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Resilience in the blood transfusion process: Everyday and long-term adaptations to ‘normal’ work
journal contribution
posted on 2019-08-05, 13:14 authored by Alison Watt, Gyuchan Thomas Jun, Patrick WatersonPatrick WatersonBlood 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.
History
School
- Design
Published in
Safety ScienceVolume
120Pages
498 - 506Publisher
Elsevier BVVersion
- AM (Accepted Manuscript)
Rights holder
© ElsevierPublisher statement
This paper was accepted for publication in the journal Safety Science and the definitive published version is available at https://doi.org/10.1016/j.ssci.2019.07.028Acceptance date
2019-07-19Publication date
2019-08Copyright date
2019ISSN
0925-7535Publisher version
Language
- en
Depositor
Dr Thomas JunUsage metrics
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