New paper – Patient safety professionals as the third victims of adverse events
This paper, co-authored with Julie Holden, builds on the logic of “second victims” (clinicians who experience harm as a result of their involvement in an adverse event) to describe the idea of “third victims,” (those who experience psychosocial harm as a result of indirect exposure to an incident, e.g., through their role in leading incident investigation or improvement activities).
Focusing primarily on patient safety professionals (and others with similar roles), we describe the causes and consequences of harm to third victims, and make a number of recommendations for prevention, mitigation, and future research. We have already received a lot of feedback from patient safety and risk management professionals about the importance of this work and shining a light on the harm they experience.
Read the full article in the Journal of Patient Safety and Risk Management:
https://journals.sagepub.com/doi/abs/10.1177/2516043519850914?journalCode=cric
Or, if you don’t have access to the journal, you can find the open access pre-print here:
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Conference presentations
In October & November I presented at the American Society for Healthcare Risk Management Annual Conference and the Health Care Design Conference, both times with colleagues from the Center for Health Design. For more details, see:
ASHRM presentation on the Safety Risk Assessment Toolkit, and how risk managers can help take the lead on designing for safety.
HCD ‘Research Matters’ presentation on ten important papers from the past year.
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New paper – “Physician burnout: Resilience training is only part of the solution”
My most recent paper tackles the subject of physician burnout. Drawing on parallels from the literature on avoidable patient suffering, I argue that we should differentiate between unavoidable occupational suffering (which is an inherent part of the physician’s work) and avoidable occupational suffering (which represents systems failures). While resilience training has become the ‘go to’ solution for physician burnout, I argue that it is only an appropriate response for unavoidable suffering. When it comes to avoidable suffering, the only ethical response is prevention through systems improvement.
You can find the physician burnout paper here:
http://www.annfammed.org/content/16/3/267.full.pdf+html
For more on avoidable patient suffering, see my earlier paper:
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New Faculty Appointment
I’ve accepted a new position as an Assistant Professor in the Department of Pediatrics at the UC San Diego School of Medicine. I’m excited to join a team of brilliant and collaborative colleagues both within the department and across UCSD and the broader San Diego community.
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Action-Planning Workshop with the North Carolina Quality Center PSO
On May 10th, I will be presenting an action planning workshop with the North Carolina Hospital Association’s Patient Safety Organization (PSO), the North Carolina Quality Center: https://www.ncqualitycenter.org/events/its-a-game-changer-overcoming-action-planning-challenges/
This hands-on workshop will introduce participants to the Active Risk Control (ARC) Toolkit, a structured approach to improving the strength and sustainability of risk control interventions.
Two follow-up events are also included:
- A webinar introducing the Structured-What-If Technique (SWIFT), a faster and more engaging alternative to failure mode and effects analysis (FMEA). By using a more rapid risk assessment approach, healthcare organizations will be able to spend more time on what really matters: developing effective solutions.
- An online interactive discussion about using the ARC Toolkit. Participants will share their “lessons learned” from using the toolkit. We will discuss facilitators and barriers to success, as well as opportunities to improve the toolkit.
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Paper on “The Problem with Plan-Do-Study-Act Cycles” among top articles tracked by Altmetric
A paper I recently co-authored with Julie Reed of CLAHRC Northwest London is among the top articles tracked by Altmetric.
Our BMJ Quality & Safety paper, “The Problem with Plan-Do-Study-Act Cycles” is in the 99th percentile for all articles ever tracked by the service, and is among the top 25 articles from BMJ Quality & Safety: https://www.altmetric.com/details/4919411#score.
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Appointed Editor of the Journal of Healthcare Risk Management from 2016
I am honored to have been appointed Editor for the Journal of Healthcare Risk Management starting in 2016. I look forward to continuing to work with my friends and colleagues on the Editorial Board, including our new Deputy Editor Johnnye Dennis, to build on the impressive progress we’ve made in recent years.
If you have high-quality work in the areas of patient safety and healthcare risk management, please consider submitting it to the JHRM.
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Presenting at the American Public Health Association (APHA) Annual Meeting
I will be delivering a presentation about my work on the Active Risk Control (ARC) Toolkit at the APHA Annual Meeting in Chicago. The presentation is entitled “Designing stronger interventions to improve patient safety” and it will take place from 11:18-11:30 on Wednesday, November 4th.
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Presented at the American Society for Healthcare Risk Management (ASHRM) Annual Conference
I recently presented at the 2015 ASHRM Annual Conference in Indianapolis, IN. I was honored to join Dr. David Sine, Chief Risk officer of the VA, to present “The Path to Improved Outcomes: Integrating Risk Assessment with Risk Control.”
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Authored a blog post on PIPSQC.org
I was recently invited to contribute a blog post to the website of the Paediatric International Patient Safety and Quality Collaborative (PIPSQC.org).
My post, entitled “Patient Harm is a Public Health Crisis, Not Just a Performance Management Issue,” is loosely based on an article I wrote for the Journal of Healthcare Risk Management (Patient Safety: This is Public Health). In the blog post, I argue for the importance of treating the pandemic of patient harm as major public health concern it is, every bit as important as heart disease or cancer. Please check it out and see if you agree.
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Elected Treasurer of the Health Administration Section, American Public Health Association (APHA)
I am grateful for the opportunity to continue my leadership role in the Health Administration Section of APHA, transitioning from Section Counselor (2012-2015) and Program Chair (2015) to Treasurer (2016-).
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Appointed Deputy Editor of the Journal of Healthcare Risk Management for 2015
I am honored to have been appointed the Deputy Editor for the Journal of Healthcare Risk Management for 2015. I look forward to continuing to work with my friends and colleagues on the Editorial Board, including our Editor for 2015 Victor Klein, to build on the impressive progress we’ve made over the past few years.
If you have high-quality work that might be of interest to the healthcare risk management community, please consider submitting it to the JHRM.
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Served as Health Administration Section Program Chair for the 2014 American Public Health Association Annual Meeting
I recently returned from the 2014 APHA Annual Meeting in New Orleans, where I served as the Program Chair for the Health Administration Section.
We assembled a fantastic lineup of sessions this year. To better reflect the diversity of our membership, we added more content in the areas of healthcare administration and public health systems and services research (PHSSR), while continuing to feature strong presentations on traditional public health administration.
Many thanks to my Co-Chair, Akilah Cadet, for her tireless support. Akilah will serve as the Program Chair for the 2015 Annual Meeting in Chicago. Thanks, also, to all who contributed as authors, reviewers, and attendees.
See our 2014 program here: https://apha.confex.com/apha/142am/webprogram/HA.html
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Research on Risk Evaluation Featured in HCPro’s Briefings on The Joint Commission
I was recently interviewed by Matt Phillion of HCPro about my work on risk evaluation using risk matrices. This article appears in the publication Briefings on The Joint Commission [paywall].
It is based on research I published as part of the paper Trust-level risk evaluation and risk control guidance in the NHS East of England, in the journal Risk Analysis (arguably the top generalist risk management journal).
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Quoted in a Second Article About Ebola
I was quoted in an article by Kayla Ruble of VICE News about the Ebola situation in West Africa. The article can be found here:
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Interviewed About Lessons Learned from the Ebola Cases in Dallas and Spain
I was recently interviewed by Kayla Ruble of VICE News about lessons learned from the Ebola cases in Dallas and Spain. The take-home messages are: 1) Risk assess your emergency operations plan before you have to use it, and 2) Make sure you have plans in place for how to properly manage contaminated environments / materials.
The article can be found here:
https://news.vice.com/article/death-of-first-ebola-patient-in-the-us-offers-lessons-for-hospitals
Here is a journal article I wrote on risk assessing emergency operations plans:
http://tinyurl.com/activeshooterpha
The Structured What-If Technique (SWIFT) would probably be a good fit for this task. You can find out more about SWIFT –and access a free SWIFT template– on the Tools and Templates page.
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American Society for Healthcare Risk Management (ASHRM) Releases a Version of the Active Risk Control (ARC) Toolkit
The American Society for Healthcare Risk Management (www.ashrm.org), the foremost professional organization for healthcare risk managers in the US, has released a pdf version of the Active Risk Control (ARC) Toolkit. It is available to ASHRM members only, and can be found at the link below:
http://www.ashrm.org/ashrm/member/ARC_Toolkit/index.shtml
The ARC Toolkit is designed to provide the same kind of structured approach to risk control that RCA and FMEA provide for risk assessment. An Excel-based version of the Toolkit is available to anyone free of charge at https://activeriskcontrol.com/tools-and-templates/.
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Article on the Lovebug Diagram in NAHQ eNews
The National Association for Healthcare Quality (NAHQ) eNews this month features an article on the Lovebug Diagram. Click here to read Getting the Whole Picture with the Lovebug Diagram. The article is open access, so you do not need to be a NAHQ member to read it. If you’re interested in NAHQ, however, you can find out more at: www.nahq.org.
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Forthcoming Poster Presentation at the Human Factors and Ergonomics Society (HFES) 2014 Healthcare Symposium
Got plans for St. Patrick’s Day? Watch the river turn green in the morning, then start off the evening with me at the HFES Healthcare Symposium and HPPS4 – Poster Session 1 in beautiful Chicago, Illinois!
On March 17th between 4:30-6:00pm, I will be giving a poster presentation about my work on risk control entitled: Improving the Design of Risk Control Interventions With the Active Risk Control (ARC) Toolkit.
Click here for more information and to register, click here: http://www.hfes.org/Web/HFESMeetings/hpps.html
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Interview about the Lovebug Diagram in HCPro’s Briefings on The Joint Commission
I was recently interviewed by Matt Phillion of HCPro about the Lovebug Diagram, and the article is out.
I haven’t seen the finished article because I don’t have a subscription, but those of you who do have a subscription can find it here: http://www.hcpro.com/QPS-301281-16/The-Lovebug-diagram-expands-risk-assessment-options.html
For more on the Lovebug Diagram see the Tools and Templates page.