Burke et al. carried out a systematic review. All studies that explored an intervention to improve failure to rescue in the adult population were considered. They found that complications occur consistently within healthcare organisations and organisations vary in their ability to manage such events. Failure to rescue is a measure of institutional competence in this context.
The authors propose “The 3 Rs of Failure to Rescue” of recognise, relay and react, and hope that this serves as a valuable framework for understanding the phases where failure of patient salvage may occur. Future efforts at mitigating the differences in outcome from complication management between units may benefit from incorporating this proposed framework into institutional quality improvement.
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.