that define interactions under traditional, non-digital care. This was manifested in expressions of uncertainty and in blurred boundaries between self-care and healthcare. We conclude that the attainment of a sustainable eHealth ecosystem will require healthcare to acknowledge eHealth as a disruptive change that may require re-organization to optimally support the productive use of eHealth services for both patients and staff, which includes agreement on new routines, as well as social interaction rules.

Objectives Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances. Design An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive–deductive content analysis from a perspective of resilience engineering. Participants A team of managers (ie, clinical coordinators, head nurses, senior medical doctors). Results The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems’ limitations. Conclusions Coordination supports a coherent goal setting by increased team collaboration and is supported by team members’ abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was ‘stretched’ or ‘needed reorganisation’ and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

Objectives Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances.Design An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive–deductive content analysis from a perspective of resilience engineering.Participants A team of managers (ie, clinical coordinators, head nurses, senior medical doctors).Results The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems’ limitations.Conclusions Coordination supports a coherent goal setting by increased team collaboration and is supported by team members’ abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was ‘stretched’ or ‘needed reorganisation’ and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

Competency is central to a sustainable and resilient emergency department. Decision-makers, including clinicians, managers, and developers, would benefit from meaningful simulated scenarios in which their skills are trained. Among the various types of skills, non-technical skills are prioritized because the failure to communicate, coordinate and cooperate effectively are common contributing factors to adverse events and involving patients at the ‘sharp-end’ of the health system. For active learning of non-technical skills, simulation and gaming have been frequently used. From the methodology point of view, there is a need to clarify these two methods in order to improve their value in training and learning. This contribution presents the reflective methodology as an option of structuring game design compared to the mainstream service system modeling. The reflective methodology starts with the underlying assumption that it is still possible to achieve gaming effectiveness, even though the baseline layer is a simulation model instead of the service system. Based on a questionnaire investigating the activation of learning of logistical skills in managing an emergency department, results are illustrative of that active learning is much improved and is moving closer to achieving intended outcomes. Analyzing results from logistical experiments in the form of a statistical summary motivates to explore the middle ground of game design and gamification further, especially when the simulation model is the steering layer in scenario generations and debriefing. This aspect might have been less supervised in the philosophy of game science, let alone the application of simulation game for human resource management in emergency department logistics.

BACKGROUND Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals. OBJECTIVE This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure. METHODS First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment. RESULTS A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR2 of 0.796 (F14,31=2725.49, P4,31=2635.31, P CONCLUSIONS The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used.

Background: Safety culture can be described and understood through its manifestations in the organisation as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers’ actually is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. Methods: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. Results: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. Conclusions: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit’s safety culture.

Background Safety culture can be described and understood through its manifestations in the organization as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers’ is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. Methods Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. Results We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. Conclusions Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit’s safety culture.

Background Patient safety issues in primary health care and in emergency departments have not been as thoroughly explored as patient safety issues in the hospital setting. Knowledge is particularly sparse regarding which patients have a higher risk of harm in these settings. The objective was to evaluate which patient-related factors were associated with risk of harm in patients with reports of safety incidents. Methods A case–control study performed in primary health care and emergency departments in Sweden. In total, 4536 patients (cases) and 44,949 controls were included in this study. Cases included patients with reported preventable harm in primary health care and emergency departments from January 1st, 2011 until December 31st, 2016. Results Psychiatric disease, including all psychiatric diagnoses regardless of severity, nearly doubled the risk of being a reported case of preventable harm (odds ratio, 1.96; p Conclusion Patients with psychiatric illness are at higher risk of preventable harm in primary care and the emergency department. Therefore, this group needs extra attention to prevent harm.

Objective Evaluate longitudinal changes in technical and non-technical skills (teamwork, situation monitoring, communication and leadership), safety culture, and clinical outcomes before and after implementation of a crew resource management (CRM) safety program. Design A multi-level prospective single case study in accordance with the SQUIRE-guidelines for reporting quality improvement efforts. Setting Large university paediatric surgical service. Participant(s) All 153 managers and staff. Interventions Training of staff in CRM, systematic risk assessments, and the redesign of work practices captured and reinforced through the development, implementation and refinement of SOPs. Main outcome measure(s) Data were collected related to: 1) Relevance of CRM training (survey), 2) Safety culture (survey), 3) Team behaviours in clinical practice (non-participatory observations with MedPACT protocol) and 4) Effects on perioperative care for laparoscopic appendectomies-a representative and frequently performed surgical procedure (electronic medical records and administrative data for length of stay, unplanned readmissions and returns to the Operating Room). Results Non-technical skills, the use of safety tools, as well as adherence to guidelines for appendectomies all improved significantly over time. Significant safety culture improvements were found in teamwork across and within units, supervisors' expectations and actions, non-punitive response to adverse events, and perceptions of overall patient safety. Unplanned readmissions following appendectomy declined significantly. Conclusions Implementation of a comprehensive CRM program including associated safety tools created sustained adherence to new work practices and improved non-technical and technical skills, surgical outcomes and safety culture.

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. Electronic supplementary material The online version of this article (10.1186/s41077-019-0091-z) contains supplementary material, which is available to authorized users.

Background Resource allocation in patient care relies heavily on individual judgements of healthcare professionals. Such professionals perform coordinating functions by managing the timing and execution of a multitude of care processes for multiple patients. Based on advances in simulation, new technologies that could be used for establishing realistic representations have been developed. These simulations can be used to facilitate understanding of various situations, coordination training and education in logistics, decision-making processes, and design aspects of the healthcare system. However, no study in the literature has synthesized the types of simulations models available for non-technical skills training and coordination of care. Methods A systematic literature review, following the PRISMA guidelines, was performed to identify simulation models that could be used for training individuals in operative logistical coordination that occurs on a daily basis. This article reviewed papers of simulation in healthcare logistics presented in the Web of Science Core Collections, ACM digital library, and JSTOR databases. We conducted a screening process to gather relevant papers as the knowledge foundation of our literature study. The screening process involved a query-based identification of papers and an assessment of relevance and quality. Results Two hundred ninety-four papers met the inclusion criteria. The review showed that different types of simulation models can be used for constructing scenarios for addressing different types of problems, primarily for training and education sessions. The papers identified were classified according to their utilized paradigm and focus areas. (1) Discrete-event simulation in single-category and single-unit scenarios formed the most dominant approach to developing healthcare simulations and dominated all other categories by a large margin. (2) As we approached a systems perspective (cross-departmental and cross-institutional), discrete-event simulation became less popular and is complemented by system dynamics or hybrid modeling. (3) Agent-based simulations and participatory simulations have increased in absolute terms, but the share of these modeling techniques among all simulations in this field remains low. Conclusions An extensive study analyzing the literature on simulation in healthcare logistics indicates a growth in the number of examples demonstrating how simulation can be used in healthcare settings. Results show that the majority of studies create situations in which non-technical skills of managers, coordinators, and decision makers can be trained. However, more system-level and complex system-based approaches are limited and use methods other than discrete-event simulation.

Background: Diagnostic errors are a major patient safety concern in primary healthcare and emergency care. These settings involve a high degree of uncertainty regarding patients’ diagnoses and appear to be those most prone to diagnostic errors. Diagnostic errors comprise missed, delayed, or incorrect diagnoses preventing the patient from receiving correct and timely treatment. Data regarding which diagnoses are affected in these settings are scarce. Objectives: To understand the distribution of diagnoses among reported diagnostic errors in primary health and emergency care as a step towards creating countermeasures for safer care. Methods: A retrospective and descriptive cohort study investigating reported diagnostic errors. A nationwide cohort was collected from two databases. The study was performed in Sweden from 1 January 2011 until 31 December 2016. The setting was primary healthcare and emergency departments. Results: In total, 4830 cases of preventable harm were identified. Of these, 2208 (46%) were due to diagnostic errors. Diagnoses affected in primary care were cancer (37% and 23%, respectively, in the two databases; mostly colon and skin), fractures (mostly hand), heart disease (mostly myocardial infarction), and rupture of tendons (mostly Achilles). Of the diagnostic errors in the emergency department, fractures constituted 24% (mostly hand and wrist, 29%). Rupture/injury of muscle/tendon constituted 19% (mostly finger tendons, rotator cuff tendons, and Achilles tendon). Conclusion: Our findings show that the most frequently missed diagnoses among reported harm were cancers in primary care and fractures in the emergency departments.

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.

Background Using serious games for learning in operations management is well established. However, especially for logistics skills in health care operations, there is little work on the design of game mechanics for learning engagement and the achievement of the desired learning goals. Objective This contribution presents a serious game design representing patient flow characteristics, systemic resource configurations, and the roles of the players based on a real Swedish emergency ward. The game was tested in a set of game-based learning practices in the modalities of a physical board game and an online multiplayer serious game that implemented the same game structure. Methods First, survey scores were collected using the Game Experience Questionnaire Core and Social Presence Modules to evaluate the experience and acceptance of the proposed design to gamify real processes in emergency care. Second, lag sequential analysis was applied to analyze the impact of the game mechanics on learning behavior transitions. Lastly, regression analysis was used to understand whether learning engagement attributes could potentially serve as significant predicting variables for logistical performance in a simulated learning environment. Results A total of 36 students from courses in engineering and management at KTH Royal Institute of Technology participated in both game-based learning practices during the autumn and spring semesters of 2019 and 2020. For the Core Module, significant differences were found for the scores for negative affect and tension compared with the rest of the module. For the Social Presence Module, significant differences were found in the scores for the psychological involvement – negative feelings dimension compared with the rest of the module. During the process of content generation, the participant had access to circulating management resources and could edit profiles. The standard regression analysis output yielded a ΔR2 of 0.796 (F14,31=2725.49, P Conclusions The high scores of positive affect and immersion compared to the low scores of negative feelings demonstrated the motivating and cognitive involvement impact of the game. The proposed game mechanics have visible effects on significant correlation parameters between the majority of scoring features and changes in learning engagement attributes. Therefore, we conclude that for enhancing learning in logistical aspects of health care, serious games that are steered by well-designed scoring mechanisms can be used.

In June 2008, WHO launched the Safe Surgery Checklist. Nine months later a Swedish translation and adaptation was launched and distributed to virtually all Swedish hospitals. It gained rapid acceptance; in the fall of 2009, 73 hospitals reported that the checklist had been implemented and that its use was part of standard routine. A questionnaire in 2010 revealed that this was true for many but not all hospitals. International studies have shown that proper use of the checklist has positive effects on postoperative morbidity and mortality. The studies also show the importance of implementing the checklist thoughtfully, thus resulting in better communication and team formation amongst the operating staff. A checklist cannot replace professional competence, but using a checklist is part of professional behaviour.

Resource allocation in patient care relies heavily on individual judgements of healthcare professionals. Such professionals perform coordinating functions by managing the timing and execution of a multitude of care processes for multiple patients. Based on advances in simulation, new technologies that could be used for establishing realistic representations have been developed. These simulations can be used to facilitate understanding of various situations, coordination training and education in logistics, decision-making processes, and design aspects of the healthcare system. However, no study in the literature has synthesized the types of simulations models available for non-technical skills training and coordination of care.A systematic literature review, following the PRISMA guidelines, was performed to identify simulation models that could be used for training individuals in operative logistical coordination that occurs on a daily basis. This article reviewed papers of simulation in healthcare logistics presented in the Web of Science Core Collections, ACM digital library, and JSTOR databases. We conducted a screening process to gather relevant papers as the knowledge foundation of our literature study. The screening process involved a query-based identification of papers and an assessment of relevance and quality.Two hundred ninety-four papers met the inclusion criteria. The review showed that different types of simulation models can be used for constructing scenarios for addressing different types of problems, primarily for training and education sessions. The papers identified were classified according to their utilized paradigm and focus areas. (1) Discrete-event simulation in single-category and single-unit scenarios formed the most dominant approach to developing healthcare simulations and dominated all other categories by a large margin. (2) As we approached a systems perspective (cross-departmental and cross-institutional), discrete-event simulation became less popular and is complemented by system dynamics or hybrid modeling. (3) Agent-based simulations and participatory simulations have increased in absolute terms, but the share of these modeling techniques among all simulations in this field remains low.An extensive study analyzing the literature on simulation in healthcare logistics indicates a growth in the number of examples demonstrating how simulation can be used in healthcare settings. Results show that the majority of studies create situations in which non-technical skills of managers, coordinators, and decision makers can be trained. However, more system-level and complex system-based approaches are limited and use methods other than discrete-event simulation.

Patient involvement in patient safety The prospect of patients contributing to safer care with their unique knowledge and experiences demands a profound change in roles and attitudes among healthcare staff and researchers. The path forward involves designing ways of coproduction in healthcare quality and safety improvement as well as in research.

Most safety-critical enterprises have programs for teaching and training non-technical skills to their employees. These skills must complement pure technical skills. Programs for teaching and introducing these skills (communication, leadership, teamwork, decision-making, handling of conflicts and feed-back) are developing also in health-care. It is important that non-technical skills in combination with technical skills are seen as the foundation when developing new and safer ways to do the daily work with patients.

Objective: To systematically review the literature regarding how statistical process control—with control charts as a core tool—has been applied to healthcare quality improvement, and to examine the benefits, limitations, barriers and facilitating factors related to such application. Data sources: Original articles found in relevant databases, including Web of Science and Medline, covering the period 1966 to June 2004. Study selection: From 311 articles, 57 empirical studies, published between 1990 and 2004, met the inclusion criteria. Methods: A standardised data abstraction form was used for extracting data relevant to the review questions, and the data were analysed thematically. Results: Statistical process control was applied in a wide range of settings and specialties, at diverse levels of organisation and directly by patients, using 97 different variables. The review revealed 12 categories of benefits, 6 categories of limitations, 10 categories of barriers, and 23 factors that facilitate its application and all are fully referenced in this report. Statistical process control helped different actors manage change and improve healthcare processes. It also enabled patients with, for example asthma or diabetes mellitus, to manage their own health, and thus has therapeutic qualities. Its power hinges on correct and smart application, which is not necessarily a trivial task. This review catalogues 11 approaches to such smart application, including risk adjustment and data stratification. Conclusion: Statistical process control is a versatile tool which can help diverse stakeholders to manage change in healthcare and improve patients’ health.

We studied the effects of the national Perinatal Patient Safety Program in Sweden, addressing local improvement measures, changes in the proportion of low Apgar score and the number of settled injury claims due to asphyxia.Final reports on achieved improvements from all Swedish obstetric units were analyzed and categories of the improvement measures taken in perinatal risk areas were established. Data on all term newborns during 2006-12 were obtained from the Medical Birth Registry. Incidence of 5-min Apgar score7 was analyzed before, during and after the intervention. The odds ratio for low Apgar score in period ÍII vs. period I was calculated. Patient injury claims from The Swedish National Patient Insurance Company (LÖF) were analyzed.Numerous local improvement initiatives were reported. The incidence of 5-min Apgar score7 on a national level remained unchanged during the study periods. The units with the highest rate of Apgar score7 showed a significant decrease in Apgar score of 4-6 after the intervention, whereas units with the lowest rate of Apgar score7 showed a significant increase in Apgar score7 after the intervention. A decline in settled claims due to substandard care was observed (7.5%, 2012-14; p for trend 0.049).The national incidence of low Apgar score remained unchanged but a reduction of settled claims of severely asphyxiated neonates was observed. The study highlights the need for robust designs when evaluating large-scale initiatives for improving patient safety at delivery, along with the difficulties in performing them.

Despite a development in Swedish patient safety work in recent years, unambiguous results are missing. Here we propose some activities that will result in improved patient safety. Patients and employees are a strong driving force, and should be given a more important role. The level of education in patient safety must be raised in all levels in the system. Effective systems for learning, sharing and follow-up need to be reinforced. The understanding on how the health-care system adapts to varying circumstances, resilience, needs development. The knowledge basis of what constitutes and creates safety in psychiatry, paediatric care, primary care, and in care of the elderly must be developed.

Background: In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems. less thanbrgreater than less thanbrgreater thanMethods: A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. less thanbrgreater than less thanbrgreater thanResults were compared with those found in one local, and four national incident-reporting systems. Results: We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable. less thanbrgreater than less thanbrgreater thanConclusions: No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety. Funding Agencies|Swedish Vinnvard programme||FORSS - the research council of Southeast Sweden||County Council of Kalmar

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 using the "Harvard Medical Practice Study" method than using the "Global Trigger Tool". Differences in review methodology, perception of less severe adverse events and context knowledge may explain the observed difference between two expert review teams in the detection of adverse events.

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

'The value of Statistical Process Control in quality improvement contexts: Commentary on Unbeck et al. (2013)' : Authors' response

Many nonhealth industries have decades of experiences working with safety systems. Similar systems are also needed in healthcare to improve patient safety. Clinical incident reporting systems in healthcare identify adverse events but seriously underestimate the incidence of adverse events. A wide range of information sources and monitoring techniques are needed to understand and mitigate healthcare risks.The purpose of this study was to identify patient safety risk factors that can lead to adverse events in adult orthopaedic inpatients.A three-stage structured retrospective patient record review of consecutively admitted patients to the inpatient service of a large, urban Swedish hospital.Records for all orthopaedic inpatients admitted during a 2-month period (n = 395) were screened using 12 criteria. Positive records were then reviewed in two stages by orthopaedic surgeons using a standardized protocol. Data were collected from the index admission and from subsequent visits or readmissions within 28 days of discharge.Sixty patients experienced 65 healthcare associated adverse events. Affected patients had a length of hospital stay double that of patients without adverse events. Adverse events were more common in patients undergoing surgical procedures and patients with risk factors for anaesthesia. Although 59 of the adverse events occurred in patients who underwent surgery, only nine of the adverse events were due to deficiencies in surgical/anaesthesia technique. The others were related to deficiencies in healthcare processes. The most common adverse events were hospital acquired infections (n = 20) and delayed detection of urinary retention (n = 13). Six adverse drug events involved elderly patients (≥65 years).Orthopaedic care is a high risk activity for its typically elderly, often debilitated patients. Reducing adverse events in orthopaedic patients will require more multidisciplinary, interdepartmental teamwork strategies that focus on healthcare processes outside the operating room.

PurposeThe purpose of this paper is to survey Swedish healthcare leaders' patient safety awareness, the priority they give to safety issues and their views on suitable safety management strategies.Design/methodology/approachA total 623 leaders of a sample of 1,129 responded to a mail questionnaire (55 percent response rate). Descriptive statistics of the responses are presented as frequency distributions across respondent subgroups. Means were tested for similarity by a repetitive one‐way ANOVA procedure. Homogeneous response groups were sought by hierarchical cluster analysis.FindingsSwedish healthcare leaders show relatively high safety awareness and how their organizations prioritize safety management. There is a marked polarization between leaders; half feel that the system works reasonably well, and that adequate funds are available to improve or maintain services. The other half thinks the system needs major change and calls for additional funding. A majority sees system errors as the main cause for adverse events; a substantial minority find human errors to be more important. Two‐thirds were willing to make safety performance information on organizations and specialties public, one third was restrictive.Research limitations/implicationsSurvey instruments used to explore leaders' patient safety views have not yet been rigorously tested against psychometric criteria. One hospital type was slightly over‐represented and three regions somewhat under‐represented in the respondent groups.Originality/valueThis is the first systematic attempt to explore the views of Swedish healthcare leaders on patient safety. It provides input to a national strategy to improve patient safety.

Background A Swedish version of the USA Agency for Healthcare Research and Quality “Hospital Survey on Patient Safety Culture” (S-HSOPSC) was developed to be used in both hospitals and primary care. Two new dimensions with two and four questions each were added as well as one outcome measure. This paper describes this Swedish version and an assessment of its psychometric properties which were tested on a large sample of responses from personnel in both hospital and primary care. Methods The questionnaire was mainly administered in web form and 84215 forms were returned (response rate 60%) between 2009 and 2011. Eleven per cent of the responses came from primary care workers and 46% from hospital care workers. The psychometric properties were analyzed using both the total sample and the hospital and primary care subsamples by assessment of construct validity and internal consistency. Construct validity was assessed by confirmatory (CFA) and exploratory factor (EFA) analyses and internal consistency was established by Cronbachs’s α. Results CFA of the total, hospital and primary care samples generally showed a good fit while the EFA pointed towards a 9-factor model in all samples instead of the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable with Cronbach’s α values above 0.7 in a major part of the dimensions. Conclusions The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome measures, is used both in hospitals and in primary care settings in Sweden for different purposes. This version of the original American instrument has acceptable construct validity and internal consistency when tested on large datasets of first-time responders from both hospitals and primary care centres. One common instrument for measurements of patient safety culture in both hospitals and primary care settings is an advantage since it enables comparisons between sectors and assessments of national patient safety improvement programs. Future research into this version of the instrument includes comparing results from patient safety culture measurements with other outcomes in relation to safety improvement strategies.