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

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

Research output: Contribution to journalArticle

Abstract

OBJECTIVE: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.

METHODS: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.

RESULTS: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36%), followed by falls (n = 32, 12%), medication (n = 31, 11%), and documentation (n = 29, 10%). Half (n = 139, 50%) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 (9%) reports. Individual and organizational learning was evident in 3% and 7% of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).

CONCLUSIONS: Incident report quality was suboptimal for individual and organizational learning. Underreporting 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, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.

Original languageEnglish
Number of pages15
JournalJournal of Patient Safety
Early online date26 Nov 2019
DOIs
Publication statusE-pub ahead of print - 26 Nov 2019

Fingerprint

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

Cite this

@article{bd9d50ffc84948a89eac4962d08f5aee,
title = "Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers, and Discharges: Do They Serve Organizations, Staff, or Patients?",
abstract = "OBJECTIVE: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.METHODS: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.RESULTS: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36{\%}), followed by falls (n = 32, 12{\%}), medication (n = 31, 11{\%}), and documentation (n = 29, 10{\%}). Half (n = 139, 50{\%}) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12{\%}) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22{\%}) reports. Patient well-being was explicit in 24 (9{\%}) reports. Individual and organizational learning was evident in 3{\%} and 7{\%} of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).CONCLUSIONS: Incident report quality was suboptimal for individual and organizational learning. Underreporting 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, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.",
keywords = "Content Analysis, Patient Safety, incident reports, patient transitions, patient transfers, patient discharge, patient harm",
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 = "11",
day = "26",
doi = "10.1097/PTS.0000000000000654",
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 Organizations, Staff, or Patients? / Scott, Jason; Dawson, Pamela; Heavey, Emily; De Brún, Aoife; Buttery, Andy; Waring, Justin; Flynn, Darren.

In: Journal of Patient Safety, 26.11.2019.

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 Organizations, 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 - 2019/11/26

Y1 - 2019/11/26

N2 - OBJECTIVE: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.METHODS: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.RESULTS: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36%), followed by falls (n = 32, 12%), medication (n = 31, 11%), and documentation (n = 29, 10%). Half (n = 139, 50%) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 (9%) reports. Individual and organizational learning was evident in 3% and 7% of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).CONCLUSIONS: Incident report quality was suboptimal for individual and organizational learning. Underreporting 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, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.

AB - OBJECTIVE: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.METHODS: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.RESULTS: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36%), followed by falls (n = 32, 12%), medication (n = 31, 11%), and documentation (n = 29, 10%). Half (n = 139, 50%) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 (9%) reports. Individual and organizational learning was evident in 3% and 7% of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).CONCLUSIONS: Incident report quality was suboptimal for individual and organizational learning. Underreporting 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, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.

KW - Content Analysis

KW - Patient Safety

KW - incident reports

KW - patient transitions

KW - patient transfers

KW - patient discharge

KW - patient harm

UR - https://journals.lww.com/journalpatientsafety/Abstract/publishahead/Content_Analysis_of_Patient_Safety_Incident.99235.aspx

U2 - 10.1097/PTS.0000000000000654

DO - 10.1097/PTS.0000000000000654

M3 - Article

C2 - 31790011

JO - Journal of Patient Safety

JF - Journal of Patient Safety

SN - 1549-8417

ER -