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Involving users in the design of a system for sharing lessons from adverse incidents in anaesthesia.

Research output: Contribution to Journal/MagazineJournal articlepeer-review

Published
  • S. Sharma
  • A. F. Smith
  • J. Rooksby
  • B. Gerry
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<mark>Journal publication date</mark>04/2006
<mark>Journal</mark>Anaesthesia
Issue number4
Volume61
Number of pages5
Pages (from-to)350-354
Publication StatusPublished
<mark>Original language</mark>English

Abstract

In this qualitative study using observation and interviews, 10 anaesthetists from five Departments of Anaesthesia in the North-West region of England were enlisted to participate in the design of an online system to allow the sharing of critical incidents. Respondents perceived that existing schemes had differing and sometimes conflicting aims. Reporting was used for reasons other than simply logging incidents in the interests of promoting patient safety. No existing scheme allowed the lessons learned from incidents to be shared between members of the professional group from which they arose. Using participants' suggestions, we designed a simple, secure, anonymous system favouring free-text description, intended to enable the on-line sharing and discussion of selected incidents. Seven incidents were posted during the 6-month pilot period. The practitioners in our study valued the opportunity to share and discuss educational incidents ‘horizontally’ within their community of practice. We suggest that large-scale reporting systems either incorporate such a function or allow other systems that permit such sharing to co-exist.

Bibliographic note

Incident reports are crucial to the maintenance and improvement of patient safety. We investigated reporting practices in the Anaesthesia departments of six NHS Trusts. We discovered that reports were not shared between Trusts and that there would be value in this. Using a synthesis of participatory design and ethnography, we developed a prototype that afforded ease of use, peer learning and addressed trust and privacy concerns. Successful trialling took place over six months, results were presented to the Royal College of Anaesthetists. This paper is co-authored with two NHS staff, and published in Anaesthesia, a high impact journal (factor 2.427). RAE_import_type : Journal article RAE_uoa_type : Computer Science and Informatics