Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers, and Discharges: Do They Serve Organizations, Staff, or Patients?. Issue 8 (December 2021)

• Record Type: Journal Article
• Authors: Scott, Jason; Dawson, Pamela; Heavey, Emily; De Brún, Aoife; Buttery, Andy; Waring, Justin; Flynn, Darren
• Is Part Of: Journal of patient safety. Volume 17:Issue 8(2021)
• Publication Date: 2021-12
• Subjects: incident reports -- patient transitions -- patient transfers -- patient discharge -- patient harm -- patient safely; Patients -- Safety measures -- Periodicals; Medicine -- Practice -- Safety measures -- Periodicals; Medical errors -- Prevention -- Periodicals; 610.289
• DOI: 10.1097/PTS.0000000000000654
• Languages: English
• ISSNs: 1549-8417

Abstract

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. Abstract : Supplemental digital content is available in the text.