Paediatric enteral feeding at home: an analysis of patient safety incidents

AimsTo describe the nature and causes of patient safety incidents relating to care at home for children with enteral feeding devices.MethodsWe analysed incident data relating to paediatric nasogastric, gastrostomy or jejunostomy feeding at home from England and Wales’ National Reporting and Learning System between August 2012 and July 2017. Manual screening by two authors identified 274 incidents which met the inclusion criteria. Each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.ResultsThe most common problems in care related to equipment and devices (n=98, 28%), procedures and treatments (n=86, 24%), information, training and support needs of families (n=54, 15%), feeds (n=52, 15%) and discharge from hospital (n=31, 9%). There was a clearly stated harm to the child in 52 incidents (19%). Contributory factors included staff/service availability, communication between services and the circumstances of the family carer.ConclusionsThere are increasing numbers of children who require specialist medical care at home, yet little is known about safety in this context. This study identifies a range of safety concerns relating to enteral feeding which need further investigation and action. Priorities for improvement are handovers between hospital and community services, the training of family carers, the provision and expertise of services in the community, and the availability and reliability of equipment. Incident reports capture a tiny subset of the total number of adverse events occurring, meaning the scale of problems will be greater than the numbers suggest.

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Analysis of paediatric long-term ventilation incidents in the community

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-317965 ◽

2019 ◽

Vol 105 (5) ◽

pp. 446-451

Author(s):

Rasanat Fatima Nawaz ◽

Bethan Page ◽

Emily Harrop ◽

Charles A Vincent

Keyword(s):

Patient Safety ◽

Learning System ◽

Free Text ◽

Delivery Of Care ◽

Contributory Factors ◽

Safety Incident ◽

Provision Of Services ◽

Patient Safety Incident ◽

Long Term Ventilation

AimTo describe the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety.MethodsWe undertook an analysis of patient safety incident data relating to long-term ventilation in the community using incident reports from England and Wales’ National Reporting and Learning System occurring between January 2013 and December 2017. Manual screening by two authors identified 220 incidents which met the inclusion criteria. The free text for each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.ResultsCommon problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment.ConclusionsThis study identifies a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.

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

Therapeutic Advances in Drug Safety ◽

10.1177/2042098620922748 ◽

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.

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Medication patient safety incidents linked to rapid tranquillisation: one year's data from the National Reporting and Learning System

Journal of Psychiatric Intensive Care ◽

10.1017/s1742646413000277 ◽

2013 ◽

Vol 11 (01) ◽

pp. 13-17 ◽

Cited By ~ 3

Author(s):

James Innes ◽

David Curtis

Keyword(s):

Patient Safety ◽

Learning System ◽

Patient Safety Incidents

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Randomized Trial of a Health Promotion Program For Frail Elders

Canadian Journal on Aging / La Revue canadienne du vieillissement ◽

10.1017/s0714980800014537 ◽

1992 ◽

Vol 11 (1) ◽

pp. 72-91 ◽

Cited By ~ 48

Author(s):

Nancy Hall ◽

Paula De Beck ◽

Debra Johnson ◽

Kelly Mackinnon ◽

Gloria Gutman ◽

...

Keyword(s):

Health Care ◽

Health Promotion ◽

Treatment Group ◽

Community Services ◽

Personal Health ◽

Control Group ◽

Elderly Persons ◽

Term Care ◽

Care At Home ◽

At Home

AbstractThis study evaluates a local health promotion project that may be widely adaptable to assist frail elderly persons to live longer at home. Subjects, enrolled in New Westminster, B.C., were men and women aged 65 and over living in their own homes but assessed and newly admitted to “personal care at home” by the Long Term Care (LTC) program of the B.C. Ministry of Health. About 90 per cent of eligible clients consented to participate. Randomized to Treatment or Control, they were followed for three years. Controls (n = 86) received standard LTC services, which included screening and pre-admission assessment, arrangement/purchase of needed services and review at three months and at least yearly thereafter. The Treatment group (n = 81) received standard LTC services plus visits from the project nurse who helped each subject to devise a personal health plan based on his or her needs in the areas of health care, substance use, exercise, nutrition, stress management, emotional functioning, social support and participation, housing, finances and transportation. The visits concentrated on setting goals and developing personal health skills, with referral to appropriate community services. An additional group of LTC clients (n = 81) from the adjacent community of Coquitlam was also followed. Success or “survival” was defined as “alive and still assessed for care at home”. After three years the “survival rate” for the Treatment group was 75.3 per cent, compared with 59.3 per cent for the Control group and 58.0 per cent for the Coquitlam group. Standard Kaplan-Meier “survival” graphs show that Treatment subjects were more likely to be alive and living at home at every time point during the three years. Differences between the Treatment and Control groups were statistically significant (p ≤ 0.05) both for simple cross-tabulations of care status at 24 and 36 months and in tests comparing “survival” curves. The results are especially striking because Control subjects received LTC services in a geographic area that offers universal access to health care and community resources and because the Control data were concurrent, not historical.

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

BMJ Supportive & Palliative Care ◽

10.1136/bmjspcare-2019-001824 ◽

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.

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Patients’ Perceptions of Health Information Given by Nurses and Clinicians at Discharge at Chiradzulu District Hospital in Malawi, Sub-Saharan Africa

European Scientific Journal ESJ ◽

10.19044/esj.2018.v14n18p65 ◽

2018 ◽

Vol 14 (18) ◽

pp. 65

Author(s):

Reuben Solomon Mumba

Keyword(s):

Health Information ◽

District Hospital ◽

Self Care ◽

Study Data ◽

Sub Saharan Africa ◽

Care At Home ◽

Sub Saharan ◽

Discharge From Hospital ◽

Information Providers ◽

At Home

Background: Hospital discharge information is a critical component of preparation to facilitate patient transition from hospital to home. Numerous studies elsewhere provide evidence that patients and families encounter a variety of problems after discharge from hospital such as difficulties with functional abilities and carrying out personal care. These problems are often attributed to having unmet informational needs at discharge. Objective: The main objective of the study was to assess patients’ perceptions of the health information provided by nurses and clinicians at discharge. Methods: The study was conducted at Chiradzulu District Hospital in Malawi. A qualitative method of data collection (in-depth interviews) was used. Convenience sampling method was used to select patients into the study. Data was analyzed using Nvivo 9 software. Findings: The study found that most patients were given information by nurses and clinicians on how to perform self-care at home on discharge from hospital. The study revealed that most patients perceived the discharge information as relevant in assisting them with home care. In addition, the study found that most patients perceived it as inadequate. The study also found that the factors that facilitated patients understanding of information were clear explanation of information and use of understandable language by information providers. Barriers included lack of encouragement from information providers to make patients speak, incomprehensive information provided to the patients and patients fear of asking information providers’ questions. Conclusion: Nurses and clinicians should make sure that all patients are given some discharge information to help them to manage their self care at home. Those patients who are at high risk for readmission should be given detailed information.

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