2134/9227033.v1
Alison Watt
Alison
Watt
Gyuchan Thomas Jun
Gyuchan Thomas
Jun
Patrick Waterson
Patrick
Waterson
Resilience in the blood transfusion process: Everyday and long-term adaptations to ‘normal’ work
Loughborough University
2019
Human Factors
Engineering
Medical and Health Sciences
Psychology and Cognitive Sciences
Blood transfusion
Healthcare
Resilience
Adaptation
Systems engineering initiative for patient safety 2.0 (SEIPS 2.0)
Concepts for applying resilience engineering (CARE)
2019-08-05 13:14:49
Journal contribution
https://repository.lboro.ac.uk/articles/journal_contribution/Resilience_in_the_blood_transfusion_process_Everyday_and_long-term_adaptations_to_normal_work/9227033
Blood transfusion is considered one of the safer aspects of healthcare,
however potentially avoidable patient-safety incidents led to 14 deaths in the
United Kingdom in 2017. Improvement initiatives often focus on staff
compliance with standard operating procedures, which fail to understand
adaptations made in a complex, dynamic environment. Therefore, the aim of
this study is to examine the extent and nature of adaptations at all stages of
the full vein to vein transfusion process. Thirty-seven employees described
sixty-six adaptations in their transfusion practices, showing clear differences
between what has been characterised as work-as-imagined (WAI) and workas-done (WAD). An analysis of the adaptations using the Systems
Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) shows that triggers for
adaptations were mostly staff-related or driven by poor information technology
systems, but the resultant adaptations were usually amendments to tasks and
processes. The majority of adaptations (83%) were forced - ideal solutions are
not possible, so workarounds and coping strategies are required, but some
(17%) were proactive - the surrounding system is adequate, but performance
is improved by adapting. Managers or colleagues were largely unaware of the
adaptations made (79%) and, as a result, opportunities may be missed to
identify and learn from resilient practices. The Concepts for Applying
Resilience Engineering (CARE) model was further articulated in order to shed
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extra light on triggers and mechanisms. We make a number of suggestions
regarding how we can better learn from adaptations and how these could be
used to improve the safety of the blood transfusion process.