Geir Sverre Braut

Incident Command and Information Flows in a Large‐Scale Emergency Operation

In this article social and information network theory is used to study information flows through the incident command post in a large-scale emergency operation. The case presented is the 2011 terrorist attacks in Norway.The data were collected from evaluation reports, media and interviews with the incident, fire, medical and ambulance commanders.The article presents the incident command system in Norway and how this was used as a base for improvisation during the operation on initiative from rescue workers on scene. The main internal information flows in each separate rescue service were connected and coordinated at the incident command point through strong ties between the commanders. Important and novel information also reached the commanders through weak and informal ties to more peripheral actors.

A model for learning in emergency response work

Several studies have shown that emergency response personnel repeatedly perform inadequately in the critical phase of responses, thus bringing into question their ability to learn from failures occurring in these situations. This paper presents a model for describing, analysing and planning learning in emergency response settings. The model focuses on the individuals need to learn, and is based on a combined approach to learning (socio-cultural elements and individual cognitive aspects). It acknowledges the importance of decision-making during emergency responses, and hence the importance of learning to make adequate decisions and reflecting on these after responses. Finally, founded on a view that learning in emergency response work is essentially about improving performance or making sure that chosen behaviour during responses is adequate and appropriate, the model considers learning to be related to changes in structures, behaviours or working methods, confirmation of existing knowledge and/or comprehension of existing practice.

Meticillin-resistant Staphylococcus aureus infection – the infectious stigma of our time?

The article discusses ethical aspects related to isolation of patients with infectious diseases. The empirical basis is a textual analysis of two national guidelines on prevention of spreading of patients with meticillin-resistant Staphylococcus aureus. The analysis shows that even though both documents are founded upon updated scientific evidence on epidemiology and infectious diseases they lack explicit ethical argumentation on several aspects relevant for treatment and care under isolation or other constraints. Presuming that written guidelines make important frames for reflection and learning among practitioners, the authors suggest that such guidelines not just in Scandinavia but internationally should show how ethical considerations can be included into the individual risk assessments concerning patients under isolation.

A Risk Analysis of Cancer Care in Norway: The Top 16 Patient Safety Hazards

BACKGROUND Cancer care processes represents a number of potential threats to patient safety. A national risk analysis of Norwegian cancer care, entailing diagnosis, treatment, follow-up, palliative care, and terminal care, was conducted. METHODS Literature review and a retrospective analysis of hazards in different national databases were combined with interviews with key health personnel in an attempt to identify 50 possible hazards. A project team from the Norwegian Board of Health Supervision (NBHS) and 23 other persons participated in the workshop in 2009. RESULTS In a stepwise, consensus-driven process, the 23 participants discussed the 50 possible hazards and then selected the 16 that they considered most important-clustered into three groups: diagnosis and primary treatment, interactions, and complications. The NBHS distributed the risk analysis report to a variety of stakeholders and asked Norways hospital trusts to address the hazards. The report generally met a positive reception, albeit with local and interdisciplinary differences in the extent of the perceived applicability of the respective hazards. Two follow-up studies in 2012 and 2013 showed that the hospital trusts lacked the implementation capacity to identify operational solutions to reduce the hazards. At the largest hospital trust in Norway-Oslo University Hospital-the Department of Oncology retested the national risk analysis in in 2011. Four groups, representing different parts of the patient care process. selected 9 of the 16 national hazards and identified 4 new ones. The department has established goals and appropriate activities for 3 of the hazards. CONCLUSIONS The Ministry of Health and Care determined that hospital trusts must increase their implementation capacity regarding operational solutions to reduce the hazards.

A retrospective review of how nonconformities are expressed and finalized in external inspections of health-care facilities.

BackgroundExternal inspections are widely used in health care as a means of improving the quality of care. However, the way external inspections affect the involved organization is poorly understood. A better understanding of these processes is important to improve our understanding of the varying effects of external inspections in different organizations. In turn, this can contribute to the development of more effective ways of conducting inspections. The way the inspecting organization states their grounds for noncompliant behavior and subsequently follows up to enforce the necessary changes can have implications for the inspected organization’s change process. We explore how inspecting organizations express and state their grounds for noncompliant behavior and how they follow up to enforce improvements.MethodsWe conducted a retrospective review, in which we performed a content analysis of the documents from 36 external inspections in Norway. Our analysis was guided by Donabedian’s structure, process, and outcome model.ResultsDeficiencies in the management system in combination with clinical work processes was considered as nonconformity by the inspecting organizations. Two characteristic patterns were identified in the way observations led to a statement of nonconformity: one in which it was clearly demonstrated how deficiencies in the management system could affect clinical processes, and one in which this connection was not demonstrated. Two characteristic patterns were also identified in the way the inspecting organization followed up and finalized their inspection: one in which the inspection was finalized solely based on the documented changes in structural deficiencies addressed in the nonconformity statement, and one based on the documented changes in structural and process deficiencies addressed in the nonconformity statement.ConclusionExternal inspections are performed to improve the quality of care. To accomplish this aim, we suggest that nonconformities should be grounded by observations that clearly demonstrate how deficiencies in the management system might affect the clinical processes, and that the inspection should be finalized based on documented changes in both structural and process deficiencies addressed in the nonconformity statement.

Exploring How Lay Rescuers Overcome Barriers to Provide Cardiopulmonary Resuscitation: A Qualitative Study.

BACKGROUND Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably among regions. The chance of survival is increased significantly by lay rescuer cardiopulmonary resuscitation (CPR) before Emergency Medical Services (EMS) arrival. It is well known that for bystanders, reasons for not providing CPR when witnessing an OHCA incident may be fear and the feeling of being exposed to risk. The aim of this study was to gain a better understanding of why barriers to providing CPR are overcome. METHODS Using a semi-structured interview guide, 10 lay rescuers were interviewed after participating in eight OHCA incidents. Qualitative content analysis was used. The lay rescuers were questioned about their CPR-knowledge, expectations, and reactions to the EMS and from others involved in the OHCA incident. They also were questioned about attitudes towards providing CPR in an OHCA incident in different contexts. RESULTS The lay rescuers reported that they were prepared to provide CPR to anybody, anywhere. Comprehending the severity in the OHCA incident, both trained and untrained lay rescuers provided CPR. They considered CPR provision to be the expected behavior of any community citizen and the EMS to act professionally and urgently. However, when asked to imagine an OHCA in an unclear setting, they revealed hesitation about providing CPR because of risk to their own safety. CONCLUSION Mutual trust between community citizens and towards social institutions may be reasons for overcoming barriers in providing CPR by lay rescuers. A normative obligation to act, regardless of CPR training and, importantly, without facing any adverse legal reactions, also seems to be an important factor behind CPR provision. Mathiesen WT , Bjørshol CA , Høyland S , Braut GS , Søreide E . Exploring how lay rescuers overcome barriers to provide cardiopulmonary resuscitation: a qualitative study. Prehosp Disaster Med. 2017;32(1):27-32.

Uncertainty—Its Ontological Status and Relation to Safety

The concept of uncertainty is difficult to comprehend, even when we restrict our focus to safety science. In a world with various scientific philosophical stances, “uncertainty” is debated in various contexts. However, in an effort to go deeper into a more basic understanding of uncertainty our knowledge is quickly challenged. What exists? How do we know what exists? What can we know about it? Aiming these questions at uncertainty reveals that interpreting uncertainty as existing in any ontological sense is difficult to defend. Does this imply that uncertainty can only be understood in an epistemological sense or merely as a construct? Epistemological understandings of uncertainty encompass, in principle, the whole rationality spectrum from relativism to positivism, thus not excluding any form of analyses or understanding of uncertainty. However, we recognize the need for an increased understanding of which elements the uncertainty concept comprises, and possible consequences of an unreflective discarding of elements. Within the framework of a linear time concept consisting of the past, the present and not least the future, we claim that uncertainty’s ontological status exists on various levels. In the present uncertainty is a purely epistemological category, and in the past uncertainty has its meaning related to what has been observed, recognized and comprehended, thus a methodological challenge. In the futuristic perspective uncertainty exists and cannot be reduced.

Components of a Tool to Address Learning From Accident Investigation in the Offshore Industry

Learning is often presented as the major goal for an accident investigation process. But it often remains unclear how learning is directed or discussed in the text of investigations reports. If learning is emphasized in the report, how is the relationship between the learning processes proposed in the investigation and theories of effective learning amongst individuals, in organizations and across organizations and societal sectors? This paper presents the results of using a suggested tool to analyze the premises for learning from accident investigations. The paper compares accident investigation reports provided by different actors (operator and authority) in the Norwegian oil and gas industry covering same events.Copyright

Next-of-kin involvement in improving hospital cancer care quality and safety – a qualitative cross-case study as basis for theory development

BackgroundNext-of-kin are an extension of healthcare professionals in all stages of cancer care. They offer care activities such as interpretations of symptoms, and reporting of negative or adverse effects of treatment, without any professional knowledge or skills. Their participation is often expected from healthcare professionals, managers, or the patient. However, there is limited knowledge of next-of-kin’s role in and contribution to quality and safety improvement in hospital cancer care. The aim of this study was to explore how managers and healthcare professionals understand the role of next-of-kin in cancer care, and what methods they use for next-of-kin involvement.MethodsThe study design was a comparative multiple embedded case study of cancer departments in two Norwegian university hospitals. Data collection methods consist of qualitative interviews with managers (13) and healthcare professionals (19) collected in 2016, and document analysis of policy documents and regulation. The interviews were analyzed according to a directed content analysis approach guided by the theoretical framework ‘Organizing for Quality’.ResultsBoth hospitals have a strategy to involve next-of-kin in treatment and care but have no formal way of doing so. Managers and healthcare professionals in the two hospitals illuminated nine areas where next-of-kin are important stakeholders in improving quality and safety. These nine areas (e.g. nutrition, observations, transitions, pain treatment, information, palliative and terminal care) are common across the two hospitals. Key challenges in the next-of-kin involvement pertain to insufficient physical working conditions and room facilities, and lack of continuity of experienced nurses and consultants.ConclusionHospital employees and managers regard next-of-kin as a safety net or a buffer that cannot be replaced by other stakeholders. This study shows a close collaboration between patient, next-of-kin and healthcare professionals in cancer care, but more effort should be invested in more systematic approaches for next-of-kin involvement in quality and safety improvement such as a guide for managers and healthcare professionals on methods and areas of involvement.

An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care

We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities.