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 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.

An analysis of general practitioners’ perspectives on patient safety incidents using critical incident technique interviews

2019 ◽  
Vol 36 (6) ◽  
pp. 736-742 ◽  
Author(s):  
Ciara Curran ◽  
Sinéad Lydon ◽  
Maureen E Kelly ◽  
Andrew W Murphy ◽  
Paul O’Connor
Keyword(s):  
Patient Safety ◽  
General Practitioners ◽  
Critical Incident ◽  
Improve Patient Safety ◽  
Critical Incident Technique ◽  
Contributory Factor ◽  
Contributory Factors ◽  
Safety Incident ◽  
The Impact ◽  
Patient Safety Incidents

Abstract Background General practitioners report difficulty in knowing how to improve patient safety. Objectives To analyse general practitioners’ perspectives of contributing factors to patient safety incidents by collecting accounts of incidents, identifying the contributory factors to these incidents, assessing the impact and likelihood of occurrence of these incidents and examining whether certain categories of contributory factors were associated with the occurrence of high-risk incidents. Methods Critical incident technique interviews were carried out with 30 general practitioners in Ireland about a patient safety incident they had experienced. The Yorkshire Contributory Factors Framework was used to classify the contributory factors to incidents. Seven subject matter experts rated the impact and likelihood of occurrence of each incident. Results A total of 26 interviews were analysed. Almost two-thirds of the patient safety incidents were rated as having a major-to-extreme impact on the patient, and over a third were judged as having at least a bimonthly likelihood of occurrence. The most commonly described active failures were ‘Medication Error’ (34.6%) and ‘Diagnostic Error’ (30.8%). ‘Situational Domain’ was identified as a contributory domain in all patient safety incidents. ‘Communication’ breakdown at both practice and other healthcare-provider interfaces (69.2%) was also a commonly cited contributory factor. There were no significant differences in the levels of risk associated with the contributory factors. Conclusions Critical incident technique interviews support the identification of contributory factors to patient safety incidents. There is a need to explore the use of the resulting data for quality and safety improvement in general practice.

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 Analysis of paediatric long-term ventilation incidents in the community

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.

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

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 Contributory factors to patient safety incidents in primary care: protocol for a systematic review

2015 ◽  
Vol 4 (1) ◽  
Author(s):  
Sally Giles ◽  
Maria Panagioti ◽  
Andrea Hernan ◽  
Sudeh Cheraghi-Sohi ◽  
Rebecca Lawton
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Patient Safety ◽  
Contributory Factors ◽  
Care Protocol ◽  
Patient Safety Incidents

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

2019 ◽  
Vol 104 (12) ◽  
pp. 1174-1180 ◽  
Author(s):  
Bethan Page ◽  
Rasanat Nawaz ◽  
Sarah Haden ◽  
Charles Vincent ◽  
Alex C H Lee
Keyword(s):  
Patient Safety ◽  
Enteral Feeding ◽  
Community Services ◽  
Learning System ◽  
Delivery Of Care ◽  
Contributory Factors ◽  
Care At Home ◽  
Discharge From Hospital ◽  
Patient Safety Incidents ◽  
At Home

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.

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.

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