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Previous Seminars


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Abstract: Never Events are patient safety incidents that can cause harm or death and are so named because policy makers argue there is enough evidence available about how to prevent them, so they should never occur. Never events include wrong site surgery, wrong route drug administration, retained foreign objects and wrong implants. Between April-November 2017 332 Never Events occurred in hospitals in England, indicating that solutions to prevent them are not working. Although Resilient Healthcare is often described as a paradigm shift in safety management it is not clear how it can contribute to the investigation of adverse incidents. Root Cause Analysis (RCA) is currently used for the investigation of Never Events, but recent studies have found the recommendations to be of low quality. There is little incentive, time or resources for healthcare organisations to consider other approaches and little work has been done on how to use Resilient Healthcare insights to augment Safety I practices such as Root Cause Analysis. In this presentation the results of an analysis of 39 Never Events that occurred at one hospital over a two-year period will be discussed. The focus will be on the new insights and perspectives that Resilient Healthcare can offer to improve learning from Never Events. Recommendations for strengthening RCA and learning from Never Events will be discussed.

Biography: Janet Anderson is Director of the Centre for Applied Resilience in Healthcare and a Reader of Healthcare Improvement at King’s College London. She is a human factors psychologist. Her research draws on psychological and organisational theories and knowledge and is focused on designing systems to support safe human activity. She has specialist expertise in the theory and practice of organisational resilience, system modelling using cognitive work analysis, incident reporting and adverse event analysis, and inter professional teamwork. Board level processes and hospital wide systems for improving quality are an area of current research.

Presentation slides available here


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Abstract: Inquiries, academic work and expert group reports on problems in the quality of care in the NHS and other healthcare systems have identified shortcomings in ‘openness’—that is, the extent to which organisations enable concerns to be raised and disclosed freely without fear—as critical to the incubation of failings in quality and safety. In response, the NHS in England has developed policy initiatives that seek to improve openness, including a statutory duty of candour when care processes give rise to harm, the introduction of ‘Freedom to Speak Up Guardians’ to facilitate staff voice about concerns, and changes to various processes, including the way serious incidents are investigated. The evidence base for many of these changes, however, is uncertain, and their impact on the quality of care unevaluated.

This paper discusses emergent findings from an ongoing evaluation of various openness initiatives in the NHS, focusing in particular on an interview-based sub-study of senior stakeholder views on the implementation and impact of these initiatives. It highlights some of the challenges involved in achieving greater openness given past experiences and deep-rooted beliefs about the (at best ambivalent, and often negative) consequences of being open, the difficulties involved in diagnosing opacity and fostering openness, and the approaches taken by senior clinicians and managers to translating policy into practice. It relates findings to current policy and wider evidence and theory on interventions to facilitate employee voice and achieve culture change.

Biography: Graham Martin is Director of Research for THIS Institute, a new unit funded by the Health Foundation at the University of Cambridge to develop the evidence base for and impact of work to improve healthcare quality and safety, and Professor of Health Organisation and Policy in the SAPPHIRE Group, University of Leicester. His research focuses on social, organisational and professional issues in healthcare system change, with a particular focus on quality improvement work and policy initiatives to address quality, safety and risk in the NHS.


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Abstract: Improving Patient Safety in Mental Health Services presents a unique set of challenges and there continues to be limited attention paid to it. This seminar will provide an insight into key issues and priorities for future research identified by staff, service users and carers. It will provide an overview of relevant work being conducted by Mental Health Research Group, School of Healthcare, University of Leeds. Examples of current work of the group include reducing restrictive interventions (restraint, seclusion and forced medication), designing safer services through improving transitions and staffing and broadening our understanding of safety incidents in inpatient mental health services.

Biography: John is the Professor of Mental Health Nursing at the University of Leeds. He leads the Mental Health Research Group in the School of Healthcare. His research focuses on the development of safe and effective mental health services and clinical interventions across secondary mental health care. He is a health services researcher who has used a variety of methods from qualitative studies to complex trials and has generated substantial research income via the NIHR including RfPB, HSDR, Programme Grants and charities such as the Health Foundation. The good practice manuals which he developed have been evaluated, cited as examples of good practice, and influenced clinical practice in the UK and abroad. The training package for patients, service users and carers to promote research awareness and understanding has been cited as an exemplar of good practice. He is also a non-executive director at Leeds and York Partnership NHS Foundation Trust.


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Abstract: In UK healthcare there has been continuous development in data collection to monitor the quality and safety of care, in the form of both local and national programmes for quality improvement, clinical audit, incident reporting, mortality surveillance and digital technology, amongst others.  In the past, feedback from large-scale monitoring programmes has been limited.  Recently, the promotion of quality improvement methods has given rise to new models for effective use of data and advances across a range of disciplines afford us opportunities to better understand how to make feedback more useful and actionable for clinicians, teams and organisations.  Such approaches promise to translate data into interventions that support professional behaviour change, local quality improvement and robust implementation.  In this research seminar, the challenges and opportunities for enhanced feedback and local use of data will be outlined, drawing upon experience across a range of research projects that have applied human and organisational perspectives to topics in quality improvement and patient safety.  Specific applications include quality in anaesthesia, national mortality alerting and patient safety incident reporting and learning systems.  The relative merits of a model for continuous monitoring and feedback, based upon industrial quality improvement practices, will be discussed.

Biography: Jonathan Benn is Associate Professor in Healthcare Quality and Safety at the School of Psychology at the University of Leeds.  With a background in Psychology and Human Factors, he has 13 years’ experience as a health services researcher using applied theory and methods from the social sciences to address a range of research questions at clinical and policy level.  His previous post was a Lectureship in Quality Improvement at Imperial College London and as Director of the MSc course there in Quality and Safety.  His work has been supported by the Health Foundation, NIHR CLAHRC and NIHR Health Services and Delivery Research programmes.  He is currently an Associate Editor for the Joint Commission Journal on Quality and Patient Safety, which publishes international improvement research and practical case studies to share learning across contexts.

Presentation slides available here


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Abstract: Clinical evidence that can improve patient outcomes does not reliably find its way into everyday care. The gap between evidence and practice limits the health, social and economic impacts of clinical research. Dissemination of evidence-based practice via clinical guidelines is necessary but seldom sufficient by itself to ensure implementation. Furthermore, the general practice context presents particular challenges – especially given limited practice organisational capacity, increasing workload and complexity of care, and competing priorities.

This presentation will report the key methods and findings from a major programme of work involving general practices across West Yorkshire.  We aimed to develop and evaluate an implementation package to support the uptake of a range of guideline recommendations and sustainably integrate it within general practice systems and resources.  We made our evaluation as pragmatic as possible to ensure relevance to ‘real world’ primary care.  Seminar participants can judge for themselves to what extent we met our goals.

Biography: Robbie Foy is Professor of Primary Care at the Leeds Institute of Health Sciences and a general practitioner in inner-city Leeds.  His field of work, implementation research, aims to inform policy decisions about how best to use resources to improve the uptake of research findings by evaluating approaches to change professional and organisational behaviour.  His former posts include a clinical senior lectureship at Newcastle University, and an MRC training fellowship in health services research based jointly between the Universities of Edinburgh and Aberdeen.  He is also trained as a public health physician.  He was a 2006-7 Harkness / Health Foundation Fellow in Health Care Policy, based jointly between the Veteran’s Administration and RAND in Los Angeles.  He was formerly Deputy Editor-in-Chief of the open access journal, Implementation Science.


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Abstract: The early stages of judgement are the most critical for the final outcome of the diagnostic process. I will present studies that used different methodologies to measure the influence of this early stage on the diagnostic process and outcome. I will also present the design of a computerised diagnostic support system (DSS) prototype for General Practitioners. Designed to support the early stages of the diagnostic process, the DSS prototype was recently evaluated in a study with GPs consulting with standardised patients (actors).

Biography: Olga studied Psychology at the National University of Athens, Greece, and obtained her MSc and PhD in Psychology from Cardiff University. Prior to her current position, she held academic positions at King’s College London, and the University of Birmingham. Her main research interest is the application of psychology theory and methods to the study of medical decisions. She has conducted research on medical judgement in a variety of healthcare settings, using predominantly quantitative experimental methods. She aims to understand the cognitive biases that can lead to diagnostic error and delay, and test ways of reducing bias and supporting judgement. Her research has been funded by Cancer Research UK, the EU and the DoH. She is Associate Editor of the journal Medical Decision Making, has served as elected Trustee on the Board of the Society, and has chaired the Society’s biennial European meeting in London (June 2016). She has given short courses and MSc modules on the psychology of medical decision making to UK and international audiences.

MEDICATION SAFETY – PROBLEMS, SOLUTIONS AND CHALLENGES: Professor Bryony Dean-Franklin, 27th October 2017

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Abstract: The use of medication is one of the most common interventions in today’s healthcare. Medication use takes place in many different settings and involves many different health care professionals as well as patients and their carers – and errors can arise at any stage. This presentation will set the scene by describing some of the problems that can occur, before considering some solutions and challenges, drawing on evidence in this field. Potential solutions include the use of technology (both high tech and low tech), human factors, system design, communication strategies and greater patient involvement. Suitable solutions must also take into account both a ‘medical’ view of safety (the avoidance of harm) and a ‘patient’ view of safety (‘feeling safe’). Challenges include the importance of context (what works in what setting may not work in another), fidelity of implementation, unintended consequences, and the ubiquitous nature of medication use and wide range of stakeholders involved.

Biography: Professor Bryony Dean Franklin is Director of the Centre for Medication Safety and Service Quality (CMSSQ), a joint research unit between Imperial College Healthcare NHS Trust and UCL School of Pharmacy, where Bryony is Professor of Medication Safety. She is a theme lead for both the NIHR Imperial Patient Safety Translational Research Centre and the NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London.

Bryony has been involved with patient safety research for nearly twenty years, and has published widely on medication safety, the evaluation of various technologies designed to reduce errors, and how we can support the public role in patient safety. Her current post combines research, education and training, and clinical practice as a hospital pharmacist. Bryony is an associate editor for the journal BMJ Quality and Safety, and on the editorial board for BMC Safety in Health. She is co-editor of the textbook “Safety in Medication Use” and co-author of “Going into Hospital? A guide for patients, carers and families”, a book aimed at the general public.

Presentation slides available here

PATIENT SAFETY: THE END OF THE BEGINNING OR THE BEGINNING OF THE END? Professor Jeffrey Braithwaite, 12th October 2017

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Abstract: I last spoke to the Bradford Institute for Health Research on the topic of Resilient health care: re-conceptualising patient safety. Two years on, and along with members of the Resilient Health Care Network, we have published another book (Braithwaite, Wears and Hollnagel, 2017, Reconciling Word-As-Imagined and Work-As-Done), with three more volumes in various stages of production. Leveraging from this work, I will analyse recent developments in patient safety and discuss a number of issues crucial to understanding where we are in the perennial search for better ways to care for patients in safe, effective environments.

I will draw not only on the compendiums making up the contributions of the Resilient Health Care Net, but also on two other recent contributions of note. One is The Sociology of Healthcare Safety and Quality (Allen, Braithwaite, Sandall, Waring, (eds.), 2016). The other is recent work on applying complexity science to health care (Braithwaite, Churruca, Ellis, Long, Clay-Williams, Damen, Herkes, Pomare, Ludlow, 2017, Complexity Science in Healthcare—Aspirations, Approaches, Applications and Accomplishments: A White Paper).

The bottom line is that despite the doomsayers saying that it is proving very hard to make progress in patient safety as it is such an intractable wicked problem, it’s better to say that we are at the end of the beginning of the patient safety movement rather than at the beginning of the end. But, in the end, that will be up to each individual in the audience. There will be time for discussion at the conclusion of this presentation.

Biography: Professor Jeffrey Braithwaite, BA, MIR (Hons), MBA, DipLR, PhD, FAIM, FCHSM, FFPHRCP (UK), FAcSS (UK), Hon FRACMA, is Foundation Director, Australian Institute of Health Innovation, Director, Centre for Healthcare Resilience and Implementation Science, and Professor of Health Systems Research, Macquarie University, Australia. His research examines patient safety, health care as a complex adaptive system, and applying complexity science to health care problems. He has attracted funding of more than AUD$102 million and has received 37 different national and international awards for his teaching and research.

REDUCING EMERGENCY ADMISSIONS: Dr Suzanne Mason, 6th July 2017

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Abstract: Emergency and urgent care provide substantial health benefit across the world but increasing demand is leading to unsustainable pressure on services and a need for innovative approaches to the delivery of emergency and urgent healthcare for patients. In the English NHS in 2012-13 there were 18.3 million attendances at major emergency departments, single specialty emergency departments, walk-in centres and minor injury units, at a cost of £2.1 billion; 5.3 million emergency hospital admissions, at a cost of £12.5 billion; 7 million ambulance service journeys; and approximately 24 million calls to NHS emergency and urgent care telephone services.

Failure of the emergency and urgent care system to manage increasing demand causes substantial public concern and political impact. Delays in ambulance response or emergency department assessment can lead to worse outcomes for patients. Emergency department crowding is internationally recognised and may be associated with avoidable mortality. These issues make the delivery of emergency and urgent care an important priority for policy-makers, service providers and the public. The emergency and urgent care system inextricably links services together that rely on each other, and also that work together to deliver care for patients. This study is using data from the Yorkshire Ambulance Service and NHS 111 and linking it with hospital data (ED/Inpatient) from every acute trust in Yorkshire and Humber to analyse patient demand, flow and outcomes through these parts of the system.  In addition to an overall view, we have focussed on patient groups who may benefit from a different approach to their emergency care. This includes vulnerable patient groups such as those who have mental health problems, the elderly, patients who attend frequently and also patients with primary care-related problems. The presentation will provide an overview of the project and describe some of the analyses and outputs to date.

Biography: Suzanne qualified in medicine from London University in 1990. She pursued her training initially in surgery and then specialised in Emergency Medicine. Suzanne spent a year as a Royal College of Surgeons of England Research Fellow and was awarded an MD whilst undertaking higher training in Emergency Medicine. She joined Sheffield University as a Senior Clinical Lecturer in 2001 and was promoted to Reader in 2007 and Personal Chair in 2010. She divides her time between the university and as a consultant at the Sheffield Teaching Hospitals Trust emergency department. Her main research interests include evaluating complex interventions in emergency and urgent care. She is particularly interested in the evaluation of new roles and alternative pathways of care.

Recent studies include evaluating junior doctor confidence and competence in carrying out their role in emergency medicine (The EDiT study), evaluating the use of a falls pathway by paramedics attending older people who have fallen (SAFER 2 Trial), and The AHEAD Study: Managing anticoagulated patients who suffer head injury, Using routine data to evaluate the Emergency and Urgent care System (


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Abstract: Healthcare organisations receive large volumes of complaints; for example in 2015-16 the NHS received over 100,000 complaints from service users (patients and their families). Traditionally complaints have been seen as something to manage or even hide.  However, listening to service user complaints can potentially provide independent, practical, and unique insights for improving patient safety and quality. This lecture reports evidence using the Healthcare Complaints Analysis Tool, which is the first reliable tool for systematically analyzing and benchmarking the nature and severity of complaints received by hospitals. It shows that complaints from patients and families highlight systemic problems in the provision of safe and high-quality healthcare, and are associated with hospital-level mortality rates. This evidence supports the idea that complaints have high validity and can be used both as an early warning system for identifying systemic failures in healthcare organisations, and as a catalyst for organizational learning.

Biography: Tom Reader is an Associate Professor in the Department of Psychological and Behavioural Science at the London School of Economics and Political Science. His research examines the relationship between organisational culture and safety management in high-risk organisations, and has been conducted in a variety of settings (healthcare, aviation, energy, finance). Dr Reader’s research has been disseminated through outlets such as Risk Analysis, BMJ: Quality and Safety, Journal of Occupational and Organizational Psychology, Human Factors, Ergonomics, and Human Relations.