Objective: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.
Methods: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.
Results: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36%), followed by falls (n = 32, 12%), medication (n = 31, 11%), and documentation (n = 29, 10%). Half (n = 139, 50%) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 (9%) reports. Individual and organizational learning was evident in 3% and 7% of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).
Conclusions: Incident report quality was suboptimal for individual and organizational learning. Underreporting level of harm suggests reporter bias, which requires reducing as much as practicable. System-level interventions are warranted to encourage use of staff reflective skills, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.
Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results From a Quantitative Analysis of the English National Reporting and Learning System DataAM Howell et al. PLoS One 10 (12), e0144107. PMID 26650823.The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall repo …
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 PracticeA Carson-Stevens et al. PMID 27656729. - ReviewAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development …
Incident Reporting in One UK Accident and Emergency DepartmentCM Tighe et al. Accid Emerg Nurs 14 (1), 27-37. PMID 16321534.Greater focus is needed on improving patient safety in modern healthcare systems and the first step to achieving this is to reliably identify the safety issues arising in …
Falls in English and Welsh Hospitals: A National Observational Study Based on Retrospective Analysis of 12 Months of Patient Safety Incident ReportsF Healey et al. Qual Saf Health Care 17 (6), 424-30. PMID 19064657.Reports of 206,350 falls were received from a total of 472 organisations. Falls incidents accounted for 32.3% of all reported patient safety incidents. 152,069 (73.7%) re …
Evidence Brief: The Effectiveness Of Mandatory Computer-Based Trainings On Government Ethics, Workplace Harassment, Or Privacy And Information Security-Related TopicsK Peterson et al. PMID 27606391. - Review
The ESP included studies that met the following criteria:…