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 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 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 What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study

2018 ◽  
Vol 27 (9) ◽  
pp. 673-682 ◽  
Author(s):  
Jane K O’Hara ◽  
Caroline Reynolds ◽  
Sally Moore ◽  
Gerry Armitage ◽  
Laura Sheard ◽  
...  
Keyword(s):  
Patient Safety ◽  
Controlled Trial ◽  
Cluster Randomised Controlled Trial ◽  
Survey Study ◽  
Safety Concerns ◽  
Safety Incident ◽  
Patient Reported ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Patient Safety Incidents

BackgroundPatient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital.MethodsFeedback about the experience of safety within hospital was gathered from 2471 inpatients as part of a multicentre, waitlist cluster randomised controlled trial of an intervention, undertaken within 33 wards across three English NHS Trusts, between May 2013 and September 2014. Patient volunteers, supported by researchers, developed a classification framework of patient-reported safety concerns from a random sample of 231 reports. All reports were then classified using the patient-developed categories. Following this, all patient-reported safety concerns underwent a two-stage clinical review process for identification of patient safety incidents.ResultsOf the 2471 inpatients recruited, 579 provided 1155 patient-reported incident reports. 14 categories were developed for classification of reports, with communication the most frequently occurring (22%), followed by staffing issues (13%) and problems with the care environment (12%). 406 of the total 1155 patient incident reports (35%) were classified by clinicians as a patient safety incident according to the standard definition. 1 in 10 patients (264 patients) identified a patient safety incident, with medication errors the most frequently reported incident.ConclusionsOur findings suggest that patients can provide insight about safety that complements existing patient safety measurement, with a frequency of reported patient safety incidents that is similar to those obtained via case note review. However, patients provide a unique perspective about hospital safety which differs from and adds to current definitions of patient safety incidents.Trial registration numberISRCTN07689702; pre-results.

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 BARRIERS TO REPORTING PATIENT SAFETY INCIDENT IN HEALTHCARE WORKERS: INTEGRATIVE LITERATURE REVIEW

2021 ◽  
Vol 9 (2) ◽  
pp. 210
Author(s):  
Deasy Amelia Nurdin ◽  
Adik Wibowo
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Literature Review ◽  
Reporting Rate ◽  
Incident Reporting ◽  
Incident Reporting Systems ◽  
Care Workers ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Patient Safety Incidents

Background: The patient safety incident reporting systems is designed to improve the health care by learning from mistakes to minimize the recurrence mistakes, however the reporting rate is low.Aims: Integrative literature review was chosen to identify and analyze the barriers of reporting patient safety incidents by Health Care Workers (HCWs) in hospital.Methods: Searching for articles in electronic database consisting of Medline, CINAHL and Scopus resulted in 11 relevant articles originating from 9 countries.Results: There are differences but similar in barriers to reporting patient safety incident among HCWs. The barriers that occur are the existence of shaming and blaming culture, lack of time to report, lack of knowledge of the reporting system, and lack of support from the management.Conclusion: Each hospital has different barriers in reporting incident and the interventions carried out must be in accordance with the existing barriers.Keywords: barrier of reporting, incident reporting, patient safety incident

scholarly journals Identifying safe care processes when GPs work in or alongside emergency departments: realist evaluation

2021 ◽  
pp. BJGP.2021.0090
Author(s):  
Alison Cooper ◽  
Andrew Carson-Stevens ◽  
Michelle Edwards ◽  
Freya Davies ◽  
Liam Donaldson ◽  
...  
Keyword(s):  
Patient Safety ◽  
Emergency Departments ◽  
Care Delivery ◽  
Care Processes ◽  
Safety Incident ◽  
Service Models ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Patient Safety Incidents ◽  
Safe Care

Background: Increasing pressure on emergency services has led to the development of different models of care delivery including GPs working in or alongside emergency departments (EDs), but with a lack of evidence for patient safety outcomes. Aim: We aimed to explore how care processes work and how patient safety incidents associated with GPs working in ED settings may be mitigated. Design and Setting: We used realist methodology with a purposive sample of 13 EDs with different GP service models. We sought to understand the relationship between contexts, mechanisms and outcomes to develop theories about how and why patient safety incidents may occur, and how safe care was perceived to be delivered. Method: We collected qualitative data (observations, semi-structured audio-recorded staff interviews and local patient safety incident reports). We coded data using ‘if, then, because’ statements to refine initial theories developed from an earlier rapid realist literature review and analysis of a sample of national patient safety incident reports. Results: We developed a programme theory to describe how safe patient care was perceived to be delivered in these service models including: an experienced streaming nurse using local guidance and early warning scores; support for GPs’ clinical decision-making with clear governance processes relevant to the intended role (traditional GP approach or emergency medicine approach); and strong clinical leadership to promote teamwork and improve communication between services. Conclusion: Our findings can be used as a focus for more in-depth human factors investigations to optimise work conditions in this complex care delivery setting.

scholarly journals Identifying ‘avoidable harm’ in family practice: a RAND/UCLA Appropriateness Method consensus study

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Andrew Carson-Stevens ◽  
Stephen Campbell ◽  
Brian G. Bell ◽  
Alison Cooper ◽  
Sarah Armstrong ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Patient Safety ◽  
Family Practice ◽  
World Health ◽  
Evidence Based ◽  
Safety Incident ◽  
Significant Harm ◽  
Definition Of ◽  
Patient Safety Incidents

Abstract Background Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

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.

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