Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

1. Viner RM, Hargreaves DS, Coffey C, Patton GC, Wolfe I. Deaths in young people aged 0–24 years in the UK compared with the EU15+ countries, 1970–2008: analysis of the WHO Mortality Database. Lancet. 2014;384(9946):880–92. doi: 10.1016/S0140-6736(14)60485-2 24929452

2. Pearson G. Why children die: a pilot study 2006. London: Confidential Enquiry into Maternal and Child Health; 2008.

3. Wolfe I, Macfarlane A, Donkin A, Marmot M, Viner R. Why children die: death in infants, children and young people in the UK. London: Royal College of Paediatrics and Child Health; 2014.

4. Carson-Stevens A, Edwards A, Panesar S, Parry G, Rees P, Sheikh A, et al. Reducing the burden of iatrogenic harm in children. Lancet. 2015;385(9978):1593–4. doi: 10.1016/S0140-6736(14)61739-6 25943799

5. Walsh KE, Bundy DG, Landrigan CP. Preventing health care-associated harm in children. JAMA. 2014;311(17):1731–2. doi: 10.1001/jama.2014.2038 24794361

6. Sheikh A, Bates D. Iatrogenic harm in primary care. Harvard Health Policy Rev. 2014;14(1):5–8.

7. Wolfe I, Cass H, Thompson MJ, Craft A, Peile E, Wiegersma PA, et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms. BMJ. 2011;342:d1277. doi: 10.1136/bmj.d1277 21385800

8. World Health Organization Regional Office for Europe. European detailed mortality database. 2015 [cited 2015 Jul 1]. Available from: http://data.euro.who.int/dmdb/.

9. Asthma UK. The asthma divide: inequalities in emergency care for people with asthma in England. London: Asthma UK; 2007.

10. Saxena S, Bottle A, Gilbert R, Sharland M. Increasing short-stay unplanned hospital admissions among children in England; time trends analysis ‘97–’06. PLoS ONE 2009;4(10):e7484. doi: 10.1371/journal.pone.0007484 19829695

11. Milne C, Forrest L, Charles T. Learning from analysis of general practitioner referrals to a general paediatric department. Arch Dis Child. 2010;96(1):A71.

12. Cecil E, Bottle A, Cowling TE, Majeed A, Wolfe I, Saxena S. Primary care access, emergency department visits, and unplanned short hospitalizations in the UK. Pediatrics. 2016;137(2):1–9.

13. Parry G, Cline A, Goldmann D. Deciphering harm measurement. JAMA. 2012;307(20):2155–6. doi: 10.1001/jama.2012.3649 22618920

14. Stockwell DC, Bisarya H, Classen DC, Kirkendall ES, Landrigan CP, Lemon V, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036–42. doi: 10.1542/peds.2014-2152 25986015

15. Chapman SM, Fitzsimons J, Davey N, Lachman P. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4(7):e005066. doi: 10.1136/bmjopen-2014-005066 24993759

16. Hibbert PD, Hallahan AR, Muething SE, Lachman P, Hooper TD, Wiles LK, et al. CareTrack Kids—part 3. Adverse events in children’s healthcare in Australia: study protocol for a retrospective medical record review. BMJ Open. 2015;5(4):e007750. doi: 10.1136/bmjopen-2015-007750 25854978

17. Mangione-Smith R, DeCristofaro AH, Setodji CM, Keesey J, Klein DJ, Adams JL, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):1515–23. doi: 10.1056/NEJMsa064637 17928599

18. Cresswell KM, Sheikh A. Information technology-based approaches to reducing repeat drug exposure in patients with known drug allergies. J Allergy Clin Immunol. 2008;121(5):1112–1117.e7. doi: 10.1016/j.jaci.2007.12.1180 18313132

19. Lamont T, Beaumont C, Fayaz A, Healey F, Huehns T, Law R, et al. Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency. BMJ. 2011;342:d2586. doi: 10.1136/bmj.d2586 21546422

20. Lamont T, Harrison S, Panesar S, Surkitt-Parr M. Safer insertion of suprapubic catheters: summary of a safety report from the National Patient Safety Agency. BMJ. 2011;342:d924. doi: 10.1136/bmj.d924 21349899

21. Lamont T, Watts F, Panesar S, MacFie J, Matthew D. Early detection of complications after laparoscopic surgery: summary of a safety report from the National Patient Safety Agency. BMJ. 2011;342:c7221. doi: 10.1136/bmj.c7221 21248017

22. Lamont T, Watts F, Stanley J, Scarpello J, Panesar S. Reducing risks of tourniquets left on after finger and toe surgery: summary of a safety report from the National Patient Safety Agency. BMJ. 2010;340:c1981. doi: 10.1136/bmj.c1981 20410165

23. Rees P, Edwards A, Panesar S, Powell C, Carter B, Williams H, et al. Safety incidents in the primary care office setting. Pediatrics. 2015;35(6):1027–35.

24. Rees P, Evans H, Panesar S, Llewelyn M, Edwards A, Carson-Stevens A. Contraindicated BCG vaccination in “at risk” infants. BMJ. 2014;349:g5388. doi: 10.1136/bmj.g5388 25208721

25. Rees P, Edwards A, Powell C, Evans HP, Carter B, Hibbert P, et al. Pediatric immunization-related safety incidents in primary care: a mixed methods analysis of a national database. Vaccine. 2015;33(32):3873–80. doi: 10.1016/j.vaccine.2015.06.068 26122580

26. National Reporting and Learning System. Organisation patient safety incident reports September 2012. London: National Health Service; 2012 Sep 13 [cited 2015 Jul 1]. Available from: http://www.nrls.npsa.nhs.uk/news-cp/organisation-patient-safety-incident-reports-september-2012/.

27. Donaldson LJ, Panesar SS, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med. 2014;11(6):e1001667. doi: 10.1371/journal.pmed.1001667 24959751

28. Carson-Stevens A, Hibbert P, Avery A, Butlin A, Carter B, Cooper A, et al. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open. 2015;5(12):e009079. doi: 10.1136/bmjopen-2015-009079 26628526

29. Hibbert PD, Runciman WB, Deakin A. A recursive model of incident analysis. Adelaide: Australian Patient Safety Foundation; 2007.

30. World Health Organization. The conceptual framework for the international classification for patient safety. Geneva: World Health Organization; 2009.

31. World Health Organization. ICD-10. International statistical classification of diseases and related health problems. Geneva: World Health Organization; 2010.

32. Paediatric Formulary Committee. BNF for children 2014–2015. London: Pharmaceutical Press; 2014.

33. Tukey JW. Exploratory data analysis. Boston: Addison-Wesley; 1970.

34. Scobie A, Cook S. Analysis of health care error reports. In: Hurwitz B, Sheikh A, editors. Health care errors and patient safety. Hoboken (New Jersey): John Wiley & Sons; 2011.

35. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

36. Denzin NK, Lincoln YS. The SAGE handbook of qualitative research. London: SAGE Publications; 2011.

37. Creswell JW, Clark VLP. Designing and conducting mixed methods research. London: SAGE Publications; 2006.

38. Roland D, Jones C, Neill S, Thompson M, Lakhanpaul M. Safety netting in healthcare settings: what it means, and for whom? Arch Dis Child Educ Pract Ed. 2014;99(2):48–53. doi: 10.1136/archdischild-2012-303056 24164728

39. Wong IC, Wong LY, Cranswick NE. Minimising medication errors in children. Arch Dis Child. 2009;94(2):161–4. doi: 10.1136/adc.2007.116442 18829622

40. Department of Health. An organisation with a memory. London: Stationary Office; 2000.

41. Department of Health. Building a safer NHS for patients. Implementing an organisation with a memory. London: Stationary Office; 2001.

42. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington (District of Columbia): National Academies Press; 1999.

43. Walsh KE, Mazor KM, Stille CJ, Torres I, Wagner JL, Moretti J, et al. Medication errors in the homes of children with chronic conditions. Arch Dis Child. 2011;96(6):581–6. doi: 10.1136/adc.2010.204479 21444297

44. Walsh KE, Roblin DW, Weingart SN, Houlahan KE, Degar B, Billett A, et al. Medication errors in the home: a multisite study of children with cancer. Pediatrics. 2013;131(5):e1405–14. doi: 10.1542/peds.2012-2434 23629608

45. Benavides S, Huynh D, Morgan J, Briars L. Approach to the pediatric prescription in a community pharmacy. J Pediatr Pharmacol Ther. 2011;16(4):298–307. doi: 10.5863/1551-6776-16.4.298 22768015

46. Asthma UK. Patient safety failures in asthma care: the scale of unsafe prescribing in the UK. London: Asthma UK; 2015.

47. Hardelid P, Dattani N, Davey J, Pribramska I, Gilbert G. Child Health Reviews–UK: overview of child deaths in the four UK countries. London: Royal College of Paediatrics and Child Health; 2013.

48. Harnden A, Mayon-White R, Mant D, Kelly D, Pearson G. Child deaths: confidential enquiry into the role and quality of UK primary care. Br J Gen Pract. 2009;59(568):819–24. doi: 10.3399/bjgp09X472520 19728902

49. Royal College of Paediatrics and Child Health. Coordinating epilepsy care: a UK-wide review of healthcare in cases of mortality and prolonged seizures in children and young people with epilepsies. London: Royal College of Paediatrics and Child Health; 2013.

50. Makeham MA, Kidd MR, Saltman DC, Mira M, Bridges-Webb C, Cooper C, et al. The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. Med J Aust. 2006;185(2):95–8. 16842067

51. Makeham MA, Stromer S, Bridges-Webb C, Mira M, Saltman DC, Cooper C, et al. Patient safety events reported in general practice: a taxonomy. Qual Saf Health Care. 2008;17(1):53–7. doi: 10.1136/qshc.2007.022491 18245220

52. Makeham MA, Mira M, Kidd MR. Lessons from the TAPS study—knowledge and skills errors. Aust Fam Physician. 2008;37(3):145–6. 18345364

53. Stewart B, Fairhurst R, Markland J, Marzouk O. Review of calls to NHS Direct related to attendance in the paediatric emergency department. Emerg Med J. 2006;23(12):911–4. doi: 10.1136/emj.2006.039339 17130596

54. Hippisley-Cox J, Fenty J, Heaps M. Trends in consultation rates in general practice 1995 to 2006: analysis of the QRESEARCH database. Nottingham: QRESEARCH; 2007.

55. Gill PJ, Wang KY, Mant D, Hartling L, Heneghan C, Perera R, et al. The evidence base for interventions delivered to children in primary care: an overview of Cochrane systematic reviews. PLoS ONE. 2011;6(8):e23051. doi: 10.1371/journal.pone.0023051 21829691

56. Royal College of General Practitioners Birmingham Research Unit. Weekly returns service annual prevalence report 2007. London: Royal College of General Practitioners; 2008.

57. Derkx HP, Rethans JJE, Muijtjens AM, Maiburg BH, Winkens R, van Rooij HG, et al. Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study. BMJ. 2008;337:a1264. doi: 10.1136/bmj.a1264 18790814

58. Giesen P, Ferwerda R, Tijssen R, Mokkink H, Drijver R, van den Bosch W, et al. Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency? Quali Saf Health Care. 2007;16(3):181–4.

59. Huibers L, Smits M, Renaud V, Giesen P, Wensing M. Safety of telephone triage in out-of-hours care: a systematic review. Scand J Prim Health Care. 2011;29(4):198–209. doi: 10.3109/02813432.2011.629150 22126218

60. McLellan N. NHS Direct: here and now. Arch Dis Child. 1999;81(5):376–8. 10519706

61. McLellan N. NHS Direct: virtually engaged. Arch Dis Child. 2004;89(1):57–9. 14709509

62. O’Cathain A, Webber E, Nicholl J, Munro J, Knowles E. NHS Direct: consistency of triage outcomes. Emerg Med J. 2003;20(3):289–92. doi: 10.1136/emj.20.3.289 12748157

63. Smits M, Huibers L, Kerssemeijer B, De Feijter E, Wensing M, Giesen P. Patient safety in out-of-hours primary care: a review of patient records. BMC Health Serv Res. 2010;10(1):335.

64. Cook R, Thakore S, Morrison W, Meikle J. To ED or not to ED: NHS 24 referrals to the emergency department. Emerg Med J. 2010;27(3):213–5. doi: 10.1136/emj.2008.064261 20304891

65. Doctor K, Correa K, Olympia RP. Evaluation of an after-hours call center: are pediatric patients appropriately referred to the emergency department? Pediatr Emerg Care. 2014;30(11):798–804. doi: 10.1097/PEC.0000000000000262 25343736

66. Leprohon J, Patel VL. Decision-making strategies for telephone triage in emergency medical services. Med Decis Making. 1995;15(3):240–53. 7564938

67. Monaghan R, Clifford C, McDonald P. Seeking advice from NHS direct on common childhood complaints: does it matter who answers the phone? J Adv Nurs. 2003;42(2):209–16. 12670388

68. Torjesen I. Ignorance about sepsis was a factor in child’s death, says report. BMJ. 2016;352:i541. doi: 10.1136/bmj.i541 26819199

69. Cresswell KM, Panesar SS, Salvilla SA, Carson-Stevens A, Larizgoitia I, Donaldson LJ, et al. Global research priorities to better understand the burden of iatrogenic harm in primary care: an international Delphi exercise. PLoS Med. 2013;10(11):e1001554. doi: 10.1371/journal.pmed.1001554 24260028

70. Stebbing C, Wong IC, Kaushal R, Jaffe A. The role of communication in paediatric drug safety. Arch Dis Child. 2007;92(5):440–5. doi: 10.1136/adc.2006.112987 17449527

71. Wong IC, Basra N, Yeung VW, Cope J. Supply problems of unlicensed and off-label medicines after discharge. Arch Dis Child. 2006;91(8):686–8. doi: 10.1136/adc.2006.093724 16717083

72. Green J, Thorogood N. Qualitative methods for health research. 2nd ed. London: SAGE Publications; 2009.

73. Mays N, Pope C. Rigour in qualitative research. BMJ. 1995;311(6997):109–12. 7613363

74. Franklin BD, Reynolds M, Sadler S, Hibberd R, Avery AJ, Armstrong SJ, et al. The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study. BMJ Qual Saf. 2014;23(8):629–38. doi: 10.1136/bmjqs-2013-002776 24742778

75. Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, Levtzion-Korach O, et al. Effect of bar-code technology on the safety of medication administration. N Engl J Med. 2010;362(18):1698–707. doi: 10.1056/NEJMsa0907115 20445181

76. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med. 2001;155(9):1002–7. 11529801

77. Morriss FH, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN, et al. Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study. J Pediatr. 2009;154(3):363–8. doi: 10.1016/j.jpeds.2008.08.025 18823912

78. Levine SR, Cohen MR, Blanchard N. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther. 2001;6:426–42.

79. Kaji AH, Gausche-Hill M, Conrad H, Young KD, Koenig WJ, Dorsey E, et al. Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting. Pediatrics. 2006;118(4):1493–500. doi: 10.1542/peds.2006-0854 17015540

80. Campino A, Lopez‐Herrera MC, Lopez‐de‐Heredia I, Valls‐I‐Soler A. Educational strategy to reduce medication errors in a neonatal intensive care unit. Acta Paediatr. 2009;98(5):782–5. doi: 10.1111/j.1651-2227.2009.01234.x 19389122

81. Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children’s hospital. Pediatrics. 2006;118(4):e1124–9. doi: 10.1542/peds.2005-3183 17015504

82. Sullivan MM, O’Brien CR, Gitelman SE, Shapiro SE, Rushakoff RJ. Impact of an interactive online nursing educational module on insulin errors in hospitalized pediatric patients. Diabetes Care. 2010;33(8):1744–6. doi: 10.2337/dc10-0031 20504898

83. Booth R, Sturgess E, Taberner-Stokes A, Peters M. Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit. Intensive Care Med. 2012;38(11):1858–67. doi: 10.1007/s00134-012-2660-7 22885650

84. Kaminski GM, Schoettker PJ, Alessandrini EA, Luzader C, Kotagal U. A comprehensive model to build improvement capability in a pediatric academic medical center. Acad Pediatr. 2014;14(1):29–39. doi: 10.1016/j.acap.2013.02.007 24369867

85. Lacobucci G. What doctors think would make NHS 111 safer. BMJ. 2016;352:i638. doi: 10.1136/bmj.i638 26843414

86. Graber ML, Kissam S, Payne VL, Meyer AND, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012:;21(7):535–57. doi: 10.1136/bmjqs-2011-000149 22543420

87. Ramnarayan P, Roberts GC, Coren M, Nanduri V, Tomlinson A, Taylor PM, et al. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study. BMC Med Inform Decis Mak. 2006;6:22. doi: 10.1186/1472-6947-6-22 16646956

88. Ramnarayan P, Steel E, Britto JF. ISABEL: a novel approach to the reduction of medical error. Clinical Risk. 2004;10(1):9–11.

89. Ramnarayan P, Winrow A, Coren M, Nanduri V, Buchdahl R, Jacobs B, et al. Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making. BMC Med Inform Decis Mak. 2006;6:37. doi: 10.1186/1472-6947-6-37 17087835

90. Singh H, Graber ML, Kissam SM, Sorensen AV, Lenfestey NF, Tant EM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf. 2012;21(2):160–70. doi: 10.1136/bmjqs-2011-000150 22129930

91. Weick KE, Sutcliffe KM. Managing the unexpected. 3rd ed. New Jersey: John Wiley & Sons; 2015.

92. Brady PW, Wheeler DS, Muething SE, Kotagal UR. Situation awareness: a new model for predicting and preventing patient deterioration. Hosp Pediatr. 2014;4(3):143–6. doi: 10.1542/hpeds.2013-0119 24785557

93. Singh H, Thomas EJ, Wilson L, Kelly PA, Pietz K, Elkeeb D, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126(1):70–9. doi: 10.1542/peds.2009-3218 20566604

94. Thammasitboon S, Cutrer WB. Diagnostic decision-making and strategies to improve diagnosis. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):232–41. doi: 10.1016/j.cppeds.2013.07.003 24070580

95. Kim SW, Maturo S, Dwyer D, Monash B, Yager PH, Zanger K, et al. Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients. Otolaryngol Head Neck Surg. 2012;146(1):129–34. doi: 10.1177/0194599811421745 21908802

96. Sahyoun C, Fleegler E, Kleinman M, Monuteaux MC, Bachur R. Early identification of children at risk for critical care standardizing communication for inter-emergency department transfers. Pediatr Emerg Care. 2013;29(4):419–24. doi: 10.1097/PEC.0b013e318289d7c1 23528500

97. Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262–70. doi: 10.1001/jama.2013.281961 24302089

98. Weingart C, Herstich T, Baker P, Garrett ML, Bird M, Billock J, et al. Making good better: implementing a standardized handoff in pediatric transport. Air Med J. 2013;32(1):40–6. doi: 10.1016/j.amj.2012.06.005 23273309

99. Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, et al. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Health Serv Deliv Res 2016;4(27).

100. Hogan H, Zipfel R, Neuburger J, Hutchings A, Darzi A, Black N. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. BMJ. 2015;351:h3239. doi: 10.1136/bmj.h3239 26174149

101. Avery AJ. Understanding the nature and frequency of avoidable significant harm in primary care (phase 2). London: Health Research Authority; 2016 Jan 14 [cited 2016 Dec 15]. Available from: http://www.hra.nhs.uk/news/research-summaries/understanding-the-nature-frequency-of-avoidable-harm-in-primary-care/.