The report highlights that:
people can expect to spend more of their lives in poor health
improvements to life expectancy have stalled, and declined for the poorest 10% of women
the health gap has grown between wealthy and deprived areas
place matters – living in a deprived area of the North East is worse for your health than living in a similarly deprived area in London, to the extent that life expectancy is nearly five years less.
Local reporting on complaints is inconsistent and inaccessible.
Staff are not empowered to communicate with the public on complaints.
Reporting focuses on counting complaints, not demonstrating learning.
This thematic review presents a detailed analysis of claims made after an individual has attempted to take their life.Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery.
The results are split into two parts. The first part analyses the problems identified from the clinical details of each claim and the second part analyses the quality of the serious incident reports.
Part one identifies recurring clinical themes and areas for improvement. Five areas where there were common issues in clinical care are discussed in depth:
communication, particularly failures in intra-agency working
Part two identifies four main areas of concern, where:
There was a lack of family involvement and staff support through the investigation and inquest process.
The quality of root cause analysis undertaken as part of the Serious Incident (SI) investigation was generally poor and did not focus on systemic issues.
Due to the poor SI report quality, the recommendations arising from SI investigations were unlikely to reduce the incidence of future harm.
Reports to prevent future deaths (PFDs) were issued to trusts by the coroner with little consistency and there were poor mechanisms to ensure that changes in response to the PFDs had been made or addressed the issues highlighted.
Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient experience.
Medication errors (MEs) are common and persistent problems that may pose significant risk to critically ill children admitted to paediatric and neonatal intensive care units.
Prescribing and medication administration errors were the common types of MEs and dosing errors were the most frequent ME subtype in both paediatric and neonatal intensive care unit settings.
Anti-infective medications were the commonly reported drug class associated with MEs/preventable adverse drug events across both intensive care unit types.
Further research is needed to examine medication administration errors and preventable adverse drug events in children’s intensive care settings.
About the authors
Robert W. Proctor is a distinguished professor of Psychological Sciences at Purdue University. He is a fellow of the American Psychological Association, Association for Psychological Science, and the Human Factors and Ergonomics Society, and recipient of the Franklin V. Taylor Award for Outstanding Contributions in the Field of Applied Experimental/Engineering Psychology from Division 21 of the American Psychological Association in 2013. He is co-author of Stimulus-Response Compatibility: Data, Theory and Application, Skill Acquisition & Training, and co-editor of Handbook of Human Factors in Web Design.
Trisha Van Zandt is a professor of Psychology at The Ohio State University. She is a member of the Society for Mathematical Psychology, of which she was President in 2006-2007, and the American Statistical Association. She has received multiple research grants from the National Science Foundation and the Presidential Early Career Award for Scientists and Engineers in 1997. She is co-author of review chapters "Designs for and Analyses of Response Time Experiments" in the Oxford Handbook of Quantitative Methods and "Mathematical Psychology" in the APA Handbook of Research Methods in Psychology.
The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.
The results of this study show that poor organisational culture and leadership negatively influences and hinders doctors who make mistakes. Leaders who promote and create environments for open and constructive dialogue following adverse events enable the concept of fallibility and imperfection to be assimilated into new ways of learning. Guilt and fear are the most consistently reported psychological symptoms along with a perception of loss of professional respect and standing. Doctors often carry unresolved trauma for several years causing them to constantly relive an event. Unchecked, this can lead to poor relationships with colleagues and impact greatly on their ability to sleep and performance at work.
The review concludes that a prevailing silence, exacerbated by poor organisational culture, inhibits proper disclosure to the first victim, the patient and family. It also impedes a healthy recovery trajectory for the doctor, the second victim. Leaders of organisations have a vital strategic and operational role in creating open, transparent and compassionate cultures where dialogue and understanding takes place for those affected by second victim phenomenon.
The review will summarise the literature relating to contributory factors to patient safety incidents in primary care. The findings from this review will provide an evidence-based contributory factors framework for use in the primary care setting. It will increase understanding of factors that contribute to patient safety incidents and ultimately improve quality of healthcare.