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.
Original 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 - Do they Serve Organisations, Staff or Patients?

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.

M3 - Article

JO - Journal of Patient Safety

JF - Journal of Patient Safety

SN - 1549-8417

ER -