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

Urquhart, Alexandra; Yardley, Sarah; Thomas, Elin; Donaldson, Liam; Carson‐Stevens, Andrew

doi:10.1177/01410768211032589

Cited by 10 publications

(12 citation statements)

References 25 publications

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“…Intervention to reduce medication-related harm for patients on transitions of care is a policy and practice priority,3 being particularly pertinent to the complexity of acutely ill patient care transition to a hospital ward 75. Our findings suggest that multicomponent interventions, including education of staff and guidelines, are promising in reducing inappropriate continuation of acute medication by hospital discharge (moderate quality of evidence).…”

Section: Discussionmentioning

confidence: 82%

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

et al. 2022

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BackgroundPatients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.MethodsThe systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.ResultsSeventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.ConclusionsMulticomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.

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Section: Discussionmentioning

confidence: 82%

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

et al. 2022

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“…Incident reporting systems (IRSs), are used to record and review SIs to facilitate improvement in patient safety and can vary in their aim, design and scale [ 3 ]. IRSs have been shown to identify safety needs, enabling improved clinical settings and processes [ 5 ], however, improved patient safety outcomes have not yet been established [ 6 , 7 ]. Despite limited evidence of the effectiveness of IRSs, healthcare organisations have been utilising them to direct priorities for patient safety [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…Despite limited evidence of the effectiveness of IRSs, healthcare organisations have been utilising them to direct priorities for patient safety [ 7 ]. A recent analysis of 10 years of accumulated serious SIs reported in medical emergency units enabled the identification of key areas of risk and actions that may be taken to mitigate these and prevent future SI occurrence [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety

Thomas

Swait²,

Finch³

2023

Chiropr Man Therap

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Background Safety incident (SI) reporting and learning via incident reporting systems (IRSs) is used to identify areas for patient safety improvement. The chiropractic patient incident reporting and learning system (CPiRLS) is an online IRS that was launched in the UK in 2009 and, from time to time, has been licensed for use by the national members of the European Chiropractors' Union (ECU), members of Chiropractic Australia and a Canada-based research group. The primary aim of this project was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement. Method All SIs reported to CPiRLS between April 2009 and March 2019 were extracted and analysed. Descriptive statistics were used to describe: (1) the frequency of SI reporting and learning by the chiropractic profession, and (2) the character of reported SIs. Key areas for patient safety improvement were developed following a mixed methods approach. Results A total of 268 SIs were recorded on the database over the 10-year period, 85% of which originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain (n = 71, 26.5%). Seven key areas for patient improvement were developed including: (1) patient trip/fall, (2) post treatment distress/pain, (3) negative effects during treatment, (4) significant post-treatment effects, (5) syncope, (6) failure to recognize serious pathology, and (7) continuity of care. Conclusion The low number of SIs reported over a 10-year period suggests significant under-reporting, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified for dissemination to the chiropractic profession. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement.

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“…Incident reporting systems (IRSs), are used to record and review SIs to facilitate improvement in patient safety and can vary in their aim, design and scale [3]. IRSs have been shown to identify safety needs, enabling improved clinical settings and processes [5], however improved patient safety outcomes have not yet been established [6,7]. Despite limited evidence of the effectiveness of IRSs, healthcare organisations have been utilising them to direct priorities for patient safety.…”

Section: Introductionmentioning

confidence: 99%

“…Following the launch of the CPiRLS, internal SI monitoring and analysis resulted in the issue of two safety notices detailing the risks of rib fracture and falls respectively [18]. A recent analysis of 10 years of accumulated serious SIs reported in medical emergency units enabled the identi cation of key areas of risk and actions that may be taken to mitigate these and prevent future SI occurrence [5]. As the number of reported SIs grows, CPiRLS provides an increasingly valuable dataset for in-depth analysis of levels of SI reporting, nature and severity of SIs, including patient harm, and potential learning and improvement from these.…”

Section: Introductionmentioning

confidence: 99%

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

Thomas

Swait²,

Finch³

2022

Preprint

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Background Safety Incident (SI) reporting and learning via incident reporting systems (IRS) is used to identify areas for patient safety improvement. The Chiropractic Patient Incident Reporting and Learning System (CPiRLS) was launched in 2009 and is currently available to all UK chiropractors and members of the European Chiropractors Union (ECU). The primary aim was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement. Method All SIs on CPiRLS were extracted and analysed over a 10-year period (April 2009 to March 2019). Frequency statistics were used to describe 1) the level of SI reporting and learning by the chiropractic profession 2) the nature of the reported SIs including levels of patient harm. Key areas for patient safety improvement were identified following review of the database and consideration by an expert panel. Results A total of 268 SIs were recorded on the database over the 10-year period, of those, 85% originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain, n = 71 (26.5%). Twenty-nine (10.8%) of all SIs involved a (potential) trip or fall with an additional eight SIs relating to syncope. A total of 26 (9.7%) SIs represented some type of rib distress or pain with 14 suggesting a rib fracture was likely to have occurred. Twenty-two (8.2%) SIs related to (potentially) missing a potential serious underlying pathology. Fourteen (5.2%) SIs involved disruption in the continuity of care. Six key areas of patient safety improvement were identified following review of the data and consideration of the expert panel. Conclusion Under-reporting of SIs is apparent on CPiRLS, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified that need to be disseminated to the chiropractic profession including through the development of safer practice notices. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement and should be reviewed periodically.

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

Cited by 10 publications

References 25 publications

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

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