Opportunities for incident reporting. Response to: ‘The problem with incident reporting’ by Macrae<i>et al</i>

Williams, Huw; Cooper, Alison; Carson‐Stevens, Andrew

doi:10.1136/bmjqs-2015-004962

Cited by 6 publications

(2 citation statements)

References 6 publications

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“…The lack of patient safety research in this area should be highlighted, [6,20,21] and teams should continue to learn from diagnostic errors, near misses and other patient safety incidents through local and national level reporting systems [60,61].…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

et al. 2021

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Background Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. Methods We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners’ reports to prevent future deaths (30.7.13–14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05–30.11.15). Results Nine Coroners’ reports (from 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. Conclusion Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.

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Section: Comparison With Existing Literaturementioning

confidence: 99%

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

et al. 2021

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“…Therefore, healthcare organisations should aim to learn from unsafe, suboptimal or excellent care. A challenge exists for organisations to invest the resources to maximise the usefulness of data provided, to analyse the data in a way that informs improvement agendas, to feedback data and learning to reporters and to demonstrate that their concerns have been addressed 4. Kelly et al 's approach addresses each of these four challenges by allocating significant resources to learning and, consequently, has shown promising results at a local level.…”

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confidence: 99%