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

Hitting the target and missing the point? A BEME systematic review of evidence regarding the efficacy of statutory and mandatory training in health and care: BEME Guide No. 87

BACKGROUND

Mandatory training is considered fundamental to establishing and maintaining high standards of professional practice. There is little evidence however, of the training either achieving its required learning outcomes, or delivering improvement in outcomes for patients. Whist organisations may be hitting their compliance target for mandatory training, is the purpose missing the point? This systematic review aims to synthesize and evaluate the efficacy of statutory and mandatory training.

METHODS

PubMed, EMBASE, CNAHL, ERIC and Cochrane Central registers were searched on 23rd May 2023. All research designs were included and reported training had to specify an organisational mandate within a healthcare setting. Data was coded using a modified Kirkpatrick (KP) rating system. Critical appraisal was undertaken using the Modified Medical Education Research Study Quality Instrument, Critical Appraisal Skills Programme Qualitative Studies checklist and Mixed Methods Assessment Tool.

RESULTS

Twenty-five studies were included, featuring 9132 participants and 1348 patient cases audited. Studies described evaluation of mandatory training according to Kirkpatrick's outcomes levels 1-4b, with the majority (68%) undertaken in the UK and within acute settings. Training duration varied from 5 min to 3 days. There is a lack of consensus regarding mandatory training rationale, core topics, duration, and optimum refresher training period. Currently, mandatory training does not consistently translate to widescale improvements in safe practice or improved patient outcomes.

CONCLUSIONS

Due to the lack of international consensus regarding the need for mandated training, most papers originated from countries with centrally administered national health care systems. The rationale for mandating training programmes remains undefined. The assumption that mandatory training is delivering safe practice outcomes is not supported by studies included in this review. The findings of this review offer a basis for further research to be undertaken to assist with the design, facilitation, and impact of mandatory training.

Measurement of Ambulatory Medication Errors in Children: A Scoping Review

BACKGROUND AND OBJECTIVES

Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability.

METHODS

We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type.

RESULTS

We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability.

CONCLUSIONS

Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis

BACKGROUND

Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them.

SETTING AND SAMPLE

UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023.

METHODS

Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts.

RESULTS

Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions.

CONCLUSION

While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study

BACKGROUND

The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context.

METHODS

We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript.

RESULTS

We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose.

CONCLUSIONS

We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

SAFETY NETTING CONCEPT IN PRIMARY CARE CONSULTATION

Introduction

Patient safety in primary care setting is important and effort geared towards this cannot be over-emphasised. Patient safety can be achieved through various means, but one mechanism to improve patient safety in resourceconstrained settings is through a practice known as safety netting. Safety netting is widely recommended in national guidelines with varying definitions and scope; hence there is no consensus on when safety netting should be used and what should be the content.

Methodology

A narrative overview of the evidence on safety netting concept in primary care consultation was conducted. Scholastic articles and Papers by International organizations were searched using terms like 'safety netting', 'primary care consultation', 'family physician', 'consultation technique', and 'patient safety' in primary care. Most resources found were in the developed countries (the West) and none was found in Africa or the Middle East.Safety netting is a technique in consultation to communicate uncertainty, provide patient information on red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient's condition. The content of safetynetting advice may encompass the chronology of the illness, advice on worrying symptoms to look out for, and specific information on how, when and where to seek help. Safety netting was considered to be particularly important when consulting with the acutely unwell, patients with multi-morbidity, children and those with mental health problems.

Conclusion

Safety netting is more than solely the communication of uncertainty within a consultation. It should include plans for follow-up as well as important administrative aspects, such as the communication of test results. Effective safety netting should be geared towards the patient and provide enough practical clue for self-care and re-consultation.

Family role in paediatric safety incidents: a retrospective study protocol

INTRODUCTION

Healthcare-associated harm is an international public health issue. Children are particularly vulnerable to this with 15%-35% of hospitalised children experiencing harm during medical care. While many factors increase the risk of adverse events, such as children's dependency on others to recognise illness, children have a unique protective factor in the form of their family, who are often well placed to detect and prevent unsafe care. However, families can also play a key role in the aetiology of unsafe care.We aim to explore the role of families, guardians and parents in paediatric safety incidents, and how this may have changed during the pandemic, to learn how to deliver safer care and codevelop harm prevention strategies across healthcare settings.

METHODS AND ANALYSIS

This will be a retrospective study inclusive of an exploratory data analysis and thematic analysis of incident report data from the Learning from Patient Safety Events service (formerly National Reporting and Learning System), using the established PatIent SAfety classification system. Reports will be identified by using specific search terms, such as *parent* and *mother*, to capture narratives with explicit mention of parental involvement, inclusive of family members with parental and informal caregiver responsibilities.Paediatricians and general practitioners will characterise the reports and inter-rater reliability will be assessed. Exploratory descriptive analysis will allow the identification of types of incidents involving parents, contributing factors, harm outcomes and the specific role of the parents including inadvertent contribution to or mitigation of harm.

ETHICS AND DISSEMINATION

This study was approved by Cardiff University Research Ethics Committee (SMREC 22/32). Findings will be submitted to a peer-reviewed journal, presented at international conferences and presented at stakeholder workshops.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study

BACKGROUND

Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons.

METHODS

Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS).

RESULTS

Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability.

CONCLUSIONS

We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.

Medication adverse events in the ambulatory setting: A mixed-methods analysis

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To characterize ambulatory care adverse drug events reported to the Collaborative Healthcare Patient Safety Organization (CHPSO), a network of 400 hospitals across the United States, and identify addressable contributing factors.

METHODS

We abstracted deidentified ambulatory care CHPSO reports compiled from May 2012 to October 2018 that included medication-related adverse events to identify implicated medications and contributing factors. We dual-coded 20% of the sample. We quantitatively calculated co-occurring frequent item sets of contributing factors and then applied a qualitative thematic analysis of co-occurring sets of contributing factors for each drug class using an inductive analytic approach to develop formal themes.

RESULTS

Of 1,244 events in the sample, 208 were medication related. The most commonly implicated medication classes were anticoagulants (n = 97, or 46% of events), antibiotics (n = 24, 11%), hypoglycemics (n = 19, 9%), and opioids (n = 17, 8%). For anticoagulants, timely follow-up on supratherapeutic international normalized ratio (INR) values often occurred before the development of symptoms. Incident reports citing antibiotics often described prescribing errors and failure to review clinical contraindications. Reports citing hypoglycemic drugs often described low blood sugar events due to a lack of patient education or communication. Reports citing opioids often described drug-drug interactions, commonly involving benzodiazepines.

CONCLUSION

Ambulatory care prescribing clinicians and community pharmacists have the potential to mitigate harm related to anticoagulants, antibiotics, hypoglycemics, and opioids. Recommendations include increased follow-up for subtherapeutic INRs, improved medical record integration and chart review for antibiotic prescriptions, enhanced patient education regarding hypoglycemics, and alerts to dissuade coprescription of opioids and benzodiazepines.

Optimising GPs' communication of advice to facilitate patients' self-care and prompt follow-up when the diagnosis is uncertain: a realist review of 'safety-netting' in primary care

BACKGROUND

Safety-netting has become best practice when dealing with diagnostic uncertainty in primary care. Its use, however, is highly varied and a lack of evidence-based guidance on its communication could be harming its effectiveness and putting patient safety at risk.

OBJECTIVE

To use a realist review method to produce a programme theory of safety-netting, that is, advice and support provided to patients when diagnosis or prognosis is uncertain, in primary care.

METHODS

Five electronic databases, web searches, and grey literature were searched for studies assessing outcomes related to understanding and communicating safety-netting advice or risk communication, or the ability of patients to self-care and re-consult when appropriate. Characteristics of included documents were extracted into an Excel spreadsheet, and full texts uploaded into NVivo and coded. A random 10% sample was independently double -extracted and coded. Coded data wasere synthesised and itstheir ability to contribute an explanation for the contexts, mechanisms, or outcomes of effective safety-netting communication considered. Draft context, mechanism and outcome configurations (CMOCs) were written by the authors and reviewed by an expert panel of primary care professionals and patient representatives.

RESULTS

95 documents contributed to our CMOCs and programme theory. Effective safety-netting advice should be tailored to the patient and provide practical information for self-care and reconsultation. The importance of ensuring understanding and agreement with advice was highlighted, as was consideration of factors such as previous experiences with healthcare, the patient's personal circumstances and the consultation setting. Safety-netting advice should be documented in sufficient detail to facilitate continuity of care.

CONCLUSIONS

We present 15 recommendations to enhance communication of safety-netting advice and map these onto established consultation models. Effective safety-netting communication relies on understanding the information needs of the patient, barriers to acceptance and explanation of the reasons why the advice is being given. Reduced continuity of care, increasing multimorbidity and remote consultations represent threats to safety-netting communication.

Evaluation of the Culture of Safety and Quality in Pediatric Primary Care Practices

OBJECTIVES

The purposes of this article were to describe the perceptions of the culture of safety in pediatric primary care and evaluate whether organizational factors and staff roles are associated with perceptions of the culture of safety.

METHODS

We conducted a secondary data analysis using 2020 Agency for Healthcare Research and Quality Medical Office Survey on Patient Safety Culture to examine the culture of safety and quality in pediatric primary care practices. We used descriptive statistics and calculated differences in perceptions of patient safety and quality based on practice size, ownership, and staff roles using bivariate and logistic regressions.

RESULTS

The sample included 99 pediatric primary care practices and 1228 staff (physicians n = 169, advanced practice providers n = 70, nurses n = 338, and administration/management n = 651). The "teamwork" domain had the highest positive ratings (≥81.6% positive responses), whereas the "work pressure and pace" domain had the lowest positive ratings (≤28.6% positive response). There were no differences in perceptions of safety or quality based on practice size or ownership. However, there were differences based on staff roles, specifically between administration/management and direct care staff.

CONCLUSIONS

Overall, perceptions of the culture of safety and quality in pediatric primary care practices were positive. Differences in perceptions existed based on staff role. Future studies are needed to determine whether differences are clinically meaningful and how to narrow differences in perceptions among staff and improve of the culture of safety as a mechanism to improve the safety and quality of pediatric primary care.

Patient Safety Incidents in Primary Care Dentistry in England and Wales: A Mixed-Methods Study

BACKGROUND

In recent decades, there has been considerable international attention aimed at improving the safety of hospital care, and more recently, this attention has broadened to include primary medical care. In contrast, the safety profile of primary care dentistry remains poorly characterized.

OBJECTIVES

We aimed to describe the types of primary care dental patient safety incidents reported within a national incident reporting database and understand their contributory factors and consequences.

METHODS

We undertook a cross-sectional mixed-methods study, which involved analysis of a weighted randomized sample of the most severe incident reports from primary care dentistry submitted to England and Wales' National Reporting and Learning System. Drawing on a conceptual literature-derived model of patient safety threats that we previously developed, we developed coding frameworks to describe and conduct thematic analysis of free text incident reports and determine the relationship between incident types, contributory factors, and outcomes.

RESULTS

Of 2000 reports sampled, 1456 were eligible for analysis. Sixty types of incidents were identified and organized across preoperative (40.3%, n = 587), intraoperative (56.1%, n = 817), and postoperative (3.6%, n = 52) stages. The main sources of unsafe care were delays in treatment (344/1456, 23.6%), procedural errors (excluding wrong-tooth extraction) (227/1456; 15.6%), medication-related adverse incidents (161/1456, 11.1%), equipment failure (90/1456, 6.2%) and x-ray related errors (87/1456, 6.0%). Of all incidents that resulted in a harmful outcome (n = 77, 5.3%), more than half were due to wrong tooth extractions (37/77, 48.1%) mainly resulting from distraction of the dentist. As a result of this type of incident, 34 of the 37 patients (91.9%) examined required further unnecessary procedures.

CONCLUSIONS

Flaws in administrative processes need improvement because they are the main cause for patients experiencing delays in receiving treatment. Checklists and standardization of clinical procedures have the potential to reduce procedural errors and avoid overuse of services. Wrong-tooth extractions should be addressed through focused research initiatives and encouraging policy development to mandate learning from serious dental errors like never events.

Extension to 'combined SNA and LDA methods to understand adverse medical events': Doctor and nurse perspectives

BACKGROUND

Physicians and nurses are responsible for reporting medical adverse events. Each views these events through a different lens subject to their role-based perceptions and barriers. Physicians typically engage with diagnosis and treatment while nurses primarily care for patients' daily lives and mental well-being. This results in reporting and describing medical adverse events differently.

OBJECTIVE

We aimed to compare adverse medical event reports generated by physicians and nurses to better understand the differences and similarities in perspective as well as the nature of adverse medical events using social network analysis (SNA) and latent Dirichlet allocation (LDA).

METHODS

The current study examined data from the Maccabi Healthcare Community. Approximately 17,868 records were collected from 2000 to 2017 regarding medical adverse events. Data analysis used SNA and LDA to perform descriptive text analytics and understand underlying phenomenon.

RESULTS

A significant difference in harm levels reported by physicians and nurses was discovered. Shared topic keyword lists broken down by physicians and nurses were derived. Overall, communication, lack of attention, and information transfer issues were reported in medical adverse events data. Specialized keywords, more likely to be used by a physician were determined as: repeated prescriptions, diabetes complications, and x-ray examinations. For nurses, the most common special adverse event behavior keywords were vaccine problem, certificates of fitness, death and incapacity, and abnormal dosage.

CONCLUSIONS

Communication and inattentiveness appeared most frequently in medical adverse events reports regardless of whether doctors or nurses did the reporting. Findings suggest feedback and information sharing processes could be implemented as a step toward alleviating many issues. Institutional management, healthcare managers and government officials should take actions to decrease medical adverse events, many of which may be preventable.

Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application

OBJECTIVES

(1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed.

DESIGN

Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service.

SETTING

24 Catalan Institute of Health PC health centres of the Tarragona region (Spain).

PARTICIPANTS

Professionals from the PC health centres and a Patient Safety Functional Unit.

MEASUREMENTS

Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions.

RESULTS

A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%).

CONCLUSIONS

PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.

Medication Safety in Mental Health Hospitals: A Mixed-Methods Analysis of Incidents Reported to the National Reporting and Learning System

BACKGROUND

Medication safety incidents commonly occur in mental health hospitals. There is a need to improve the understanding of the circumstances that are thought to have played a part in the origin of these incidents to design safer systems to improve patient safety.

AIM

This study aimed to undertake a mixed-methods analysis of medication safety incidents reported to the National Reporting and Learning System in England and Wales in 2010 to 2017.

METHOD

Quantitative analyses of anonymized medication safety incidents occurring in mental health hospitals that were reported to the National Reporting and Learning System during an 8-year period were undertaken to characterize their type, severity, and the medication(s) involved. Second, a content analysis of the free-text reports associated with all incidents of at least moderate harm severity was undertaken to identify the underlying contributory factors.

RESULTS

Overall, 94,134 medication incident reports were examined, of which 10.4% (n = 9811) were reported to have resulted in harm. The 3 most frequent types of reported medication incidents involved omission of medication (17,302; 18.3%), wrong frequency (11,882; 12.6%), and wrong/unclear dose of medication (10,272; 10.9%). Medicines from the central nervous system (42,609; 71.0%), cardiovascular (4537; 7.6%), and endocrine (3669; 6.1%) medication classes were the most frequently involved with incidents. Failure to follow protocols (n = 93), lack of continuity of care (n = 92), patient behaviors (n = 62), and lack of stock (n = 51) were frequently reported as contributory factors.

CONCLUSIONS

Medication incidents pose an enduring threat to patient safety in mental health hospitals. This study has identified important targets that can guide the tailored development of remedial interventions.

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care

Background

The COVID-19 pandemic has resulted in the rapid reorganisation of health and social care services. Patients are already at significant risk of healthcare-associated harm and the wholesale disruption to service delivery during the pandemic stood to heighten those risks.

Objectives

We explored the type and nature of patient safety incidents in French primary care settings during the COVID-19 first wave to make tentative recommendations for improvement.

Methods

A national patient safety incident reporting survey was distributed to General Practitioners (GPs) in France on 28 April 2020. Reports were coded using a classification system aligned to the WHO International Classification for Patient Safety (incident types, contributing factors, incident outcomes and severity of harm). Analysis involved data coding, processing, iterative generation of data summaries using descriptive statistical analysis. Clinicaltrials.gov: NCT04346121.

Results

Of 132 incidents, 58 (44%) related to delayed diagnosis, assessments and referrals. Cancellations of appointments, hospitalisations or procedures was reported in 22 (17%) of these incidents. Home confinement-related incidents accounted for 13 (10%) reports and inappropriate medication stopping for five (4%). Patients delayed attending or did not consult their general practitioner or other healthcare providers due to their fear of contracting COVID-19 infection at an in-person visit in 26 (10%) incidents or fear of burdening their GPs in eight (3%) incidents.

Conclusion

Constraints from the first wave of the COVID-19 pandemic have contributed to patient safety incidents during non-COVID-19 care. Lessons from these incidents pinpoint where primary care services in France can focus resources to design safer systems for patients.

Patient participation in care safety: Primary Health Care professionals' perception

OBJECTIVES

to analyze health professionals' perception about the meaning and practice of patient involvement in care safety in Primary Health Care.

METHODS

this is an exploratory, qualitative study, developed with 22 professionals in the Federal District, Brazil. A semi-structured interview was conducted between October and November/2018. Content analysis was carried out according to Bardin.

RESULTS

nurses, physicians, dentists, among others, participated. The following categories emerged: Meaning of patient involvement in care safety; Factors intervening in patient involvement in care safety; Strategies for patient involvement in care safety; Qualification for patient involvement in care safety.

FINAL CONSIDERATIONS

the meaning of patient involvement for care safety was associated with co-responsibility and patient-centered care. Professionals' practice revealed intervening factors and the use of involvement strategies. A gap was identified in training on patient involvement in care safety.

A Mixed-Methods Analysis of Medication Safety Incidents Reported in Neonatal and Children's Intensive Care

BACKGROUND

Critically ill neonates and paediatric patients may be at a greater risk of medication-related safety incidents than those in other clinical areas.

OBJECTIVE

This study aimed to examine the nature of, and contributory factors associated with, medication-related safety incidents reported in neonatal and paediatric intensive care units (ICUs).

METHODS

We carried out a mixed-methods analysis of anonymised medication safety incidents reported to the National Reporting and Learning System that involved children (aged ≤ 18 years) admitted to ICUs across England and Wales over a 9-year period (2010-2018). Data were analysed descriptively, and free-text descriptions of harmful incidents were examined to explore potential contributory factors associated with incidents.

RESULTS

In total, 25,567 eligible medication-related incident reports were examined. Incidents commonly occurred during the medicines administration (n = 13,668 [53.5%]) and prescribing stages (n = 7412 [29%]). The most commonly implicated error types were drug omission (n = 4812 [18.8%]) and dosing errors (n = 4475 [17.5%]). Neonates were commonly involved in reported incidents (n = 12,235 [47.9%]). Anti-infectives (n = 6483 [25.4%]) were the medications most commonly associated with incidents and commonly involved neonates. Incidents that were reported to have caused patient harm accounted for 12.2% (n = 3129) and commonly involved neonates (n = 1570/3129 [50.2%]). Common contributing factors to harmful incidents included staff-related factors (68.7%), such as failure to follow protocols or errors in documentation, which were often associated with working conditions, inadequate guidelines, and design of systems and protocols.

CONCLUSIONS

Neonates were commonly involved in medication-related incidents reported in children's intensive care settings. Improvements in staffing and workload, design of systems and processes, and the use of anti-infective medications may reduce this risk.

Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England

BACKGROUND

Patient engagement in safety has shown positive effects in preventing or reducing adverse events and potential safety risks. Capturing and utilising patient-reported safety incident data can be used for service learning and improvement.

OBJECTIVE

The aim of this study was to characterise the nature of patient-reported safety incidents in primary care.

DESIGN

Secondary analysis of two cross sectional studies.

PARTICIPANTS

Adult patients from Australian and English primary care settings.

MEASURES

Patients' self-reported experiences of safety incidents were captured using the validated Primary Care Patient Measure of Safety questionnaire. Qualitative responses to survey items were analysed and categorised using the Primary Care Patient Safety Classification System. The frequency and type of safety incidents, contributory factors, and patient and system level outcomes are presented.

RESULTS

A total of 1329 patients (n=490, England; n=839, Australia) completed the questionnaire. Overall, 5.3% (n=69) of patients reported a safety incident over the preceding 12 months. The most common incident types were administration incidents (n=27, 31%) (mainly delays in accessing a physician) and incidents involving diagnosis and assessment (n=16, 18.4%). Organisation of care accounted for 27.6% (n=29) of the contributory factors identified in the safety incidents. Staff factors (n=13, 12.4%) was the second most commonly reported contributory factor. Where an outcome could be determined, patient inconvenience (n=24, 28.6%) and clinical harm (n=21, 25%) (psychological distress and unpleasant experience) were the most frequent.

CONCLUSIONS

The nature and outcomes of patient-reported incidents differ markedly from those identified in studies of staff-reported incidents. The findings from this study emphasise the importance of capturing patient-reported safety incidents in the primary care setting. The patient perspective can complement existing sources of safety intelligence with the potential for service improvement.

Characterising the types of paediatric adverse events detected by the global trigger tool – CareTrack Kids

Introduction

A common method of learning about adverse events (AEs) is by reviewing medical records using the global trigger tool (GTT). However, these studies generally report rates of harm. The aim of this study is to characterise paediatric AEs detected by the GTT using descriptive and qualitative approaches.

Methods

Medical records of children aged 0–15 were reviewed for presence of harm using the GTT. Records from 2012–2013 were sampled from hospital inpatients, emergency departments, general practice and specialist paediatric practices in three Australian states. Nurses undertook a review of each record and if an AE was suspected a doctor performed a verification review of a summary created by the nurse. A qualitative content analysis was undertaken on the summary of verified AEs.

Results

A total of 232 AEs were detected from 6,689 records reviewed. Over four-fifths of the AEs (193/232, 83%) resulted in minor harm to the patient. Nearly half (112/232, 48%) related to medication/intravenous (IV) fluids. Of these, 83% (93/112) were adverse drug reactions. Problems with medical devices/equipment were the next most frequent with nearly two-thirds (32/51, 63%) of these related to intravenous devices. Problems associated with clinical processes/procedures comprise one in six AEs (38/232, 16%), of which diagnostic problems (12/38, 32%) and procedural complications (11/38, 29%) were the most frequent.

Conclusion

Adverse drug reactions and issues with IVs are frequently identified AEs reflecting their common use in paediatrics. The qualitative approach taken in this study allowed AE types to be characterised, which is a prerequisite for developing and prioritising improvements in practice.

Characteristics of Reported Pediatric Medication Errors in Northern Ireland and Use in Quality Improvement

BACKGROUND

To protect children from harm, clinicians, educators, and patient safety champions need information to direct improvement efforts. Critical incident data could provide this but are often disregarded as a source of evidence because under-reporting makes them an inaccurate measure of error rates.

OBJECTIVE

Our aim was to identify key targets for pediatric healthcare quality improvement. The objective was to evaluate the types, characteristics, and areas of risk within reported medication errors in pediatric patients.

METHODS

We conducted a retrospective study of a large regional dataset of 1522 pediatric medication errors reported from secondary care between 2011 and 2015, including all hospitals and community pediatric settings in Northern Ireland. The following characteristics were included: error severity, patient age, drug involved, error type, and area of practice. Two academic pediatricians, a senior medicines governance pharmacist, a Reader in Pharmacy Practice, and a Professor of Medical Education analyzed the data. Validity checks included comparing the findings against key published literature and discussion by a practitioner panel representing five multidisciplinary stakeholder groups.

RESULTS

Neonates, particularly in intensive care, were implicated in 19% of all errors. The medications most represented in risk were antimicrobials, paracetamol, vaccines, and intravenous fluids. The error types most implicated were dosing errors (32%) and omissions (21%).

CONCLUSIONS

Incident reports identified neonates, a shortlist of drugs, and specific error types, associated with modifiable behaviors, as priority improvement targets. These findings direct further study and inform intervention development, such as specific training in calculations to prevent dosing errors. Involving experienced practitioners both endorsed the findings and engaged the practice community in their future implementation. The utility of incident reports to direct improvement efforts may offset the limitations in their representativeness.

What Safety Events Are Reported For Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization

INTRODUCTION

Health care staff document patient safety events using incident reporting systems, which are compiled within Patient Safety Organization databases. Researchers sought to describe the patterns and characteristics of incident reporting behaviors for ambulatory care from in-situ reporting systems from the United States.

METHODS

The team analyzed safety reports in ambulatory settings collected from a Patient Safety Organization comprising 400 hospital members in 10 states, from May 2012 to October 2018. All events involving moderate harm, severe harm, and death were included, as well as subsamples of events with missing harm, no harm, and mild harm. The team deductively coded incident types and if patient or caregiver challenges were involved. A multivariate logistic regression was conducted to identify predictors of higher harm (severe harm and death) among safety events reported.

RESULTS

Of 2,701 events, there were 51 deaths, 159 severe harm events, 1,180 moderate harm, 926 mild harm, 384 no harm, and 1 unknown. Most were from outpatient subspecialty care, while 5.2% were from home/community, and 2.1% were from primary care. Medication-related events were most common (45.3%). In multivariate analysis, diagnostic errors (adjusted odds ratio [aOR] 11.5), patient/caregiver challenges (aOR 2.2), and events in the home/community (aOR 2.0) and in psychiatric settings (aOR 5.0) were associated with higher harm.

CONCLUSION

Outpatient reporting systems are limited for primary care and home/community settings, but ambulatory care systems report more harmful events related to diagnosis and patient and caregiver challenges. Improved standardization of reporting, focus on diagnosis, and novel approaches of safety reporting that engage patients will be necessary to improve capture of preventable events affecting patients and to develop system-level solutions.

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

PURPOSE

Patient 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.

METHODS

This 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.

RESULTS

Of 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.

CONCLUSION

This 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.

"Iatrogenic Medication Errors reported to the Victorian Poisons Information Centre"

BACKGROUND

Iatrogenic medication errors are a cause of medical morbidity and mortality. They result in significant cost to the Australian healthcare system each year. There is limited Australian evidence describing the iatrogenic errors occurring within the hospital system.

AIMS

To examine and describe iatrogenic medication errors occurring in Victorian healthcare settings through analysis of referrals to a state Poisons Information Centre (PIC).

METHODS

A retrospective review of iatrogenic medication errors reported to the Victorian PIC from community and hospital healthcare settings from January 2015-December 2019.

RESULTS

Over a five year period, 357 iatrogenic errors were identified, 63% (n = 224) of which occurred in a hospital setting. The remaining errors occurred in a community healthcare setting. One in five patients were symptomatic from the medication error at the time of the call to the VPIC, and a change in management was required in 45% (n = 165) of all cases. 5% (n = 17) of patients developed moderate to severe clinical toxicity as determined by the recorded PSS, and 88% (n = 18) of these required critical care management. Incorrect medication dosing accounted for 62% (n = 221) of errors. Common medication dosing errors included: double dose (51%, n = 114), incorrect medication administered (14%, n = 49), incorrect route (9%, n = 31), incorrect patient (6%, n = 22) and adult dose given to a child (4%, n = 15).

CONCLUSIONS

Iatrogenic errors are occurring in the Victorian health care system. These errors can result in serious morbidity. Identification of causative factors and investment in preventative strategies will likely reduce associated morbidity and healthcare costs. This article is protected by copyright. All rights reserved.

Combined SNA and LDA methods to understand adverse medical events

OBJECTIVE

To compare primary medical adverse event keywords from reporters (e.g. physicians and nurses) and harm level perspectives to explore the underlying behaviors of medical adverse events using social network analysis (SNA) and latent Dirichlet allocation (LDA) leading to process improvements.

DESIGN

Used SNA methods to explore primary keywords used to describe the medical adverse events reported by physicians and nurses. Used LDA methods to investigate topics used for various harm levels. Combined the SNA and LDA methods to discover common shared topic keywords to better understand underlying behaviors of physicians and nurses in different harm level medical adverse events.

SETTING

Maccabi Healthcare Community is the second largest healthcare organization in Israel.

DATA

17,868 medical adverse event data records collected between 2000 and 2017.

METHODS

Big data analysis techniques using social network analysis (SNA) and latent Dirichlet allocation (LDA).

RESULTS

Shared topic keywords used by both physicians and nurses were determined. The study revealed that communication, information transfer, and inattentiveness were the most common problems reported in the medical adverse events data.

CONCLUSIONS

Communication and inattentiveness were the most common problems reported in medical adverse events regardless of healthcare professional reporting or harm levels. Findings suggested that an information-sharing and feedback mechanism should be implemented to eliminate preventable medical adverse events. Healthcare institutions managers and government officials should take targeted actions to decrease these preventable medical adverse events through quality improvement efforts.

Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths

This study aimed to operationalise and use the World Health Organisation's International Classification for Patient Safety (ICPS) to identify incident characteristics and contributing factors of deaths involving complications of medical or surgical care in Australia. A sample of 500 coronial findings related to patient deaths following complications of surgical or medical care in Australia were reviewed using a modified-ICPS (mICPS). Over two-thirds (69.0%) of incidents occurred during treatment and 27.4% occurred in the operating theatre. Clinical process and procedures (55.9%), medication/IV fluids (11.2%) and healthcare-associated infection/complications (10.4%) were the most common incident types. Coroners made recommendations in 44.0% of deaths and organisations undertook preventive actions in 40.0% of deaths. This study demonstrated that the ICPS was able to be modified for practical use as a human factors taxonomy to identify sequences of incident types and contributing factors for patient deaths. Further testing of the mICPS is warranted.

Diagnostic error in the emergency department: learning from national patient safety incident report analysis

BACKGROUND

Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

METHODS

A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

RESULTS

There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

CONCLUSIONS

Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Quality improvements of safety-netting guidelines for cancer in UK primary care: insights from a qualitative interview study of GPs

BACKGROUND

Safety netting is a diagnostic strategy that involves monitoring patients with symptoms possibly indicative of serious illness, such as cancer, until they are resolved. Optimising safety-netting practice in primary care has been proposed to improve quality of care and clinical outcomes. Introducing guidelines is a potential means to achieve this.

AIM

To seek the insight of frontline GPs regarding proposed safety-netting guidelines for suspected cancer in UK primary care.

DESIGN AND SETTING

A qualitative interview study with 25 GPs practising in Oxfordshire, UK.

METHOD

Transcripts from semi-structured interviews were analysed thematically by a multidisciplinary research team using a mind-mapping approach.

RESULTS

GPs were supportive of initiatives to optimise safety netting. Guidelines on establishing who has responsibility for follow-up, keeping patient details up to date, and ensuring test result review is conducted by someone with knowledge of cancer guidelines were already being followed. Sharing diagnostic uncertainty and ensuring an up-to-date understanding of guidelines were only partially implemented. Neither informing patients of all (including negative) test results nor ensuring recurrent unexplained symptoms are always flagged and referred were considered feasible. The lack of detail, for example, the expected duration of symptoms, caused some concern. Overall, doubts were expressed about the feasibility of the guidelines given the time, recruitment, and resource challenges faced in UK primary care.

CONCLUSION

GPs expressed general support for safety netting, yet were unconvinced that key elements of the guidelines were feasible, especially in the context of pressures on general practice staffing and time.

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

AIMS

To describe the nature and causes of patient safety incidents relating to care at home for children with enteral feeding devices.

METHODS

We 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.

RESULTS

The 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.

CONCLUSIONS

There 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.

Safety netting in routine primary care consultations: an observational study using video-recorded UK consultations

Background

Safety-netting advice is information shared with a patient or their carer designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health.

Aim

To assess when and how safety-netting advice is delivered in routine GP consultations.

Design and setting

This was an observational study using 318 recorded GP consultations with adult patients in the UK.

Method

A safety-netting coding tool was applied to all consultations. Logistic regression for the presence or absence of safety-netting advice was compared between patient, clinician, and problem variables.

Results

A total of 390 episodes of safety-netting advice were observed in 205/318 (64.5%) consultations for 257/555 (46.3%) problems. Most advice was initiated by the GP (94.9%) and delivered in the treatment planning (52.1%) or closing (31.5%) consultation phases. Specific advice was delivered in almost half (47.2%) of episodes. Safety-netting advice was more likely to be present for problems that were acute (odds ratio [OR] 2.18, 95% confidence interval [CI] = 1.30 to 3.64), assessed first in the consultation (OR 2.94, 95% CI = 1.85 to 4.68) or assessed by GPs aged ≤49 years (OR 2.56, 95% CI = 1.45 to 4.51). Safety-netting advice was documented for only 109/242 (45.0%) problems.

Conclusion

GPs appear to commonly give safety-netting advice, but the contingencies or actions required on the patient’s part may not always be specific or documented. The likelihood of safety-netting advice being delivered may vary according to characteristics of the problem or the GP. How to assess safety-netting outcomes in terms of patient benefits and harms does warrant further exploration.

Interactional misalignment in the UK NHS 111 healthcare telephone triage service

BACKGROUND

A recent review of primary care serious incidents suggests that diagnosis and assessment problems, underpinned by communication failures, involving the UK telephone triage service, NHS 111, may contribute to patient harm.

METHODS

The present study utilised conversation analysis to address the lack of evaluative research examining the NHS 111 system and in particular interactions between system components (call handler, computerized decision support system, patients/caller).

RESULTS

Analysis of audio recorded call interactions revealed interactional misalignment across four mapped call phases (eliciting caller details, establishing reason for call, completing the Pathways assessment, and agreeing the outcome). This misalignment has the capacity to increase the risk of system failure, particularly in relation to assessment problems and issues related to the accurate transfer of care advice. Our analysis suggests that efforts to enhance the NHS 111 system, similar telehealth services, and patient safety management more generally, should shift their focus from a limited set of individual components towards a system-specific interactionist perspective encompassing all elements.

CONCLUSIONS

Further evaluative research is required in order to build a comprehensive evidence-base concerning the multiple interacting factors influencing patient safety in the NHS 111 system.

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study

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.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0990-z) contains supplementary material, which is available to authorized users.

Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database

Background:

Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. The identification of improved ways of delivering palliative care outside working hours is a priority area for policymakers.

Aim:

To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary-care services outside normal working hours.

Design:

A mixed-methods cross-sectional analysis of patient safety incident reports from the National Reporting and Learning System. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care.

Setting/participants:

A total of 1072 patient safety incident reports involving patients receiving sub-optimal palliative care via the out-of-hours primary-care services.

Results:

Incidents included issues with: medications (n = 613); access to timely care (n = 123); information transfer (n = 102), and/or non-medication-related treatment such as pressure ulcer relief or catheter care (n = 102). Almost two-thirds of reports (n = 695) described harm with outcomes such as increased pain, emotional, and psychological distress featuring highly. Commonly identified contributory factors to these incidents were a failure to follow protocol (n = 282), lack of skills/confidence of staff (n = 156), and patients requiring medication delivered via a syringe driver (n = 80).

Conclusion:

Healthcare systems with primary-care-led models of delivery must examine their practices to determine the prevalence of such safety issues (communication between providers; knowledge of commonly used, and access to, medications and equipment) and utilise improvement methods to achieve improvements in care.

Safety netting for primary care: evidence from a literature review

BACKGROUND

Ensuring patient safety is vital in primary care. One mechanism to increase patient safety is through a practice known as safety netting. Safety netting is widely recommended in national guidelines; however, a variety of definitions exist with no consensus on when safety netting should be used and what advice or actions it should contain.

AIM

This study aimed to identify different definitions of safety netting to provide conceptual clarity and propose a common approach to safety netting in primary care.

DESIGN AND SETTING

Literature review and evidence synthesis of international articles relating to safety netting in primary care.

METHOD

An electronic database and grey-literature search was conducted using terms around the theme of safety netting with broad inclusion criteria.

RESULTS

A total of 47 studies were included in the review. Safety netting was defined as a consultation technique to communicate uncertainty, provide patient information on red-flag symptoms, and plan for future appointments to ensure timely re-assessment of a patient's condition. Safety-netting advice may include information on the natural history of the illness, advice on worrying symptoms to look out for, and specific information on how and when to seek help. In addition to advice within the consultation, safety netting includes follow-up of investigations and hospital referrals. Safety netting was considered to be particularly important when consulting with children, the acutely unwell, patients with multimorbidity, and those with mental health problems.

CONCLUSION

Safety netting is more than solely the communication of uncertainty within a consultation. It should include plans for follow-up as well as important administrative aspects, such as the communication of test results and management of hospital letters.

Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports

BACKGROUND

Incident reporting can be used to inform imaging departments about adverse events and near misses.

OBJECTIVE

To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports.

MATERIALS AND METHODS

All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed.

RESULTS

During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001).

CONCLUSION

Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.

Understanding Test Results Follow-Up in the Ambulatory Setting: Analysis of Multiple Perspectives

BACKGROUND

Delayed or incomplete test result follow-up, which can lead to missed and/or delayed diagnosis, is an important issue in the ambulatory setting. Delayed test result follow-up has been linked to poorer patient outcomes and increased risk of mortality and accounts for a large portion of medical malpractice claims. Yet improvements are difficult, reflecting the complexity of the test result follow-up process. Test result follow-up safety culture was investigated using qualitative and quantitative patient safety and quality of care data at an academic medical center.

METHODS

After an environmental scan, five sources of data were used to compass multiple perspectives on safety culture-two national surveys (AHRQ MO SOPS for safety culture and CG-CAHPS for patient satisfaction); patient and family complaints; safety reports; and provider response times to test message results in the electronic health record.

RESULTS

The following metrics were inspected: how patients and providers estimated the frequency for providing timely test results; how patients' satisfaction with their provider correlated with their provider's response time to test result messages; and qualitative themes in patient complaints and safety reports filed by clinic. The institution was compared to national benchmarks using surveys. As test result response time decreased, patient satisfaction increased (p = 0.0073).

CONCLUSION

Test result follow-up culture was investigated using tools typically used to examine patient satisfaction and experience and staff culture. Use of these five sources of data led to an examination of multiple perspectives in follow-up culture and identification of possible explanations for inappropriate follow-up. These data sources can be further explored to identify possible solutions.

The Rise of Patient Safety-II: Should We Give Up Hope on Safety-I and Extracting Value From Patient Safety Incidents? Comment on "False Dawns and New Horizons in Patient Safety Research and Practice"

Who could disagree with the seemingly common-sense reasoning that: "We must learn from the things that go wrong."? Despite major investments to improve patient safety, relatively few evaluations demonstrate convincing reductions in risk, harm, serious error or death. This disappointing trajectory of improvement from learning from errors or Safety-I as it is sometimes known has led some researchers to argue that there is more to be gained by learning from the majority of healthcare episodes: the things that go right. Based on this premise, socalled Safety-II has emerged as a new paradigm. In this commentary, we consider the ongoing value of Safety-I based approaches and explore whether now is the time to abandon learning from "the bad" and re-energise data collection and analysis by focusing on "the good."

Community Pharmacy Use by Children across Europe: A Narrative Literature Review

The use of community pharmacies across Europe has potential to alleviate the burden on overstretched healthcare providers. Children and young people (0–18 years) account for a large number of primary care attendances. This narrative literature review between January 2000 and December 2017 examines the use of community pharmacy by paediatric patients in Europe. The results report both positive and negative perceptions of community pharmacy by parents and children, opportunities for an extended role in Europe, as well as the need for further training. The main limitations were the inclusion of English language papers only and an initial review of the literature carried out by a single researcher. It remains to be seen whether a ‘new-look’ role of the community pharmacist is practical and in alignment with specific European Commission and national policies.

Classification of patient-safety incidents in primary care

Primary care lags behind secondary care in the reporting of, and learning from, incidents that put patient safety at risk. In primary care, there is no universally agreed approach to classifying the severity of harm arising from such patient-safety incidents. This lack of an agreed approach limits learning that could lead to the prevention of injury to patients. In a review of research on patient safety in primary care, we identified 21 existing approaches to the classification of harm severity. Using the World Health Organization’s (WHO’s) International Classification for Patient Safety as a reference, we undertook a framework analysis of these approaches. We then developed a new system for the classification of harm severity. To assess and classify harm, most existing approaches use measures of symptom duration (11/21), symptom severity (11/21) and/or the level of intervention required to manage the harm (14/21). However, few of these approaches account for the deleterious effects of hospitalization or the psychological stress that may be experienced by patients and/or their relatives. The new classification system we developed builds on WHO’s International Classification for Patient Safety and takes account not only of hospitalization and psychological stress but also of so-called near misses and uncertain outcomes. The constructs we have outlined have the potential to be applied internationally, across primary-care settings, to improve both the detection and prevention of incidents that cause the most severe harm to patients.

Safety analysis over time: seven major changes to adverse event investigation

BACKGROUND

Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.

MAIN TEXT

The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects. We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.

CONCLUSIONS

Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.

Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents

Introduction

Recent National Institute for Health and Care Excellence (NICE) guidelines aim to improve intravenous (IV) fluid prescribing for children, but existing evidence about how and why fluid prescribing errors occur is limited. Studying this can lead to more effective implementation, through education and systems design.

Aims

Methods

Mixed methods observational study which analysed critical incident reports relating to IV fluid prescribing errors in children aged 0–16, occurring between 2011 and 2015 in UK secondary care. We quantified characteristics and types of errors, then qualitatively analysed narrative descriptions, identifying underlying contributing factors.

Results

In the 40 incidents analysed, principal types of errors were incorrect rate of fluids, inappropriate choice of solution, and incorrect completion of prescription charts. Prescribers had to negotiate complex patients, interactions with other practitioners and teams, and challenging work environments; errors resulted from these inter-related contributing factors.

Conclusions

This study highlights the diverse range and complex nature of IV fluid prescribing errors reported in practice. While these findings have the inherent limitations of critical incident reports, they point to areas of potential improvement in education and systems design. Practising prescribing in context, inducting doctors within the many specialties who contribute to care of children, and educating them in joint working with nurses and pharmacists could help reduce errors.

Implementing the Comprehensive Unit-Based Safety Program (CUSP) to Improve Patient Safety in an Academic Primary Care Practice

BACKGROUND

While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice.

METHODS

As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire.

RESULTS

Ninety-six percent of staff completed science of safety training as part of CUSP implementation, and 100% of staff completed the two-question safety assessment. The most frequently identified safety concerns were related to medications (n = 11, 28.2), diagnostic testing (n = 9, 25), and communication (n = 5, 14). The CUSP team initially prioritized communication and infection control, which led to standardization of work flows within the practice. Six months following CUSP implementation, large but nonstatistically significant increases were found for the percentage of survey respondents who reported knowledge of the proper channels for questions about patient safety, felt encouraged to report safety concerns, and believed that the work setting made it easy to learn from the errors of others.

CONCLUSION

CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.

Donaldson L, Carson-Stevens A. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

Background

older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting.

Objectives

to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care.

Design and Setting

a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013.

Subjects

1,591 primary care patient safety incident reports regarding patients aged 65 years and older.

Methods

we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care.

Results

the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm).

Conclusion

priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.

Sick Children Crying for Help: Fostering Adverse Event Reports

In a Perspective, Gordon Schiff discusses the importance of appropriately analyzing adverse event reports.