Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents

Yardley, Iain; Yardley, Sarah; Williams, Huw; Carson‐Stevens, Andrew; Donaldson, Liam

doi:10.1177/0269216318776846

Cited by 45 publications

(55 citation statements)

References 34 publications

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“…Incidents relating to broken or faulty equipment and the availability of equipment were common, and have also been reported in palliative care settings elsewhere 23. The cause of faulty or broken equipment is likely to be a mixture of issues in product design and misuse of equipment by parents and staff, and is therefore partly a training problem.…”

Section: Discussionmentioning

confidence: 97%

“…Incident reports are excellent tools for learning and for generating improvements to current systems. Patient safety incidents have been extensively studied in the hospital setting, but to date there has been limited research in other care settings 23 34. Our study is, to our knowledge, the first to examine incidents relating to the safety of enteral feeding at home.…”

Section: Discussionmentioning

confidence: 99%

“…The free text descriptions were coded to identify the problems in care, any stated contributory factors and patient outcomes. An adapted framework approach was used 23. Two authors (BP and RN) familiarised themselves with the data and noted relevant themes.…”

Section: Methodsmentioning

confidence: 99%

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Paediatric enteral feeding at home: an analysis of patient safety incidents

et al. 2019

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AimsTo describe the nature and causes of patient safety incidents relating to care at home for children with enteral feeding devices.MethodsWe analysed incident data relating to paediatric nasogastric, gastrostomy or jejunostomy feeding at home from England and Wales’ National Reporting and Learning System between August 2012 and July 2017. Manual screening by two authors identified 274 incidents which met the inclusion criteria. Each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.ResultsThe most common problems in care related to equipment and devices (n=98, 28%), procedures and treatments (n=86, 24%), information, training and support needs of families (n=54, 15%), feeds (n=52, 15%) and discharge from hospital (n=31, 9%). There was a clearly stated harm to the child in 52 incidents (19%). Contributory factors included staff/service availability, communication between services and the circumstances of the family carer.ConclusionsThere are increasing numbers of children who require specialist medical care at home, yet little is known about safety in this context. This study identifies a range of safety concerns relating to enteral feeding which need further investigation and action. Priorities for improvement are handovers between hospital and community services, the training of family carers, the provision and expertise of services in the community, and the availability and reliability of equipment. Incident reports capture a tiny subset of the total number of adverse events occurring, meaning the scale of problems will be greater than the numbers suggest.

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

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Paediatric enteral feeding at home: an analysis of patient safety incidents

et al. 2019

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“…The free text boxes for each incident were coded to identify the reported problems in care, any stated contributory factors and any stated patient outcome where evident from the reporter’s narrative. An adapted framework approach was used 15. An initial framework was created for problems in care, contributory factors and patient outcomes based on the framework used in a previous study by the same authors, which was developed by adapting existing frameworks for categorising problems in care, contributory factors and patient outcomes primarily in hospital settings 16.…”

Section: Methodsmentioning

confidence: 99%

Analysis of paediatric long-term ventilation incidents in the community

Nawaz

Page

Harrop³

et al. 2019

Arch Dis Child

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AimTo describe the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety.MethodsWe undertook an analysis of patient safety incident data relating to long-term ventilation in the community using incident reports from England and Wales’ National Reporting and Learning System occurring between January 2013 and December 2017. Manual screening by two authors identified 220 incidents which met the inclusion criteria. The free text for each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.ResultsCommon problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment.ConclusionsThis study identifies a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.

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“…1 2 Uncertainty about the goals of treatment, inappropriate presumptions or a desire to adhere to the prevailing clinical ethos in a given context can precipitate flawed skin care-related decisionmaking concerning patients receiving palliative care. [1][2][3] There are many guidelines [4][5][6][7][8] and publications 9 10 which are designed to inform healthcare professionals' decisions about end-of-life skin care. These national and international guidelines [4][5][6][7][8] set out the prevailing consensus on best practice with regard to end-of-life skin care, which maintains skin integrity for as long as possible and facilitates a dignified death that is in line with the patient's preferences.…”

Section: Introductionmentioning

confidence: 99%

Nurses’ decision-making about cancer patients’ end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol

Samuriwo

Lovell-Smith²,

Anstey

et al. 2020

BMJ Open

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IntroductionPatients with cancer are at high risk of developing pressure ulcers at the end of life as a result of their underlying condition or cancer treatment. There are many guidelines which set out best practice with regard to end-of-life skin care. However, the complexity of palliative cancer care often means that it is challenging for nurses to make the appropriate person-centred decisions about end-of-life skin care. This study seeks to explore the perceived importance that nurses place on different factors in their end-of-life skin care for patients with cancer. The utility, face validity and content validity of a prototype decision-making tool for end-of-life skin care will also be evaluated.Methods and analysisA mixed-method design will be used to gather data from primary and secondary care nurses working in different hospitals and local authority areas across Wales. Clinical vignettes will be used to gather qualitative and quantitative data from nurses in individual interviews. Qualitative data will be subject to thematic analysis and quantitative data will be subject to descriptive statistical analysis. Qualitative and quantitative data will then be synthesised, which will enhance the rigour of this study, and pertinently inform the further development of an end-of-life skin care decision-making tool for patients with cancer.Ethics and disseminationEthical approval to undertake the study has been granted by Cardiff University School of Healthcare Sciences Research Governance and Ethics Screening Committee. Informed consent will be obtained in writing from all the participants in this study. The results of this study will be disseminated through journal articles, as well as presentations at national and international conferences. We will also report our findings to patient and public involvement groups with an interest in improving cancer care, palliative care as well as skin care.

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Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents

Abstract: 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.

Cited by 45 publications

References 34 publications

Paediatric enteral feeding at home: an analysis of patient safety incidents

Paediatric enteral feeding at home: an analysis of patient safety incidents

Analysis of paediatric long-term ventilation incidents in the community

Nurses’ decision-making about cancer patients’ end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol

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