Enabling healthcare systems to maximise learning from unsafe care – an exploratory mixed methods study.
The Lead supervisor on this project is, Professor Maneesh Kumar, [Email Address Removed]
This project is in collaboration with the School of Medicine and Cardiff and Vale University Health Board. The joint supervisors for this project are Dr Andrew Carson-Stevens (School of Medicine ) and Dr. Rajesh Krishnan, Assistant Medical Director.
Healthcare is dangerous with one in 20 patients exposed to preventable harm in medical care. This translates to one patient safety incident occurs every 26 seconds in the NHS. The WHO recognises this a major threat to public health.
Healthcare organisational learning is key to minimising risk and improving patient safety. Despite major investments in health systems worldwide to understand risk, the statistic show minimal reductions in harm, serious error or death commensurate with the effort and costs of the system.
The fundamental flaw is that existing approaches seek to identify ‘linear’ cause&effect relationships in otherwise complex, adapting, fast-moving systems. Recent work from Kumar et al.[1-3] emphasises the importance of systems thinking for better internal and external supply chain integration, and the importance of organisational learning that enables employees to identify weak signals before they transform into catastrophic failures [1-3]. Similarly, healthcare researchers[4-6] highlighted the importance of organisational learning to minimise healthcare errors.
Rationale
The PhD will tackle the fundamental flaw identified by Kumar (1-3), and will explore and develop a solution to sensitively explore complex patterns of risk(s) with healthcare professionals involved in a patient safety incident to quickly learn why a medical error (or near-miss) occurred and enable timely decisions about intervention priorities and actions for improvement.
Probable aims
Explore how healthcare organisations can maximise learning from patient safety incidents through the development and testing of a Patient SafeTy risk Assessment tool (‘PASTA’ tool).
Likely research questions
How can contributory factors be effectively identified to promote future unsafe patient care that can be targeted by preventive/mitigating interventions?
Anticipated design and methods
We anticipate the student will benefit from the methodological expertise and perspectives of each supervisor, and with our support combine disciplinary perspectives, and gain a rich understanding of health services improvement research using qualitative and quantitative methods.
We expect the student to combine their clinical placement experience with relevant existing literature to inform the development of a PASTA tool (possibly a list of focussed questions about contributory factors) for exploring risk after a patient safety incident has occurred (Year 1).
From supervisory discussions, the student will appreciate the importance of tool validation and will plan experiments in conjunction with NHS partners to test the tool in a range of formats (e.g. face-to-face interview, telephone-supported completion, self-administration) to understand if and how it works, and how the NHS can effectively use such learning (Years 2-3).
References
Please see bottom of references section for further details.
Eligibility for the studentship
Applications are invited from exceptional candidates with a first class or strong upper second class honours degree, or appropriate Master’s degree. The University and ESRC Wales DTP value diversity and equality at all levels and we encourage applications from all sections of the community, irrespective of age, disability, sex, gender identity, marital or civil partnership status, pregnancy or maternity, race, religion or belief and sexual orientation. In line with our commitment to supporting and promoting equality, diversity and inclusion, and to increase recruitment of currently underrepresented groups, applications from Black British, Asian British, minority ethnicity British and mixed race British candidates are particularly encouraged and welcomed. We welcome applications for both full and part-time study, and studentships are available as either ‘1+3’ (i.e. one full time year of research training Masters followed by three years of full-time Doctoral study, or the part-time equivalent), or ‘+3’ (i.e. three years of full-time doctoral study or its part-time equivalent), depending on the needs of the applicant.
Please visit here for further information about the PhD Programme at Cardiff Business School.
Applications welcomed by 2nd June 2021 (1200 hours).
Please see references section for further details on how to apply. Applications should be made online, please visit the Business School website and click "apply now" Business Studies - Study - Cardiff University
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