Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers and Discharges: Do they Serve Organisations, Staff or Patients?

Jason Scott, Pamela Dawson, Emily Heavey, Aoife De Brún, Andy Buttery, Justin Waring, Darren Flynn

Research output: Contribution to journalArticle

Abstract

Objectives: Analyse content of incident reports during patient transitions in the context of care of 38 older people, cardiology, orthopaedics and stroke. 39 40 Methods: A structured search strategy identified incident reports involving patient transitions 41 (March 2014 – August 2014, January 2015 – June 2015) within two NHS Trusts (in upper and 42 lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopaedics 43 and stroke. Content analysis identified: incident classifications; active failures; latent conditions; 44 patient/relative involvement; and evidence of individual or organisational learning. Reported harm 45 was interpreted with reference to National Reporting and Learning System criteria. 46 47 Results: A total 278 incident reports were analysed. Fourteen incident classifications were 48 identified, with pressure ulcers the modal category (n=101; 36%) followed by falls (n=32, 12%), 49 medication (n=31, 11%) and documentation (n=29, 10%). Half (n=139; 50%) of incident reports 50 related to inter-unit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; 51 most frequently, these related to inadequate resources/staff and concomitant time pressures (n=13). 52 Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 53 (9%) reports. Individual and organisational learning was evident in 3% and 7% of reports 54 respectively. Reported harm was significantly lower than coder-interpreted harm (p<0.0001). Conclusions: Incident report quality was sub-optimal for individual and organisational learning. Under-reporting 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, emphasising joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimise organisational learning.
LanguageEnglish
JournalJournal of Patient Safety
Publication statusAccepted/In press - 31 Jul 2019

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Patient Handoff
Patient Transfer
Patient Discharge
Patient Safety
Learning
Organizations
Cardiology
Orthopedics
Stroke
Pressure Ulcer
Ownership
Documentation

Cite this

@article{a3db7b25ba3145bd8bac04b951fce342,
title = "Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers and Discharges: Do they Serve Organisations, Staff or Patients?",
abstract = "Objectives: Analyse content of incident reports during patient transitions in the context of care of 38 older people, cardiology, orthopaedics and stroke. 39 40 Methods: A structured search strategy identified incident reports involving patient transitions 41 (March 2014 – August 2014, January 2015 – June 2015) within two NHS Trusts (in upper and 42 lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopaedics 43 and stroke. Content analysis identified: incident classifications; active failures; latent conditions; 44 patient/relative involvement; and evidence of individual or organisational learning. Reported harm 45 was interpreted with reference to National Reporting and Learning System criteria. 46 47 Results: A total 278 incident reports were analysed. Fourteen incident classifications were 48 identified, with pressure ulcers the modal category (n=101; 36{\%}) followed by falls (n=32, 12{\%}), 49 medication (n=31, 11{\%}) and documentation (n=29, 10{\%}). Half (n=139; 50{\%}) of incident reports 50 related to inter-unit/department/team transfers. Latent conditions were explicit in 33 (12{\%}) reports; 51 most frequently, these related to inadequate resources/staff and concomitant time pressures (n=13). 52 Patient/family involvement was explicit in 61 (22{\%}) reports. Patient well-being was explicit in 24 53 (9{\%}) reports. Individual and organisational learning was evident in 3{\%} and 7{\%} of reports 54 respectively. Reported harm was significantly lower than coder-interpreted harm (p<0.0001). Conclusions: Incident report quality was sub-optimal for individual and organisational learning. Under-reporting 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, emphasising joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimise organisational learning.",
author = "Jason Scott and Pamela Dawson and Emily Heavey and {De Br{\'u}n}, Aoife and Andy Buttery and Justin Waring and Darren Flynn",
year = "2019",
month = "7",
day = "31",
language = "English",
journal = "Journal of Patient Safety",
issn = "1549-8417",
publisher = "Lippincott Williams and Wilkins",

}

Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers and Discharges : Do they Serve Organisations, Staff or Patients? / Scott, Jason; Dawson, Pamela; Heavey, Emily; De Brún, Aoife; Buttery, Andy; Waring, Justin; Flynn, Darren.

In: Journal of Patient Safety, 31.07.2019.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers and Discharges

T2 - Journal of Patient Safety

AU - Scott, Jason

AU - Dawson, Pamela

AU - Heavey, Emily

AU - De Brún, Aoife

AU - Buttery, Andy

AU - Waring, Justin

AU - Flynn, Darren

PY - 2019/7/31

Y1 - 2019/7/31

N2 - Objectives: Analyse content of incident reports during patient transitions in the context of care of 38 older people, cardiology, orthopaedics and stroke. 39 40 Methods: A structured search strategy identified incident reports involving patient transitions 41 (March 2014 – August 2014, January 2015 – June 2015) within two NHS Trusts (in upper and 42 lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopaedics 43 and stroke. Content analysis identified: incident classifications; active failures; latent conditions; 44 patient/relative involvement; and evidence of individual or organisational learning. Reported harm 45 was interpreted with reference to National Reporting and Learning System criteria. 46 47 Results: A total 278 incident reports were analysed. Fourteen incident classifications were 48 identified, with pressure ulcers the modal category (n=101; 36%) followed by falls (n=32, 12%), 49 medication (n=31, 11%) and documentation (n=29, 10%). Half (n=139; 50%) of incident reports 50 related to inter-unit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; 51 most frequently, these related to inadequate resources/staff and concomitant time pressures (n=13). 52 Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 53 (9%) reports. Individual and organisational learning was evident in 3% and 7% of reports 54 respectively. Reported harm was significantly lower than coder-interpreted harm (p<0.0001). Conclusions: Incident report quality was sub-optimal for individual and organisational learning. Under-reporting 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, emphasising joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimise organisational learning.

AB - Objectives: Analyse content of incident reports during patient transitions in the context of care of 38 older people, cardiology, orthopaedics and stroke. 39 40 Methods: A structured search strategy identified incident reports involving patient transitions 41 (March 2014 – August 2014, January 2015 – June 2015) within two NHS Trusts (in upper and 42 lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopaedics 43 and stroke. Content analysis identified: incident classifications; active failures; latent conditions; 44 patient/relative involvement; and evidence of individual or organisational learning. Reported harm 45 was interpreted with reference to National Reporting and Learning System criteria. 46 47 Results: A total 278 incident reports were analysed. Fourteen incident classifications were 48 identified, with pressure ulcers the modal category (n=101; 36%) followed by falls (n=32, 12%), 49 medication (n=31, 11%) and documentation (n=29, 10%). Half (n=139; 50%) of incident reports 50 related to inter-unit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; 51 most frequently, these related to inadequate resources/staff and concomitant time pressures (n=13). 52 Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 53 (9%) reports. Individual and organisational learning was evident in 3% and 7% of reports 54 respectively. Reported harm was significantly lower than coder-interpreted harm (p<0.0001). Conclusions: Incident report quality was sub-optimal for individual and organisational learning. Under-reporting 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, emphasising joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimise organisational learning.

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JO - Journal of Patient Safety

JF - Journal of Patient Safety

SN - 1549-8417

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