scholarly journals Patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis

2020 ◽  
Vol 7 (Suppl 1) ◽  
pp. s78-s79
Author(s):  
Alexandra Urquhart ◽  
Andrew Carson-Stevens ◽  
Sarah Yardley ◽  
Elin Thomas
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
England And Wales ◽  
Patient Safety Incidents

scholarly journals Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

PLoS Medicine ◽  
2017 ◽  
Vol 14 (1) ◽  
pp. e1002217 ◽  
Author(s):  
Philippa Rees ◽  
Adrian Edwards ◽  
Colin Powell ◽  
Peter Hibbert ◽  
Huw Williams ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
England And Wales ◽  
Sick Children ◽  
Patient Safety Incidents

Barriers to Self-Reporting Patient Safety Incidents by Paramedics: A Mixed Methods Study

2018 ◽  
Vol 22 (6) ◽  
pp. 762-772
Author(s):  
Julie E. Sinclair ◽  
Michael A. Austin ◽  
Christopher Bourque ◽  
Jennifer Kortko ◽  
Justin Maloney ◽  
...  
Keyword(s):  
Patient Safety ◽  
Mixed Methods ◽  
Mixed Methods Study ◽  
Patient Safety Incidents

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 A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice

BMJ Open ◽  
2015 ◽  
Vol 5 (12) ◽  
pp. e009079 ◽  
Author(s):  
Andrew Carson-Stevens ◽  
Peter Hibbert ◽  
Anthony Avery ◽  
Amy Butlin ◽  
Ben Carter ◽  
...  
Keyword(s):  
General Practice ◽  
Patient Safety ◽  
Mixed Methods ◽  
Study Protocol ◽  
Mixed Methods Study ◽  
Cross Sectional ◽  
Patient Safety Incidents

scholarly journals Patient Safety Incidents in Primary Care Dentistry in England and Wales

2018 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Eduardo Ensaldo-Carrasco ◽  
Asiyah Sheikh ◽  
Kathrin Cresswell ◽  
Raman Bedi ◽  
Andrew Carson-Stevens ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
England And Wales ◽  
Patient Safety Incidents

scholarly journals A mixed methods analysis of lithium-related patient safety incidents in primary care

2020 ◽  
Vol 11 ◽  
pp. 204209862092274
Author(s):  
Richard Simon Young ◽  
Paul Deslandes ◽  
Jennifer Cooper ◽  
Huw Williams ◽  
Joyce Kenkre ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
Improve Patient Safety ◽  
Descriptive Analysis ◽  
Learning System ◽  
Contributory Factors ◽  
Safety Incident ◽  
Patient Safety Incidents ◽  
Dispensing Errors

Background: Lithium is a drug with a narrow therapeutic range and has been associated with a number of serious adverse effects. This study aimed to characterise primary care lithium-related patient safety incidents submitted to the National Reporting and Learning System (NRLS) database with respect to incident origin, type, contributory factors and outcome. The intention was to identify ways to minimise risk to future patients by examining incidents with a range of harm outcomes. Methods: A mixed methods analysis of patient safety incident reports related to lithium was conducted. Data from healthcare organisations in England and Wales were extracted from the NRLS database. An exploratory descriptive analysis was undertaken to characterise the most frequent incident types, the associated chain of events and other contributory factors. Results: A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded. Community pharmacies reported 100 incidents (96 dispensing related, two administration, two other), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. A total of 99 dispensing-related incidents were recorded, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging ( n = 41), and ‘mistakes’ ( n = 22), whereas no information regarding contributory factors was provided in 41 reports. Conclusion: Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly described contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce the risk of incidents and improve patient safety.

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.

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