Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement

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.

Keywords: Clinical; emergency medicine; health service research; medical error/patient safety; medical management; other emergency medicine; other statistics and research methods; quality improvement.

Figure 1.

Flow chart showing the number of reports and how the data sample was selected. AMU: acute medical unit.

Figure 2.

Process map of the complexities, and interacting elements of a patient journey through the acute medical unit, showing the qualitative codes in blue, the themes in green and the overarching metathemes in red. Themes and metathemes are shown to overlap as ‘Metathemes’ is a term describing themes that are overarching and cross-cutting (i.e. intersecting with each other) in the data. For example, ‘Lack of active decision making and communication between teams’ is a specific theme which interacts with (i.e. both results from and exacerbates). ‘Lack of care coordination between health professionals and different teams, lack of knowledge of who is in charge’, while the latter is also resulting from and exacerbated by other themes such as patient monitoring = not done or acted on, and indeed codes such as reliance on the most junior members of staff attending to patients first.

Figure 3.

Driver diagram showing the key areas causing iatrogenic harm to patients in the acute medical unit and potential interventions to target these areas.^,,,– These exemplar interventions were identified in scoping searches of pre-existing literature.