Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012

English version České info

Background:
Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced.

Methods and Findings:
The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement.

Conclusions:
Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives.

Please see later in the article for the Editors' Summary

Vyšlo v časopise: Patient-Safety-Related Hospital Deaths in England: Thematic Analysis of Incidents Reported to a National Database, 2010–2012. PLoS Med 11(6): e32767. doi:10.1371/journal.pmed.1001667
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pmed.1001667

Souhrn

Zdroje

1. EpsteinNE (2012) Morbidity and mortality conferences: their educational role and why we should be there. Surg Neurol Int 3(Suppl 5): S377–S388.

2. LauH, LitmanKC (2011) Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety. Jt Comm J Qual Patient Saf 37: 400–408.

3. HoganH, HealeyF, NealeG, ThomsonR, VincentC, et al. (2012) Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual Saf 21: 737–745.

4. ChongCA, NguyenGC, WilcoxME (2012) Trends in Canadian hospital standardised mortality ratios and palliative care coding 2004–2010: a retrospective database analysis. BMJ Open 2: e001729.

5. Department of Health (2001) The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984–1995: learning from Bristol. Available: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.bristol-inquiry.org.uk/final_report/report/index.htm. Accessed 28 May 2014.

6. Francis Q (2013) Mid Staffordshire NHS Foundation Trust public inquiry. Final Report. Available: http://www.midstaffspublicinquiry.com/report. Accessed 21 May 2014.

7. Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts: overview report. Available: http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/outcomes/keogh-review-final-report.pdf. Accessed 21 May 2014.

8. National Patient Safety Agency (2014) About reporting patient safety incidents. Available: http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents/. Accessed 21 May 2014.

9. National Health Service (2014) Quarterly data summaries [database]. Available: http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/. Accessed 28 May 2014.

10. National Patient Safety Agency (2011) What is a patient safety incident? Available: http://www.npsa.nhs.uk/nrls/reporting/what-is-a-patient-safety-incident/. Accessed 21 May 2014.

11. PanesarSS, ClearyK, SheikhA (2009) Reflections on the National Patient Safety Agency's database of medical errors. J R Soc Med 102: 256–258.

12. NHS Commissioning Board (2012) Transfer of patient safety function to the NHS Commissioning Board Authority. Available: http://www.commissioningboard.nhs.uk/2012/05/31/npsa-transfer/. Accessed 21 May 2014.

13. National Patient Safety Agency (2011) Proposed transfer of the operational management of the National Reporting and Learning System to Imperial College Healthcare NHS Trust. Available: http://www.npsa.nhs.uk/corporate/news/proposed-transfer-of-nrls/. Accessed 21 May 2014.

14. Lewis G, editor(2007) Confidential Enquiry into Maternal and Child Health. Saving mothers' lives: reviewing maternal deaths to make motherhood safer—2003–2005. Available: http://www.publichealth.hscni.net/sites/default/files/Saving%20Mothers%27%20Lives%202003-05%20.pdf. Accessed 28 May 2014.

15. (2014) National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Available: http://www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci. Accessed 21 May 2014.

16. Daly J, Kellehear A, Gliksman M (1997) The public health researcher: a methodological approach. Melbourne: Oxford University Press.

17. Boyatzis R (1998) Transforming qualitative information. Thematic analysis and code development. Thousand Oaks (California): Sage.

18. PhamJC, FrickKD, PronovostPJ (2013) Why don't we know whether care is safe? Am J Med Qual 28: 457–463.

19. NobleDJ, PanesarSS, PronovostPJ (2011) A public health approach to patient safety reporting systems is urgently needed. J Patient Saf 7: 109–112.

20. WallaceLM, SpurgeonP, BennJ, KoutantjiM, VincentC (2009) Improving patient safety incident reporting systems by focusing upon feedback—lessons from English and Welsh trusts. Health Serv Manage Res 22: 129–135.

21. McQuillanP, PilkingtonS, AllanA, TaylorB, ShortA, et al. (1998) Confidential inquiry into quality of care before admission to intensive care. BMJ 316: 1853–1858.

22. National Confidential Enquiry into Patient Outcome and Death (2005) An acute problem? Available: http://www.ncepod.org.uk/2005aap.htm. Accessed 21 May 2014.

23. Patient Safety Observatory (2007) Safer care for the acutely ill patient: learning from serious incidents. National Patient Safety Agency. Available: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59828. Accessed 21 May 2014.

24. National Institute for Health and Care Excellence (2007) Acutely ill patients in hospital—recognition of and response to acute illness in adults in hospital. Available: http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf. Accessed 21 May 2014.

25. Royal College of Physicians (2012) National Early Warning Score (NEWS): standardising the assessment of acute-illness severity in the NHS. Available: http://www.rcplondon.ac.uk/sites/default/files/documents/national-early-warning-score-standardising-assessment-acute-illness-severity-nhs.pdf. Accessed 21 May 2014.

26. National Health Service (2013) Locally developed CQUIN schemes 2012 and 2013 [database]. Available: http://www.institute.nhs.uk/commissioning/pct_portal/locally_developed_cquin_schemes_2012_and_2013_/. Accessed 21 May 2014.

27. Health Protection Agency (2011) English national point prevalence survey on healthcare-associated infections and antimicrobial use, 2011. Available: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317134304594. Accessed 28 May 2014.

28. VTE Prevention England (2014) CQUIN. Available: http://www.vteprevention-nhsengland.org.uk/commissioning/cquin. Accessed 21 May 2014.

29. RobertsLN, PorterG, BarkerRD, YorkeR, BonnerL, et al. (2013) Comprehensive venous thromboembolism prevention programme incorporating mandatory risk assessment reduces the incidence of hospital-associated thrombosis. Chest 144: 1276–1281.

30. House of Commons Health Committee (2005) The prevention of venous thromboembolism in hospitalised patients. Second report of session 2004–05. Available: http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/99/99.pdf. Accessed 21 May 2014.

31. WhiteRH (2003) The epidemiology of venous thromboembolism. Circulation 107(23 Suppl 1): I4–I8.

32. Patient Safety First Campaign. Case studies—falls. Available: http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/falls/. Accessed 28 May 2014.

33. OliverD, HealeyF, HainesT (2010) Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 26: 645–692.

34. RadleyDC, WassermanMR, OlshoLE, ShoemakerSJ, SprancaMD, et al. (2013) Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inform Assoc 20: 470–476.

35. Gallimore SC, Hoile RW, Ingram GS, Sherry KM (1997) The report of the National Confidential Enquiry into Perioperative Deaths: 1994/1995. Available: http://www.ncepod.org.uk/pdf/1994_5/Full%20Report%201994-1995.pdf. Accessed 21 May 2014.

36. McDonaldKM, MatesicB, Contopoulos-IoannidisDG, LonhartJ, SchmidtE, et al. (2013) Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 158: 381–389.

37. Institute for Healthcare Improvement (2005) SBAR technique for communication: a situational briefing model. Cambridge (Massachusetts): Institute for Healthcare Improvement.

38. Raduma-TomàsMA, FlinR, YuleS, WilliamsD (2011) Doctors' handovers in hospitals: a literature review. BMJ Qual Saf 20: 128–133.

39. UK Government (2013) Prime Minister announces £500 million to relieve pressures on A&E. Available: https://www.gov.uk/government/news/prime-minister-announces-500-million-to-relieve-pressures-on-ae. Accessed 21 May 2014.

40. YardleyIE, DonaldsonLJ (2010) Patient safety matters: reducing the risks of nasogastric tubes. Clin Med 10: 228–230.

41. National Patient Safety Agency (2012) Harm from flushing of nasogastric tubes before confirmation of placement. Available: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=133441. Accessed 21 May 2014.

42. PanesarSS, SalvillaSA, PatelB, DonaldsonSL (2011) Laparoscopic cholecystectomy: device-related errors revealed through a national database. Expert Rev Med Devices 8: 555–560.

43. NHS England (2013) A promise to learn—a commitment to act. Improving the safety of patients in England. London: National Health Service England.

44. BarbieriJS, FuchsBD, FishmanN, CutilliCC, UmscheidCA, et al. (2013) The Mortality Review Committee: a novel and scalable approach to reducing inpatient mortality. Jt Comm J Qual Patient Saf 39: 387–395.