Iain Yardley1,2, Sarah Yardley3,4,5, Huw Williams6, Andrew Carson-Stevens6,7,8, Liam J Donaldson9. 1. 1 Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK. 2. 2 King's College, London, UK. 3. 3 Central and North West London NHS Foundation Trust, London, UK. 4. 4 Marie Curie Palliative Care Research Department, University College London, London, UK. 5. 5 Medical Education, Keele University Medical School, Keele, UK. 6. 6 Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK. 7. 7 Department of Family Practice, University of British Columbia, Vancouver, BC, Canada. 8. 8 Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia. 9. 9 Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
Abstract
BACKGROUND: Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. AIM: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. DESIGN: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. SETTING AND PARTICIPANTS: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. RESULTS: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. CONCLUSION: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.
BACKGROUND:Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. AIM: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. DESIGN: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. SETTING AND PARTICIPANTS: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. RESULTS: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. CONCLUSION: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.
Authors: Huw Williams; Sir Liam Donaldson; Simon Noble; Peter Hibbert; Rhiannon Watson; Joyce Kenkre; Adrian Edwards; Andrew Carson-Stevens Journal: Palliat Med Date: 2018-12-12 Impact factor: 4.762
Authors: Sarah Yardley; Huw Williams; Paul Bowie; Adrian Edwards; Simon Noble; Liam Donaldson; Andrew Carson-Stevens Journal: BMJ Open Date: 2022-01-03 Impact factor: 2.692
Authors: Sarah Yardley; Sally-Anne Francis; Antony Chuter; Stuart Hellard; Julia Abernethy; A Carson-Stevens Journal: BMJ Open Date: 2021-09-13 Impact factor: 2.692
Authors: Sarah Yardley; Sally-Anne Francis; Bryony Dean Franklin; Margaret Ogden; Anu Kajamaa; Karen Mattick Journal: BMJ Open Date: 2022-03-17 Impact factor: 2.692