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Dr Andrew Carson-Stevens

Clinical Reader of Patient Safety and Quality Improvement

School of Medicine

Email
carson-stevensap@cardiff.ac.uk
Telephone
+44 (0)29 2068 7779
Campuses
Room 808E, 8th Floor, Neuadd Meirionnydd, Division of Population Medicine, Neuadd Meirionnydd, University Hospital of Wales, Heath Park, Cardiff, CF14 4YS
Users
Available for postgraduate supervision

Overview

I am an academic general practitioner and health services researcher leading research and pedagogical advances in how health and social care organisations learn from unsafe care experienced by patients and families.

My major contributions to patient safety research include developing methodological approaches for generating learning from patient safety incidents in primary care where there has been a major paucity (worldwide) in its research and development. My work has provided a foundation for other researchers to replicate and extend the research internationally. 

I have made significant contributions to the pedagogy / orthodoxy of patient safety and the improvement of professional practice, notably I co-created the evaluation methodology used by the Institute of Healthcare Improvement (Boston, USA) which has been applied in numerous evaluations (>120 citations) of patient safety initiatives globally. 

Outline of research programme

I founded and convene the Patient Safety Research Group (the 'PISA group') in the Division of Population Medicine, School of Medicine, Cardiff University, and our portfolio of research is supported by major funders (e.g. NIHR, Health Foundation, THIS Institute, Cancer Research UK, Health and Care Research Wales) and includes:

  • investigating the frequency and avoidability of significant harm in healthcare;
  • identifying patient safety priority areas from analysis of patient safety data and knowledge mobilisation with stakeholders including NHS organisations and policymakers;
  • methodological innovation for sharing learning from medical error within (national) and between countries (international) including the development of taxonomy;
  • developing machine learning (artificial intelligence) approaches for automating patient safety data analysis;
  • development and implementation of interventions to minimise harm to patients in health and social care settings; and,
  • mixed methods evaluation of quality improvement initiatives.

National academic leadership

Across Wales, I am the Primary Care Research Specialty Lead at Health and Care Research Wales and Patient Safety Research Leader at the Wales Centre for Primary and Emergency Care Research (PRIME Centre Wales; re-funded 2020-2025, £5.2 Million), supporting the development of funding bids between researchers across four universities: Cardiff University, Swansea University, Bangor University and the University of South Wales. I am a member of several Welsh Government and Improvement Cymru Boards and Comittees relating to patient safety and quality improvement in primary care.  

From 2016-2017, I was the Royal College of General Practitioner's Clinical Lead for Quality Improvement in Patient Safety and I continue to support RCGP's agenda to enable practitioners to improve patient safety in primary care as an invited speaker at regional faculty meetings and national events. I am Scientific Advisor to NHS Education for Scotland's programme on 'Patient Safety and Quality Improvement Research and Educational Development' (April 2018 –).  

I am a member of the National Cancer Research Institute's (NCRI) Working Group for 'Living With and Beyond Cancer'

International academic leadership

In the field of patient safety, I receive regular invitations to: deliver plenaries and keynotes; contribute to expert advisory groups which have substantial influence over the direction and importance of patient safety and healthcare improvement research globally (e.g. guideline groups and priority setting panels / roundtable / consultation events at the World Health Organization); review for international funding bodies (Health Research Boards in Ireland and New Zealand) and fellowship, project and programme grant applications for major UK funders (e.g. Medical Research Council and NIHR programmes); review for leading 3* and 4* journals (e.g. The Lancet, BMJ, BMC Medicine, BMJ Quality and Safety); and, examine and supervise external PhDs. 

I am a long-standing adviser to the World Health Organization on patient safety and Welsh Government's representative at the Organisation for Economic Co-operation and Development (OECD) Working Party for the Patient-Reported Indicator Surveys (PaRIS) research programme. I am also a member of the OECD Working Group for Patient-reported Safety Outcomes

I am Honorary Professor at the Australian Institute of Health Innovation, Macquarie University, Australia (2016 –), Adjunct Professor at Queen's University, Canada (2019 –), and previously the Visiting Professor in Health Care Improvement and Leadership in the Department of Family Practice, University of British Columbia (UBC), Canada (2015-2018) and concurrently a prestigious Peter Wall International Visiting Scholar at the Institute for Advanced Studies, UBC (2017-2018). 

Biography

Education and qualifications

  • 2019: Value Measurement for Health Care, Harvard Business School Executive Education, Boston USA
  • 2018: Member of the Royal College of General Practitioners
  • 2017: Doctor of Philosophy, Generating learning from patient safety incident reports from general practice, Cardiff University, UK
  • 2014: Improvement Advisor Professional Development Program, Institute for Healthcare Improvement, Cambridge, USA
  • 2011: Leading Innovation in Health Care & Education, Harvard Macy Institute, Harvard University, Boston, USA
  • 2010: Master of Philosophy (Medical Education), Cardiff University, Cardiff, UK
  • 2010: MB BCh, University of Wales College of Medicine, Cardiff, UK
  • 2007: BSc (1st Class Hons, Public Health), University of Wales, Cardiff, UK

Honours and awards

Awards

  • Yvonne Carter Award for Outstanding New Researcher, Royal College of General Practitioners / Society for Academic Primary Care, 2018
  • Awarded 'ISQua expert' status by the The International Society for Quality in Healthcare (ISQua), 2018
  • Public Involvement Achievement Award – Runner-up, Health and Care Research Wales, 2018
  • Honorary Membership of The Faculty of Public Health, 2017
  • Best Research Team Award (Primary and Emergency Care Research Centre), School of Medicine, Cardiff University, 2017
  • Royal College of General Practitioners 'Spotlight Award', 2016
  • International Visiting Peter Wall Scholar, Institute of Advanced Studies, University of British Columbia, 2016/17
  • Health Service Journal Rising Star Award, 2015
  • Churchill Fellow, Winston Churchill Memorial Trust, 2013–2015
  • Innovation and Engagement Award, School of Medicine Cardiff University, 2013
  • NHS Wales Award (co-recipient) for Promoting Clinical Research and Application to Practice, 2012
  • Permanente Journal Health Services Award, 2012
  • Gold Award Winner, Worshipful Livery Company of Wales, 2010

Peer esteem

International

  • Invited speaker and co-chair of working group for 'Measurement, reporting, learning and surveillance', Global Consultation – A Decade of Patient Safety 2020-2030: Formulating the Global Patient Safety Action Plan, World Health Organization, Geneva, Switzerland, February 2020
  • International project grant reviewer, Health Research Council, New Zealand, January 2020
  • Member of International Research Advisory Panel, Centre for Research Excellence for Indigenous Health Care Equity funded by the Australian Government's National Health and Medical Research Council (NHMRC) Centre for Research Excellence, January 2020
  • Member of international expert advisory group, WHO Patient Safety Meeting on Global Knowledge Sharing, Florence, Italy, December 2019
  • Grant reviewer, Health Research Board, Ireland, October 2019 –
  • Member (Welsh Government's representative) of International Working Party, OECD Patient Reported Indicator Surveys (PaRiS) programme. Organisation for Economic Co-operation and Development (OECD), Paris, France, May 2019 –
  • Member of International Working Group, OECD Patient-reported Experiences of Safety project. OECD, Paris, France, February 2019 – 
  • Keynote speaker, Queen's University Health Quality Research Forum, Kingston, ON, Canada, May 2019
  • Invited member of international implementation group, WHO Medication Safety Challenge, World Health Organization, Geneva, Switzerland, November 2018
  • Invited speaker, WHO Ministerial Summit on Patient Safety, Tokyo, Japan, April 2018
  • ISQua expert, The International Society for Quality in Healthcare, March 2018
  • Invited speaker, WHO Patient Safety Expert Meeting on Global Knowledge Sharing, Florence, Italy, November 2017
  • Member of international research advisory board, Harnessing systems science to build an effective and efficient health system programme grant, NHMRC, Australia, July 2017 –
  • Guest lecturer, Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA, January 2017
  • Member, World Health Organization Patient Safety Incident Reporting System Guideline Review Group, Geneva, Switzerland, November 2016
  • Invited member, WHO Global Consultation `Setting Priorities for Global Patient Safety', Florence, Italy, September 2016
  • External assessor, European Commission-appointed assessor, "Improvement Science Training for European Healthcare Workers (ISTEW)" programme (Funder: The European Lifelong Learning Erasmus programme for multilateral project), 2014-2015
  • UK and Ireland Faculty Lead, IHI Open School, Institute for Healthcare Improvement, Boston, USA, 2012-2016

National

  • Invited speaker, 30th Conference of the European Wound Management Association, London UK, May 2020
  • Invited plenary, 'Learning from patient safety incidents in primary care: the pros, the challenges and opportunities ahead', Inquests, Indemnity and Incidents in Primary Care, Royal Society of Medicine, London, UK, April 2020
  • Keynote speaker, 999 EMS Research Forum, Brighton, UK, March 2020
  • Invited speaker, Marie Curie Out of Hours Palliative and End of Life Care Workshop, London UK, January 2020
  • Invited expert advisor to NIHR panel, National Institute for Health Research Policy Programme, December 2019
  • Invited workshop and 'Dragon's Den Judge', 9th Annual Patient Safety Trainees and Students Day, Royal Society of Medicine, London, UK, November 2019
  • Grant reviewer for Medical Research Council, Clinical Research Fellowship, London, UK, November 2019
  • Appointed member of the Advanced Disease and End of Life Care Workstream, Living With and Beyond Cancer Group, National Cancer Research Institute (NCRI), London, UK, November 2019 –
  • Scientific advisory committee (evaluation), Advancing Quality Alliance (AQuA), Manchester, UK, September 2019
  • Programme grant reviewer, NIHR Programme Grants for Applied Research, UK, September 2019
  • Grant reviewer, NIHR Health Services and Delivery Research, February 2019
  • Peer reviewer, NHS Innovation Accelerator Fellowships, November 2018
  • Scientific advisor to NHS Education for Scotland, Patient Safety and Quality Improvement Research and Educational Development, Scotland, UK, April 2018 –  
  • Invited participant, International Symposium on Safety Investigation in Healthcare, organised by the Healthcare Safety Investigation Branch (England), March 2018
  • Invited member, Reducing Medicines Related Harm in NHS Wales Working Group, Welsh Government, Wales, UK, November 2017 –
  • Keynote speaker, National Association of Educators in Practice, UK, March 2015

Professional memberships

  • Member, Royal College of General Practitioners (2018–)
  • Fellow, Royal Society of Arts (2018–)
  • Member, Q initiative, Health Foundation (2017–)
  • Member, European Public Health Association (2017–)
  • Honorary Member, UK Faculty of Public Health (2017–)
  • Associate Member, Royal College of General Practitioners (2012–8)
  • Registered medical practitioner, General Medical Council (2010–)

Academic positions

  • 2019 – present: Adjunct Professor, Queen's University, Kingston, ON, Canada
  • 2016 – present: Honorary Professor, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
  • 2015 – 2018: Visiting Chair (Professor) of Healthcare Improvement and Leadership, Department of Family Practice, University of British Columbia
  • 2015 – present: Patient Safety Research Lead, Primary and Emergency Care Research Centre, Wales
  • 2012 – 2018: Wales Clinical Academic Training Lectureship (Clinical Lecturer), Cardiff University
  • 2010 – 2012: Clinical Fellow, Cochrane Institute of Public Health, Cardiff University

Speaking engagements

INVITED PRESENTATIONS 

a). International (since 2015) 

  • 02/2020 BIG DATA meets patient safety. PyCon. Windhoek, Namibia.  
  • 08/2019 Piecing together healthcare’s data jigsaw puzzle for data-driven healthcare improvement. Healthcare Quality Exchange [online]. Queen's University. Kingston, Ontario. 
  • 06/2019 Value-Based Health Care across the NHS in Wales. 2nd Meeting of the Working Party for the OECD Patient Reported Indicator Surveys. Paris, France.
  • 06/2019 Patient safety research in Wales – making the most of data we already have. School of Public Health, University of Zambia. Lusaka, Zambia. 
  • 05/2019 Maximising learning from unsafe care. Queen's University Health Quality Research Forum, Kingston, ON, Canada.
  • 05/2019 Investigating unsafe primary care. Department of Family Practice Grand Rounds, Queen's University, Kingston, ON, Canada. 
  • 05/2019 Navigating the Black Hole of Patient Safety Incident Reporting. Anaesthetic Grand Rounds, Kingston General Hospital, Kingston, ON, Canada. 
  • 04/2018 Sources of unsafe care for older adults: lessons from a National Reporting and Learning System. WHO Global Ministerial Summit on Patient Safety. Tokyo, Japan.
  • 11/2017 Methodological advances to analyse patient safety incident reports. WHO Patient Safety Expert Group. Florence, Italy.
  • 11/2017 Recommendations for learning from incident reports. 12th Forum Risk Management in Sanità. Florence, Italy.
  • 10/2017 Safety standards for digital health services – learning from a shared international perspective. ISQua Scientific Meeting on Quality and Safety in Healthcare. London, UK.
  • 06/2017 Masterclass – the basics of quality improvement in healthcare. Delivered as faculty for the Institute for Healthcare Improvement. University of British Columbia. Vancouver, Canada.
  • 01/2017 Generating hypotheses to improve healthcare from patient safety data. Epidemiologic methods to improve patient safety course, Harvard Chan School of Public Health. Boston, USA.
  • 07/2016 Ask One Question to Learn and Act on What Matters to Patients. Institute for Patient- and Family-Centred Care 7th International Conference. New York City, USA.
  • 04/2016 Mobilising rising leaders to improve care. International Forum on Quality and Safety in healthcare. Gothenburg, Sweden.
  • 10/2015 System diagnostics for enhanced quality improvement. Menzies School of Public Health. Workshop. Brisbane, Australia.
  • 10/2015 Improving primary care safety. Better Patient Safety Program. Victoria Risk Management and Insurance. Victoria, Australia.
  • 10/2015 Improving medication safety by utilising the insights of frontline practitioners. University of Sydney. Sydney, Australia.
  • 09/2015 Generating learning about patient safety in general practice – implications for policy and practice. Macquarie University. Sydney, Australia.
  • 09/2015 Patient safety in primary care. Australian Commission on Safety and Quality in Health Care. Sydney, Australia.
  • 08/2015 IHI Open School Student Organizing Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA.
  • 03/2015 Using incident report data to improve paediatric safety. Institute for Professionalism & Ethical Practice, Boston Children’s Hospital. Boston, USA.
  • 03/2015 Improving safety by maximising participation in quality improvement – summarising analysis of incidents using driver diagrams. Institute for Healthcare Improvement. Cambridge, USA.
  • 02/2015 Improving the quality of ‘x’. British Columbia Family Practice Scientific Meeting. University of British Columbia. Vancouver, Canada.

b). National (since 2017 – full list available on request)

  • 06/2019 Collaboration between academic leaders in primary and emergency care and research and development departments across Wales. R&D Directors Meeting. Welsh Government, Cardiff, UK.
  • 01/2019 Measuring significant avoidable harm in general practice. National Quality Safety Forum Meeting. Welsh Government, Cardiff, UK. 
  • 01/2019 Navigating the black hole of patient safety incident reporting. Department of Pharmacy, University of Nottingham. Nottingham, UK. 
  • 05/2018 Primary Care Safety Data – What is out there and how do we use it? 1000 Lives learning event. Cardiff, UK.
  • 03/2018 Service improvement in palliative care and supportive services. APM Supportive and Palliative Care conference. Bournemouth, UK.
  • 02/2018 Methods for improving patient safety in general practice. Royal College of General Practitioners (Regional Faculty event). Birmingham, UK.
  • 01/2018 Quality improvement in patient safety. Royal College of General Practitioners (Regional Faculty event). Glasgow, UK.
  • 10/2017 Learning from patient safety incidents in practice. Royal College of General Practitioners Annual Conference. Liverpool, UK.
  • 10/2017 Epidemiology of patient safety in primary care. 1000 Lives Primary Care Expert Reference Group. Wales, UK.
  • 10/2017 Wales leading patient safety research for the world. Primary and Emergency Care Research Annual Conference. Swansea, UK.
  • 06/2017 Realising a data-driven healthcare improvement agenda for NHS Wales. All Wales Therapeutic and Toxicology Centre Annual Conference. Cardiff, UK.
  • 05/2017 Entering the Premier League – Research in Acute Medicine. Society for Acute Medicine Spring Meeting. Cardiff, UK.
  • 04/2017 Realising quality improvement in primary care. One day workshop for the Improving Patient Safety in Primary Care programme organised by 1000 Lives. Cardiff, UK.
  • 03/2017 Improving patient safety in primary care. Designed and delivered a one day workshop for the Improving Patient Safety in Primary Care programme organised by the Royal College of General Practice. Liverpool and London, UK.

SCIENTIFIC MODERATION AT MEETINGS 

a). International 

  • 12/2016 Patient Safety Incident Report Expert Meeting. World Health Organization. Geneva, Switzerland.
  • 09/2016 World Health Organization Global Consultation for “Setting Priorities for Global Patient Safety”. Florence, Italy.

Committees and reviewing

National

  • Grant / final report reviewer for: National Institute for Health Research – HS&DR (2015-); Policy Research Programme (2019–), Health Foundation (2017–), NIHR Programme grants for Applied Research (2018-); NHS Innovation Accelerator Awards (2018–); Medical Research Council (2019-)
  • Invited expert, Funding Committee of the National Institute for Health Research Policy Research Programme (2019)
  • Member, Salford Integrated Care Organisation Evaluation Panel, Advancing Quality Alliance (AQuA) (2019-)
  • Scientific advisor, Patient Safety and Quality Improvement Research and Educational Development, NHS Education for Scotland (2018-)
  • Member, College of Assessors for Innovating for Improvement and Scaling Up Improvement grants, Health Foundation (2017-)
  • Member, Primary Care Safety Expert Group, 1000 Lives Improvement Service, Public Health Wales (2017-)
  • Member, Reducing Medicines Related Harm in NHS Wales Working Group, Welsh Government (2017-)
  • Executive Management Committee, PRIME Centre Wales (2015-)

International

  • Peer reviewer for 3* and 4* journals e.g. The Lancet, BMC Medicine, BMJ Quality and Safety. 
  • Grant reviewer, Health Research Board, New Zealand (2020)
  • Grant reviewer, Health Research Board, Ireland (2019) 
  • Member, Working Party for the OECD Patient Reported Indicator Surveys (PaRIS) programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-)
  • Member, Working Group for the OECD Patient Reported Safety Outcomes programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-)
  • Expert advisory group, WHO Global Knowledge Sharing Platform for Patient Safety (1st meeting 2017, 2nd meeting 2019) 
  • International scientific advisory board, "Care Track Aged: appropriate care delivered to Australians living in residential aged care." Project No. 1143223 awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2018-)
  • International scientific advisory board, “Harnessing systems science to build an effective and efficient health system” programme grant ($10.75 million) awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2017-)
  • Editorial advisory board, BMJ Open Quality (2017-)
  • Institute for Healthcare Improvement Scientific Symposium Advisory Board Member (2013)
  • Coordinating member, World Health Organization Safer Primary Care Expert Group, (2012-)

Publications

2020

2019

2018

2017

2016

2015

2014

2013

2011

2010

Teaching

Overview of educational scholarship

I have made significant contributions to the pedagogy of patient safety and the improvement of professional practice. I have taught quality improvement in Europe, Canada, USA and Australia, and frequently serve as Faculty for the Institute for Healthcare Improvement.

Internationally, I have shared the innovative mixed method approaches developed by my research group to investigate and understand the epidemiology of patient safety incidents with other researchers. I have trained over 60 health services researchers to investigate patient safety incidents and this has led to numerous international invitations for conducting research and co-authoring publications.

I was guest lecturer at the Harvard Chan School of Public Health in 2017 and co-taught a one-week course on epidemiological methods for understanding patient safety. I also endeavour to support frontline healthcare staff, managers and leaders to learn from unsafe healthcare; for example, I was the Clinical Lead for Quality Improvement in Patient Safety at the Royal College of General Practitioners (2016-17) and co-authored the 'RCGP Guide for Reporting and Learning from Patient Safety Incidents in General Practice' and developed two online modules hosted by RCGP Learning. I have also contributed internationally to Boston Children's Hospital / Harvard Medical School's OPEN Pediatrics programme, aimed predominantly at learners from low- and middle-income settings, on disclosure and apology to patients and families following unsafe healthcare

From 2012-16, I was the Institute for Healthcare Improvement UK and Ireland Faculty Lead for the online and community-based educational programme, the IHI Open School (2012-16) – now the largest provider of quality improvement and patient safety education worldwide.

In 2008, I was an intern to Professor Donald Berwick at the Institute for Healthcare Improvement in Cambridge, USA. I was a co-founding leader of the IHI Open School. Utilising social organising methods and the IHI Open School's growing network of quality improvement enthusiasts, I was co-founder of a global patient safety campaign for junior healthcare professionals called "Check a Box. Save a Life." supporting the spread and dissemination of the WHO Surgical Safety Checklist. In later years, as a faculty member, I developed methods for students to learn about the experience of patients and families in healthcare to inform quality improvement through Ask One Question – encouraging students to adopt simple strategies like asking every patient they meet, "What can I do to improve your care today?". These educational innovations have since been implemented into multiple medical curricula, for example, at Cardiff University and the University of British Columbia (Canada). 

Educational leadership at Cardiff University

Module leadership and contributions

Year from/ to

School

Module/ course title

Level of study

Role

2019/2020

Medicine

Quality and Safety (20 credits), Critical Care MSc and Clinical Leadership and Change Management in Cardiology MSc

MSc

Module leader

2019/2020

Business

Strategic Planning and Innovation

PG Diploma in Healthcare Planning

Faculty

2019/2020

Medicine

Year 5 Medicine: Changing Practice, MB BCh

Year 5 Medical Students (n=300+)

Module leader since August 2014

2018/2019

Medicine

Improving the quality of clinical care

Population Medicine Intercalated BSc (n=10+)

Module leader since August 2017

2018/2019

Medicine

Year 2 SSC Research Taster Week

Year 2 Medical Students (n=20)

SSC Tutor

2018/2019

Medicine

Tutorial facilitation for Clinical Epidemiology programme delivered by Division of Population Medicine

Year 3 Medical Students (n=60)

Tutor

2018/2019

Medicine

Practical Research Experience Student Selected Component

Year 1 Medical Students (n=10)

Tutor

Academic leadership, management and teaching/research-related administration roles

  • Medical students interviewer, December 2019 –
  • Wellcome INSPIRE taster day, December 2019 – 
  • PhD Exam Board Chair, September 2019
  • Member of the winning multi-school team led by Cardiff Business School (Prof Aoife McDermott et al.) that attended shortlisting interviews to secure c.£800,000 funding to deliver the Cardiff University Diploma in Healthcare Planning.
  • Member of Cardiff University Phoenix project, November 2018 –
  • Division of Population Medicine Academic Meeting Schedule Co-ordinator, November 2018 –
  • C21 Lead and Member, Education Management Group, Division of Population Medicine, School of Medicine, October 2018 –
  • Quality and safety theme leader, Division of Population Medicine, School of Medicine, August 2018 –
  • Member of Senior Leadership Team, Division of Population Medicine, School of Medicine, August 2018 –
  • Member of Research Management Group, Division of Population Medicine, August 2018 –
  • Primary and Emergency Care Centre: work package lead for patient safety, May 2015 –
  • Exam board for Intercalated BSc Clinical Epidemiology, June 2017 –
  • Academic mentor / personal tutor, November 2015 –

External teaching contributions

  • Invited plenary, 'Learning from patient safety incidents in primary care: the pros, the challenges and opportunities ahead', Inquests, Indemnity and Incidents in Primary Care, Royal Society of Medicine, London, UK, April 2020
  • Invited workshop, 'Generating actionable learning from healthcare-associated harm', 9th Annual Patient Safety Trainees and Students Day, Royal Society of Medicine, London, UK, November 2019
  • Expert advisor, Cancer Research UK's project to develop a series of educational screencasts on 'Quality Improvement to Aid Early Diagnosis of Cancers in General Practice', Royal College of General Practitioners, London, UK, March – October 2019
  • Expert advisor, as above for CRUK, for RCGP 'Improvement of End of Life Care' screencasts, Royal college of General Practitioners, July 2019 – 
  • Developed two online e-learning modules on 'Improving patient safety in general practice', RCGP eLearning modules, Royal College of General Practitioners, London, UK, April 2018
  • Delivered national workshops on 'Learning from patient safety incidents in general practice', Royal College of General Practitioners (Cardiff, Liverpool, London), Spring 2017
  • Invited speaker at RCGP Faculty events (RCGP Midlands, RCGP West of Scotland, Winter 2017 / Spring 2018) and RCGP Annual Conference (Liverpool), October 2017 
  • Faculty, 'Building Essential QI Skills', co-taught (with Dr Kedar Mate) one-day course for Institute for Healthcare Improvement at the University of British Columbia, Vancouver, Canada, June 2017
  • Invited faculty, 'Epidemiologic methods for patient safety', co-taught (with Prof Malcolm Maclure) one-week course at the Harvard Chan School of Public Health, Boston, USA, January 2017
  • Online lecturer, 'Disclosure and apology to patients and families following unsafe healthcare', Boston Children's Hospital / Harvard Medical School's OPEN Pediatrics programme, Boston, USA, December 2015 (delivered for CPD on a recurring annual basis)
  • Faculty, IHI Open School Student Organizing Leadership Academy, Institute for Healthcare Improvement, Cambridge, USA; and, delivered workshop on 'Utilising social media for social mobilizing to improve patient and population health', August 2015
  • Online lecture, 'What is quality Improvement?' for the Master of Public Health Programme at King's College London, 2015
  • Co-organiser, Quality Improvement Masterclass for Healthcare and Policy Leaders, Faculty of Medical Leadership and Management, March 2013

Quality assurance / examiner roles

  • PhD Examiner, University of Glasgow and University College London
  • PhD Examination Chair, Cardiff University
  • External Examiner, Quality Improvement in MB BS curriculum, King's College London
  • External Evaluator for the European Commission to the 'Improvement Science Training for European Healthcare Workers' Study, a multi-country educational research and development project

Educational moderation at meetings (international)

  • IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. Gothenburg, Sweden. April, 2016
  • IHI Open School National (United States) Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2015
  • IHI Open School Student Organising for Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA. August, 2015
  • IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. London, UK. April, 2015
  • IHI Open School Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2014
  • IHI Open School Student Quality Leadership Academy. Institute for Healthcare Improvement. Cambridge, USA. August, 2014
  • IHI Open School International Meeting. BMJ / Institute for Healthcare Improvement International Conference on Quality in Healthcare. Paris, France. April, 2014
  • IHI Open School Congress. Institute for Healthcare Improvement Annual Conference. Florida, USA. December, 2013

Textbook

Overview of Research

Broadly, my research and development activities aim to determine the frequency, burden and preventability of healthcare associated harm in primary and emergency care settings, and to develop and implement interventions to improve patient safety in priority areas

I regularly share learning from my research and development with national (Welsh Government, UK Department of Health) and international policy makers (World Health Organization member state representatives), professional organisations (Royal College of General Practitioners; Care Quality Commission; Health Inspectorate Wales) and other researchers / practitioners / educators through diverse influential national and international professional fora. 

Learning from unsafe health and social care experienced by patients and families

I have developed a mixed-methods approach, which subsequently informed a natural language processing-based (machine learning) method, for:

(i) investigating the frequency and avoidability of significant harm in healthcare; and,
(ii) identifying patient safety priority areas from analysis of patient safety data for knowledge mobilisation with multiple stakeholders including NHS organisations and policymakers. 

My methodological advances for generating learning from patient safety incidents were developed during my leadership of a national agenda setting study of patient safety incidents in General Practice (funded by NIHR Health Services and Delivery Research programme and colloquially known as the 'PISA study').

The PISA study was (and remains) the largest characterisation of patient safety incidents in general practice worldwide.

The PISA study's methodological outputs have provided a foundation for other researchers to replicate and extend the research, and advance the primary care patient safety agenda, internationally. Within the UK, for example, a study to identify 'significant avoidable harm' in General Practices in England (funded by the NIHR Policy Research Programme) used my methods to investigate and learn from cases of avoidable harm identified in clinical practice. Next, the approach will now be applied in a new NIHR-funded study to investigate avoidable harm in prison healthcare services across England from June 2019.   

The NIHR HS&DR-funded PISA study (2013-15) to characterise patient safety incidents occurring in in general practice identified a range of vulnerable patient groups and systemic weakness which warranted more in-depth investigation.

Subsequently, I have led over twenty major studies of identified priority areas for patient safety across the health and social care continuum, including: unsafe discharge from secondary to primary care settings and errors experienced by children in primary care, older adults, patients receiving palliative care, advanced care planning, patients with dementia, adults receiving mental health services in primary care, and adults receiving opiate replacement

Major studies completed, include:

  • Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice – published in the NIHR HS&DR journal https://doi.org/10.3310/hsdr04270
  • Patient safety incidents involving sick children in primary care in England and Wales: A mixed methods analysis – published in PLOS Medicine https://doi.org/10.1371/journal.pmed.1002217
  • Automated classification of primary care patient safety incident report content and severity using supervised machine learning (ML) approaches – published in Health Informatics https://doi.org/10.1177/1460458219833102
  • Safety incidents involving children in general practice – published in Pediatrics https://doi.org/10.1542/peds.2014-3259
  • Harms from discharge to primary care: Mixed methods analysis of incident reports – published in British Journal of General Practice https://doi.org/10.3399/bjgp15X687877
  • Development of an international classification system for patient safety in primary care – published in the Bulletin of the World Health Organization http://dx.doi.org/10.2471/BLT.17.199802 
  • Nature of blame in patient safety incident reports: Mixed methods analysis of a national database – published in Annals of Family Medicine http://dx.doi.org/10.1370/afm.2123 
  • Paediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database– published in Vaccine https://doi.org/10.1016/j.vaccine.2015.06.068
  • Sources of unsafe primary care for older adults: A mixed-methods analysis of patient safety incident reports – published in Age and Ageing https://dx.doi.org/10.1093%2Fageing%2Fafx044
  • Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database – published in Palliative Medicine https://doi.org/10.1177%2F0269216318817692 
  • Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents – published in Palliative Medicine https://doi.org/10.1177/0269216318776846 
  • Patient safety incidents in primary care dentistry in England and Wales: A mixed-methods study – published in the Journal of Patient Safety http://dx.doi.org/10.1097/PTS.0000000000000530
  • Patient safety incidents in advance care plans for serious illness: a mixed methods analysis – published in BMJ Supportive and Palliative Care http://dx.doi.org/10.1136/bmjspcare-2019-001824
  • Diagnostic error in the emergency department: learning from national patient safety incident report analysis – published in BMC Emergency Medicine https://doi.org/10.1186/s12873-019-0289-3.
  • Mitigating healthcare harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports – to be published in Archives of Disease in Childhood. In press. 

Multiple additional studies are currently under peer review at 3* and 4* academic journals. 


Learning how to improve patient safety in different health and social care contexts (including care homes)

I have led impactful research which seeks to improve the safety of care experienced across the health and social care continuum through the:

(iii) development and implementation of interventions to minimise harm to patients in health and social care settings; and,
(iv) mixed methods evaluation of quality improvement initiatives implementing evidence-based interventions.

Findings from previous analyses of patient safety incidents in primary care have been used to empirically inform the design of quality improvement initiatives and projects to improve patient safety in healthcare organisations. Lessons learnt from our primary care studies are being used by the 1000 Lives Improvement service in Wales to design their national-level improvement strategy for primary care patient safety. At a local level, one health board in Wales, used our analysis of reports about anticoagulation-related errors to highlight risks to patients being initiated on Warfarin in hospital. The subsequent quality improvement project led to a national Directed Enhanced Service for anticoagulation services to be delivered to patients in community settings instead (for more detail, watch a short video on YouTube).

We conceptualise, investigate and support teams to improve patient safety for vulnerable patient groups across the care continuum. For example, with support from a Royal College of General Practitioners and Marie Curie funded fellowship, we have developed a 'researcher-in-residence' model of working at a large health board in Wales to evaluate a quality improvement project aiming to improve end-of-life care in the GP out of hours care setting. In collaboration with PRIME Centre Wales colleagues, the PISA group is also contributing to the design of an intervention to support primary health care teams, with the intention of reducing the time to diagnosis and improving cancer outcomes via the Cancer Research UK funded WICKED trial (CI: Neal, University of Leeds).

We evaluate the development, testing and implementation of patient safety interventions to understand how and in what contexts they can improve outcomes. The PISA Group use a theory-driven process evaluation approach developed with colleagues at Harvard Medical School and the Institute for Healthcare Improvement (see Parry, Carson-Stevens et al. 2013 for more detail). For example, supported by Health Foundation, we are evaluating an intervention, called the Polypharmacy Adverse Drug Reaction (PADRe tool), to detect adverse drug reactions experienced by residents in care homes.


Building capacity and capability to enable a transition from 'learning to action'

I work closely with NHS organisations to implement methodological innovations and explore how to maximise the reach and impact of the benefits to patients and their families (including informal care givers), for example, through:  

(v) developing machine learning (artificial intelligence) approaches for automating patient safety data analysis;
(vi) methodological innovation for sharing learning from medical error within (national) and between countries (international) including the development of taxonomy;

Previous attempts to identify and learn from the most important sources of harm to patients have been restricted by the lack of a universal standard system for classifying harm severity and the general neglect of psychological harm in this context. My research group has empirically developed a series of classification systems, for example the Primary Care Harm Severity Classification System published in the Bulletin of the World Health Organization, to be applied internationally, across primary-care settings, to improve the detection and prevention of incidents that cause the most severe harm to patients

Harrowing, unsafe care experiences of patients and their families are depicted in patient safety incident reports. Such reports represent a unique perspective for learning. However, the volume of data in many patient safety incident reporting systems is so great that much have never been analysed or used to support improvement in patient safety.

We have developed machine learning approaches (i.e. text classification methods) to overcome this challenge which will automate the capture of essential information to understand patient safety incidents including extracting details about what happened (incident type), why it happened (contributory factors) and the severity of the outcome (harm severity).

Organisations have also been hindered by lack of investment for building capacity and capability of staff to analyse such data. Supported by a Health Foundation Advancing Analytics Award, we are currently exploring methods for 'harnessing data analytics to maximise NHS learning from patient safety incident reports' and working to realise the synergy between data analysts, managers and clinicians for identifying and acting on learning from patient safety data

Lessons learnt from my research projects has been disseminated with support from the Royal College of General Practitioners to train the workforce to recognise, report and learn from patient safety incidents through e-learning courses, national seminars, and a practical ‘how to’ guide

The PISA Group endeavours to build the capacity and capability of health service researchers to investigate patient safety (postgraduate students, clinical academics, post-doctoral fellows) through visiting appointments with the PISA group. 

Grant awards

Since 2012, I have secured or supported capture of research and programme awards in excess of £15.2 million from major health services research funders and charities, including:

  • Cancer Research UK
  • Health and Care Research Wales
  • Health Foundation (Advancing Analytics Award, Innovating for Improvement)
  • NIHR Health Services and Delivery Research
  • Royal College of General Practitioners
  • Royal College of Physicians (Wolfson Award)
  • NIHR Health Policy Research Programme
  • THIS Institute (post-doctoral award)


Academic collaborators

International 
Harvard Medical School, Boston, USA
Institute for Healthcare Improvement, Boston, USA
Macquarie University, Sydney, Australia
University of British Columbia, Vancouver, Canada
Queen's University, Kingston, Canada

National 
Marie Curie Research Centre, Cardiff University and University College London
NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre
The University of Edinburgh
The University of Manchester
The University of Nottingham
The London School of Hygiene and Tropical Medicine

Supervision

Outcomes from my academic supervisions

I have supervised with excellent outcomes over 60 healthcare professionals to complete higher degrees and research fellowships (including 16 intercalated students, 10 clinical academic GPs and four post-doctoral researchers) and I am currently a senior academic mentor to three post-docs

My supervision of early career academics has culminated, to date, in 40 peer-reviewed publications, 30 conference papers (14 international and 16 national), and 8 conference posters (5 international, 3 national). All my students have completed their intended programme of study or are on course for completion. Six of my former research students or mentees have secured competitive clinical academic training posts or research fellowships. One has given a keynote address at the King’s Fund and another a plenary at an international conference. 

With post-doctoral colleagues, I have recently supported securing: a post-doctoral fellowship from the THIS Institute (Health Foundation, co-main supervisor), an NHS Researcher Time Award (Health and Care Research Wales, main supervisor), and supported an early career academic to secure KESS-2 PhD funding to recruit a student to explore patient safety in eye health.  

Current PhD / supervision of researchers / postgraduate research students:

Current supervision

1st supervisor

2nd supervisor

3rd supervisor

Cardiff Medical School

Dr Jaafer Qasem (year 2)

Dr Alison Cooper (part-time, writing up thesis in year 3 of 6)

Intra-university

Elinor MacFarlane, School of Optometry / School of Medicine (year 1)

 

External

Queen’s University Canada: Dr Anthony Train (year 1)

University of Nottingham: Khalid Muhammad (final year)

University of Nottingham: Mohammed Alsubaie (final year)

Member of PhD project team as subject matter expert

Fatema Alqenae (Year 2), Ghadah Alshehri (Year 2) and Anwar Alghamdi (Year 1) at The University of Manchester

Senior academic mentor for post-doctoral researchers

Dr Sarah Yardley, Post-doctoral Research Fellowship, THIS Institute (Health Foundation), University of Cambridge;

Dr Lynette James, NHS Researcher Time Award, Health and Care Research Wales.


Completed Doctor of Physiotherapy (DPT), Master of Public Health (MPH), MPhil, PhD supervisions:

Degree

Role (e.g. Supervisor/ Co-supervisor)

Status (e.g. awarded, submitted, in-progress)

Flore Laforest, MPH, and Jawaher Alkhaldi, MPH,Cardiff University

Supervisor

Awarded, 2019

Doctoral students at Macquarie University, Sydney: Melissa Riddoch DPT, Avanthi Rajaratnam DPT,  Natalie Fowler DPT, Kelsy Weavil DPT, Michelle Khan DPT, Maxine Delaney DPT.

Co-supervisor

Awarded, 2019

Haroon Chughtai, MSc Clinical Bioinformatics, University of Liverpool

Co-supervisor

Awarded, 2019

Doctoral students at Macquarie University, Sydney: Harriet Amey DPT, Luke Davies DPT, Sarah Trifogli DPT, Kathryn Walker DPT

Co-supervisor

Awarded, 2018

Eduardo Ensaldo-Carrasco, PhD, University of Edinburgh

Current job: Head of Research, National Commission for Medical Arbitration

Co-supervisor

Awarded, 2018

Huw Evans, MSc Health Informatics, Swansea University

Co-supervisor

Awarded, 2016

Philippa Claire Rees, MPhil, Cardiff University (intercalating medical student)

Current job: Academic Clinical Fellow of Paediatrics, University College London & Honorary Lecturer, School of Medicine, Cardiff University

Supervisor

Awarded, 2015

Past projects

Engagement

Phoenix Project, Cardiff University 

I am a member of the Phoenix Project which is a partnership between Cardiff University and the University of Namibia. The Phoenix Project has over 50 sub-projects aligned to delivering the United Nations Sustainable Development Goals and is seeking to reduce poverty, promote health and support sustainable environmental development.

Since October 2018, from participating in the Phoenix Project, I have enjoyed numerous rewarding experiences from collaborating with research, teaching and professional services staff from multiple schools across Cardiff University. I have been able to draw upon my discipline expertise (patient safety, healthcare improvement, global health) and methodological expertise (mixed methods research, evaluation of complex interventions) and have applied myself to a diverse range of roles, for example: 

  • Visiting Namibia and Zambia to explore areas of mutual interest and opportunity for collaboration; 
  • Delivering workshops to visiting Commonwealth Fellows on the methods for investigating healthcare-associated harm (unsafe care) and evaluating complex interventions;
  • Co-developing a conceptual framework for the evaluation of the Phoenix Project working with the project's senior leadership team; 
  • Supporting the writing of academic publications (with collaborators in Zambia); and,
  • Development of programme grant applications.


Examples of other engagement activities

Activity

Partner

Effect

A study to improve the quality of out of hours palliative care services for end of life patients (Marie Curie / RCGP Research Fellowship, 2016–2018)

Aneurin Bevan University Health Board (ABUHB)

  • Nine-fold increase of anticipatory prescribing documentation, a 42% rise in documentation of resuscitation preferences and improved  sharing of information with out of hours services;
  • Two peer-reviewed publications (Palliative Medicine, BMJ Supportive & Palliative Care) and three oral presentations at international conferences (one prize winning) outlining the patient safety priorities for improving out of hours general practice for end of life patients;
  • 'how to' guide, with exemplars from the quality improvement project undertaken at ABUHB, to be published by Royal College of General Practitioners; and,
  • A new funded research collaboration to study human-dependent factors for safe / unsafe care in Palliative and Mental Health Carebetween Marie Curie Palliative Care Research Department, UCL and the Marie Curie Research Centre, Cardiff University (successful bid for post-doctoral fellowship, THIS Institute, University of Cambridge).

Harnessing data analytics to maximise NHS learning from patient safety incident reports; funded by Health Foundation (Advancing Analytics Award, September 2019-2020)

Cardiff and Vale University Health Board

  • Improving how a large NHS organisation organises, supports access and learns from patient safety data;
  • Junior doctors are carrying out quality improvements projects to mitigate risks to patients identified during the project;
  • Generated a funding application for further work;
  • Multiple CPD e-learning modules for staff;
  • Early findings showcased via plenary at Health Education and Improvement Wales conference (12/2019).

KESS-2 funded PhD to explore patient safety in eye health

Optometry Wales

  • Project has initiated a pipeline of safety-related projects between MEDIC and OPTOM schools, and preliminary work and grant funding bids in development;
  • Informed the content and format of a 'Serious Incident Reporting Form' for optometry in Wales (01/2020); 
  • Workshops on reporting and learning from patient safety incidents with optometry professionals (02/2020); and,
  • Excellent stakeholder access and clear channel for knowledge dissemination via Optometry (umbrella organisation for primary eye health profession in Wales).

Sustained research-based contributions to knowledge translation within the general practice profession (external to HEI sector)

Royal College of General Practitioners

External profiles