BackgroundLittle is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala.MethodsWe used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation.ResultsWe found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions.ConclusionImplementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.

An innovative approach to underbalanced perforating in horizontal and highly deviated wells uses a new perforating head specifically developed to leverage the conveyance and real-time telemetry capabilities of coiled tubing (CT) equipped with fiber optics. The results and advantages of this approach have been demonstrated in wells in mature Mexican fields featuring significant reach and pressure limitations.In recent years, CT equipped with real-time fiber-optic telemetry has been a method of choice to perform interventions in deviated or horizontal wells, as it provides a cost-efficient and flexible alternative to heavier wired CT. In the Mexican fields, this real-time telemetry capability is used to accurately place the guns thanks to downhole casing collar locater and gamma ray tools. The need for pumping fluids to enable detonation, often performed during typical CT perforating operations, is eliminated through the use of a downhole microprocessor-controlled firing head, which is directed by commands sent from surface through the optical fiber.The result is a nearly instantaneous detonation downhole and positive confirmation provided in real time through an array of sensors in the bottomhole assembly (e.g., accelerometers, pressure, and temperature). The absence of working fluid eliminates any concern of hydraulically loading the well or the need for shut-in, thus significantly reducing the extent of deferred production. It also mitigates uncertainties linked to the influence of downhole conditions on the behavior of working fluids or the potential malfunctions of drop balls. This system is capable of multizone, selective detonation, therefore improving operational flexibility through reduced gun runs. It is also compatible with any other traditional CT service and can easily be combined with a bridge plug setting, a nitrogen lift, or a cleanout within the same run. The approach and its associated workflow enabled a significant reduction in intervention turnaround time by cutting as much as 75% of the time necessary to detonate the guns once the depth has been correlated, while providing fast and clear confirmation of downhole detonation.This evolved approach not only addresses the conveyance limitations of highly deviated and horizontal wells, it also greatly improves the safety, reliability, and efficiency of underbalanced perforating interventions by leveraging the real-time downhole monitoring and control capabilities of CT with fiber optic telemetry.