scholarly journals Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

2017 ◽  
Vol 46 (5) ◽  
pp. 833-839 ◽  
Author(s):  
Alison Cooper ◽  
Adrian Edwards ◽  
Huw Williams ◽  
Huw P. Evans ◽  
Anthony Avery ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports

scholarly journals Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

2017 ◽  
Vol 15 (5) ◽  
pp. 455-461 ◽  
Author(s):  
Jennifer Cooper ◽  
Adrian Edwards ◽  
Huw Williams ◽  
Aziz Sheikh ◽  
Gareth Parry ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
National Database ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports

scholarly journals 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

2016 ◽  
Vol 4 (27) ◽  
pp. 1-76 ◽  
Author(s):  
Andrew Carson-Stevens ◽  
Peter Hibbert ◽  
Huw Williams ◽  
Huw Prosser Evans ◽  
Alison Cooper ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
General Practice ◽  
Patient Safety ◽  
Learning System ◽  
England And Wales ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Patient Safety Incidents

BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

scholarly journals Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement

2021 ◽  
pp. 014107682110325
Author(s):  
Alexandra Urquhart ◽  
Sarah Yardley ◽  
Elin Thomas ◽  
Liam Donaldson ◽  
Andrew Carson-Stevens
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Mixed Methods ◽  
Diagnostic Errors ◽  
Learning System ◽  
England And Wales ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
National Analysis

Objective Six per cent of hospital patients experience a patient safety incident, of which 12% result in severe/fatal outcomes. Acutely sick patients are at heightened risk. Our aim was to identify the most frequently reported incidents in acute medical units and their characteristics. Design Retrospective mixed methods methodology: (1) an a priori coding process, applying a multi-axial coding framework to incident reports; and, (2) a thematic interpretative analysis of reports. Setting Patient safety incident reports (10 years, 2005–2015) collected from the National Reporting and Learning System, which receives reports from hospitals and other care settings across England and Wales. Participants Reports describing severe harm/death in acute medical unit were identified. Main outcome measures Incident type, contributory factors, outcomes and level of harm were identified in the included reports. During thematic analysis, themes and metathemes were synthesised to inform priorities for quality improvement. Results A total of 377 reports of severe harm or death were confirmed. The most common incident types were diagnostic errors ( n = 79), medication-related errors ( n = 61), and failures monitoring patients ( n = 57). Incidents commonly stemmed from lack of active decision-making during patient admissions and communication failures between teams. Patients were at heightened risk of unsafe care during handovers and transfers of care. Metathemes included the necessity of patient self-advocacy and a lack of care coordination. Conclusion This 10-year national analysis of incident reports provides recommendations to improve patient safety including: introduction of electronic prescribing and monitoring systems; forcing checklists to reduce diagnostic errors; and increased senior presence overnight and at weekends.

scholarly journals Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports

2020 ◽  
Vol 105 (8) ◽  
pp. 731-737
Author(s):  
Adhnan Omar ◽  
Philippa Rees ◽  
Alison Cooper ◽  
Huw Evans ◽  
Huw Williams ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
Social Care ◽  
National Database ◽  
Free Text ◽  
Vulnerable Children ◽  
Health And Social Care ◽  
Safety Incident ◽  
Incident Reports

PurposePatient safety failures are recognised as a global threat to public health, yet remain a leading cause of death internationally. Vulnerable children are inversely more in need of high-quality primary health and social-care but little is known about the quality of care received. Using national patient safety data, this study aimed to characterise primary care-related safety incidents among vulnerable children.MethodsThis was a cross-sectional mixed methods study of a national database of patient safety incident reports occurring in primary care settings. Free-text incident reports were coded to describe incident types, contributory factors, harm severity and incident outcomes. Subsequent thematic analyses of a purposive sample of reports was undertaken to understand factors underpinning problem areas.ResultsOf 1183 reports identified, 572 (48%) described harm to vulnerable children. Sociodemographic analysis showed that included children had child protection-related (517, 44%); social (353, 30%); psychological (189, 16%) or physical (124, 11%) vulnerabilities. Priority safety issues included: poor recognition of needs and subsequent provision of adequate care; insufficient provider access to accurate information about vulnerable children, and delayed referrals between providers.ConclusionThis is the first national study using incident report data to explore unsafe care amongst vulnerable children. Several system failures affecting vulnerable children are highlighted, many of which pose internationally recognised challenges to providers aiming to deliver safe care to this at-risk cohort. We encourage healthcare organisations globally to build on our findings and explore the safety and reliability of their healthcare systems, in order to sustainably mitigate harm to vulnerable children.

scholarly journals Automated classification of primary care patient safety incident report content and severity using supervised machine learning (ML) approaches

2019 ◽  
Vol 26 (4) ◽  
pp. 3123-3139 ◽  
Author(s):  
Huw Prosser Evans ◽  
Athanasios Anastasiou ◽  
Adrian Edwards ◽  
Peter Hibbert ◽  
Meredith Makeham ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Primary Care Patient ◽  
Care Patient ◽  
Free Text ◽  
Incident Report ◽  
Incident Type ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports

Learning from patient safety incident reports is a vital part of improving healthcare. However, the volume of reports and their largely free-text nature poses a major analytic challenge. The objective of this study was to test the capability of autonomous classifying of free text within patient safety incident reports to determine incident type and the severity of harm outcome. Primary care patient safety incident reports (n=31333) previously expert-categorised by clinicians (training data) were processed using J48, SVM and Naïve Bayes. The SVM classifier was the highest scoring classifier for incident type (AUROC, 0.891) and severity of harm (AUROC, 0.708). Incident reports containing deaths were most easily classified, correctly identifying 72.82% of reports. In conclusion, supervised ML can be used to classify patient safety incident report categories. The severity classifier, whilst not accurate enough to replace manual processing, could provide a valuable screening tool for this critical aspect of patient safety.

scholarly journals Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

PLoS ONE ◽  
2015 ◽  
Vol 10 (12) ◽  
pp. e0144107 ◽  
Author(s):  
Ann-Marie Howell ◽  
Elaine M. Burns ◽  
George Bouras ◽  
Liam J. Donaldson ◽  
Thanos Athanasiou ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quantitative Analysis ◽  
Learning System ◽  
Hospital Safety ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
System Data ◽  
Incident Reports

scholarly journals Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis

2019 ◽  
pp. bmjspcare-2019-001824
Author(s):  
Toby Dinnen ◽  
Huw Williams ◽  
Sarah Yardley ◽  
Simon Noble ◽  
Adrian Edwards ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
Advance Care Planning ◽  
Learning System ◽  
Care Planning ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Advance Care ◽  
National Analysis ◽  
Patient Safety Incidents

ObjectivesAdvance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life.MethodsThe National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005–December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement.ResultsWe identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission.ConclusionThis national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.

scholarly journals An Analysis of Patient Safety Incident Reports Associated with Electronic Health Record Interoperability

2017 ◽  
Vol 08 (02) ◽  
pp. 593-602 ◽  
Author(s):  
Katharine Adams ◽  
Jessica Howe ◽  
Allan Fong ◽  
Joseph Puthumana ◽  
Kathryn Kellogg ◽  
...  
Keyword(s):  
Patient Safety ◽  
Electronic Health Record ◽  
Health Record ◽  
Health It ◽  
Specific Patient ◽  
It Systems ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Electronic Health

SummaryBackground: With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care. While it is generally recognized that poor interoperability negatively impacts patient care, little is known about the specific patient safety implications. Understanding the patient safety implications will help prioritize interoperability efforts around architectures and standards.Objectives: Our objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports to understand the health IT systems involved, the clinical care processes impacted, whether the incident occurred within or between provider organizations, and the reported severity of the patient safety events.Methods: From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, 2625 reports that were indicated as being health IT related by the event reporter were reviewed to identify EHR interoperability related reports. Through a rigorous coding process 209 EHR interoperability related events were identified and coded.Results: The majority of EHR interoperability PSE reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems as opposed to the EHR sending information to other systems. The majority of EHR interoperability challenges were within a provider organization and while many of the safety events reached the patient, only a few resulted in patient harm.Conclusions: Interoperability efforts should prioritize systems in pharmacy, laboratory, and radiology. Providers should recognize the need to improve EHRs interfacing with other health IT systems within their own organization.Citation: Adams KT, Howe JL, Fong A, Puthumana JS, Kellogg KM, Gaunt M, Ratwani RM. An analysis of patient safety incident reports associated with electronic health record interoperability. Appl Clin Inform 2017; 8: 593–602 https://doi.org/10.4338/ACI-2017-01-RA-0014

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