Humanising processes after harm part 2: compounded harm experienced by patients and their families after safety incidents.

Background: Healthcare organisations risk harming patients and their families twofold. First, through the physical, emotional and/or financial harm caused by safety incidents themselves, and second, through the organisational response to incidents. The former is well-researched and targeted by interventions.

Do healthcare professionals work around safety standards, and should we be worried? A scoping review.

Background: Healthcare staff adapt to challenges faced when delivering healthcare by using workarounds. Sometimes, safety standards, the very things used to routinely mitigate risk in healthcare, are the obstacles that staff work around. While workarounds have negative connotations, there is an argument that, in some circumstances, they contribute to the delivery of safe care.

Care partner engagement in patient safety at the direct care level in hospital: a qualitative systematic review protocol.

Objective: The objective of this systematic review is to understand the experiences of care partner engagement in patient safety at the direct care level from the perspective of care partners, patients, and health care professionals.

Introduction: Care partner engagement is a strategy for promoting patient safety in hospitals at the direct care level (ie, at the point where patient care is delivered). When present, care partners can increase safety by watching, listening, and taking action to protect admitted patients.

Sailing Too Close to the Wind? How Harnessing Patient Voice Can Identify Drift towards Boundaries of Acceptable Performance.

This opinion paper investigates how healthcare organizations identify and act upon different types of risk signals. These signals may generally be acknowledged, but we also often see with hindsight that they might not be because they have become a part of normal practice. Here, we detail how risk signals from patients and families should be acknowledged as system-level safety critical information and as a way of understanding and changing safety culture in healthcare.

A service-user digital intervention to collect real-time safety information on acute, adult mental health wards: the WardSonar mixed-methods study.

Background: Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives.

Objective(s): Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety.

Evaluating an intervention to improve the safety and experience of transitions from hospital to home for older people (Your Care Needs You): a protocol for a cluster randomised controlled trial and process evaluation.

Background: Older patients often experience safety issues when transitioning from hospital to home. The 'Your Care Needs You' (YCNY) intervention aims to support older people to 'know more' and 'do more' whilst in hospital so that they are better prepared for managing at home.

Methods: A multi-centre cluster randomised controlled trial (cRCT) will evaluate the effectiveness and cost-effectiveness of the YCNY intervention.

Exploring the "Black Box" of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review.

Background: Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. There is little empirical evidence about how-in real-world hospital settings-recommendations are generated or judged for effectiveness.

Objectives: Our research questions, concerning internal hospital investigations, were as follows: (1) What approaches to incident investigation are used before the generation of recommendations? (2) What are the processes for generating recommendations after a patient safety incident investigation? (3) What are the number and types of recommendations proposed? (4) What criteria are used, by hospitals or study authors, to assess the quality or strength of recommendations made?

Methods: Following PRISMA-ScR guidelines, we conducted a scoping review.

Unpacking the Cinderella black box of complex intervention development through the Partners at Care Transitions (PACT) programme of research.

Introduction: Complex intervention development has been described as the 'Cinderella' black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste.

Methods: We applied a new consensus-based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people.

Patient and public co-creation of healthcare safety and healthcare system resilience: The case of COVID-19.

Introduction: Healthcare system resilience is a conceptual approach that seeks to explore how health services adapt and respond to variability in demand and resources. As has been witnessed since the beginning of the COVID-19 pandemic, healthcare services have undergone many reconfigurations. One understudied aspect of how the 'system' is able to adapt and respond is the contribution of key stakeholders-patients and families, and in the context of the pandemic, the general public as a whole.

Developing a research community within an online healthcare feedback platform.

Introduction: Care Opinion is an online feedback platform supporting patients to author stories about their care. It is not known whether authors would be willing to be involved in improving care through research. The aims of this study were to explore the views and preferences of Care Opinion authors about joining an online research community and to pilot new research community functionality.

A glimpse behind the organisational curtain: A dramaturgical analysis exploring the ways healthcare staff engage with online patient feedback 'front' and 'backstage' at three hospital Trusts in England.

Healthcare staff are encouraged to use feedback from their patients to inform service and quality improvement. Receiving patient feedback via online channels is a relatively new phenomenon that has rarely been conceptualised. Further, the implications of a wide, varied and unknown(able) audience being able to view and interact with online patient feedback are yet to be understood.

The feasibility and acceptability of implementing video reflexive ethnography (VRE) as an improvement tool in acute maternity services.

Background: Video-reflexive ethnography (VRE) has been argued to be an alternative approach to collaborative learning in healthcare teams, more able to capture the complexities of the healthcare environment than simulation. This study aims to explore the feasibility and acceptability of employing VRE as an improvement tool in acute maternity services.

Method: Focused ethnography and semi-structured interviews (n = 17) explored the feasibility of employing VRE from the perspective of the researcher-facilitator, and that of the healthcare staff participants.

Exploring the sociocultural contexts in which healthcare staff respond to and use online patient feedback in practice: In-depth case studies of three NHS Trusts.

Objectives: Patients are increasingly reporting about their healthcare experiences online and NHS Trusts are adopting different approaches to responding. However, the sociocultural contexts underpinning these organisational approaches remain unclear. Therefore, we aimed to explore the sociocultural contexts underpinning three organisations who adopted different approaches to responding to online patient feedback.

Improving the safety and experience of transitions from hospital to home: a cluster randomised controlled feasibility trial of the 'Your Care Needs You' intervention versus usual care.

Background: The 'Your Care Needs You' (YCNY) intervention aims to increase the safety and experience of transitions for older people through greater patient involvement during the hospital stay.

Methods: A cluster randomised controlled feasibility trial was conducted on NHS inpatient wards (clusters) where ≥ 40% of patients were routinely ≥ 75 years. Wards were randomised to YCNY or usual care using an unequal allocation ratio (3:2).

A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home.

Background: The Partners at Care Transitions (PACTs) intervention was developed to support older people's involvement in hospital to improve outcomes at home. A booklet, question card, record sheet, induction leaflet, and patient-friendly discharge letter support patients to be more involved in their health and wellbeing, medications, activities of daily living and post-discharge care. We aimed to assess intervention acceptability, identify implementation tools, and further develop the intervention.

Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence.

Objectives: Investigations of healthcare harm often overlook the valuable insights of patients and families. Our review aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.

Methods: The authors searched three databases (Medline, PsycInfo, and CINAHL) and Connected Papers software for qualitative studies in which patients and families were involved in serious incident investigations until no new articles were found.

Differences in comprehending and acting on pandemic health risk information: a qualitative study using mental models.

Background: A worldwide pandemic of a new and unknown virus is characterised by scientific uncertainty. However, despite this uncertainty, health authorities must still communicate complex health risk information to the public. The mental models approach to risk communication describes how people perceive and make decisions about complex risks, with the aim of identifying decision-relevant information that can be incorporated into risk communication interventions.

What Do Patients and Their Carers Do to Support the Safety of Cancer Treatment and Care? A Scoping Review.

Background: Cancer patients and their carers face a multitude of challenges in the treatment journey; the full scope of how they are involved in promoting safety and supporting resilient healthcare is not known.

Objective: The study aimed to undertake a scoping review to explore, document, and understand existing research, which explores what cancer patients and their carers do to support the safety of their treatment and care.

Design: This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines.

What do primary care staff think about patients accessing electronic health records? A focus group study.

Background: Patients have expressed a growing interest in having easy access to their personal health information, and internationally there has been increasing policy focus on patient and care records being more accessible. Limited research from the UK has qualitatively explored this topic from the primary care staff perspective. This study aimed to understand what primary care staff think about patients accessing electronic health records, highlighting errors in electronic health records, and providing feedback via online patient portals.

Humanizing harm: Using a restorative approach to heal and learn from adverse events.

Background: Healthcare is not without risk. Despite two decades of policy focus and improvement efforts, the global incidence of harm remains stubbornly persistent, with estimates suggesting that 10% of hospital patients are affected by adverse events.

Methods: We explore how current investigative responses can compound the harm for all those affected-patients, families, health professionals and organizations-by neglecting to appreciate and respond to the human impacts.

Creating Effective, Evidence-Based Video Communication of Public Health Science (COVCOM Study): Protocol for a Sequential Mixed Methods Effect Study.

Background: The nonlinear nature of contagious diseases and the potential for exponential growth can be difficult to grasp for the general public. This has strong implications for public health communication, which needs to be both easily accessible and efficient. A pandemic is an extreme situation, and the accompanying strict societal measures are generally easier to accept if one understands the underlying reasoning behind them.