Urquhart, A;
Yardley, S;
Thomas, E;
Donaldson, L;
Carson-Stevens, A;
(2021)
Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.
Journal of the Royal Society of Medicine
10.1177/01410768211032589.
(In press).
Preview |
Text
Yardley_Severe harms and death AMU R3. clean10.05.21.pdf - Accepted Version Download (358kB) | Preview |
Abstract
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.
| Type: | Article |
|---|---|
| Title: | Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement |
| Open access status: | An open access version is available from UCL Discovery |
| DOI: | 10.1177/01410768211032589 |
| Publisher version: | http://dx.doi.org/10.1177/01410768211032589 |
| Language: | English |
| Additional information: | This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions. |
| Keywords: | emergency medicine, health service research, medical error, patient safety, medical management, other emergency medicine, other statistics and research methods, quality improvement |
| UCL classification: | UCL UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Division of Psychiatry UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Division of Psychiatry > Marie Curie Palliative Care |
| URI: | https://discovery.ucl.ac.uk/id/eprint/10134155 |
Archive Staff Only
 |
View Item |
