RESEARCH

1/ Build on the knowledge and experience gained in the D-Map program of research.

(1.1) The research vision of the PSCP is informed by a study of accountability failure in 18 cases of health-care catastrophes documented in the reports of 18 public inquiries in the U.K. and Canada . Published in 2018, the findings of this study showed that fixation on the marketplace model had led to many factors that created conditions in which many preventable deaths occurred. Suppression of speaking up was also a factor in many of the cases.

(1.2) As this work began to be cited by researchers in other provinces and countries, many additional cases have been identified, including reports of government and organizational responses to COVID. Committed to continuing their work, Dr. Church and the original team discussed priorities and approaches for continuing their research under the programmatic name, Decision-Making and Accountability Projects (D-Map).

2/ Advocate for and initiate new projects in under-researched areas of patient safety science.

(2.1) Human factors affecting judgement and contributing to errors at the levels of policy, governance and management decision making are known to be the root cause of most avoidable health-care harm because they create conditions where harm is inevitable. Most human factors research has focused on the clinical or “sharp-end” factors; plans for continuation of the D-Map research program will focus on the under-researched questions about how “blunt-end” policy, governance and management decisions are associated with avoidable health-care harm.

(2.2) Relationships among regulatory processes, just culture, and avoidable harm emerged as an issue in the original D-Map research, which revealed that regulatory bodies were not successful in identifying or limiting damage caused by reckless, malicious or criminal members. The role of workplace factors affecting professionals’ ability to meet standards include staff and equipment shortages, incivility, and other stressors that must be considered by regulatory bodies. Conditions that create moral distress and workplace injury for care providers also endanger patients. Plans for expansion of the D-Map research program include work in this priority area.

(2.3) Relationships between increased death and complication rates and short staffing have been studied extensively and are well documented in the nursing literature and, to a lesser extent, in other disciplines. These established research findings have generally been dismissed and ignored in health-system policy, governance and management decision-making over the last few decades. A PSCP priority will be dissemination of existing research findings and engagement of Alberta students and academics, as well as leaders and policy influencers in this area.

(2.4) Suppression, intimidation and retaliation against speaking-up is recognized as a factor in catastrophes in many sectors, including health care, and continues to be documented despite legislation to protect whistle blowers. Additional research and education in this area is a patient safety priority.

(2.5) Care Settings and Populations Under-represented in Patient Safety Science

• rural and remote health care

• home care, community

• health services for marginalized and underserved populations

• First Nations health programs.

• Services for immigrant populations

PSCP will identify important issues and encourage research development focused on these settings and populations.