Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

Abstract

BackgroundThe UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.Methods and FindingsWe undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales’ National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions.Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.ConclusionsThis study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.

Classification of patient-safety incidents in primary care

“…Together, we have experience in coding and analysing over 60 000 reports of patient-safety incidents in primary care for several mixed-methods research studies 13 , 35 – 39 …”

Patient and Family Partnership for Safer Health Care

“…6 Communication errors underpin many serious safety events. 2,5,6 These include communication errors between doctors, nurses, pharmacists, parents, and patients. Despite ∼60% of pediatric safety events being deemed preventable (eg, through better communication) the number of children harmed has remained unchanged since the millennium.…”

“…Patients and families play an important role in health care safety in the hospital and the community as contributors to, detectors of, and mitigators of medical error. 2 Parents may not understand or have the skills to manage their children's home medication regimen, resulting in errors. Families are, however, well placed to detect errors and are equipped with extensive knowledge and astute observations of the child and their conditions.…”

Intravenous fluid prescribing errors in children: Mixed methods analysis of critical incidents

“…Researchers recently used this mixed methods approach to study patient safety issues and identify improvement opportunities in incident reports. [20,21] This article reports a mixed methods analysis of IV fluid prescribing incidents, categorising types of errors and identifying factors contributing to their occurrence.…”