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Patient safety

Review of hospital deaths identifies possible safety improvements

Researchers aimed to identify situations where frontline staff perceived their patients’ care to have been unsafe.

Nurse standing at a drugs trolley

Source: John Cole/Science Photo Library

Medication errors were responsible for 60 deaths over the study period

Patients’ lives could be saved through changes in six categories of hospital practice, researchers say, after an analysis of in-hospital deaths related to safety incidents identified “systemic failure”, PLoS Medicine reports[1] (24 June 2014).

Liam Donaldson, chair of health policy at Imperial College London, and his co-authors found that, between June 2010 and October 2012, 2,010 adult deaths in NHS hospitals in England were reported as being due to unsafe care.

It is mandatory for healthcare staff in England and Wales to report instances of safety-related hospital death or severe harm. However, the researchers say that their aim was not to determine the absolute incidence of severe harm but “to identify situations where frontline staff perceived their patients’ care to have been unsafe and associated with death”.

By reviewing detailed reports on each death over the 29-month period, the researchers classified incidents into one of 18 types, which fell into six broad categories of systemic failure: mismanagement of deterioration (35% of incidents); failure of prevention (26%); deficient checking and oversight (11%); dysfunctional patient flow (10%); equipment-related errors (6%); and other incidents where the problem underlying death was unclear (12%).

The largest single category — management of deterioration — included reasons such as “failure to act on or recognise deterioration” (23% of reported incidents), “failure to give ordered treatment/support in a timely manner” (6%) and “failure to observe” (6%). The second-largest category — failure of prevention — included “falls” and “healthcare-associated infections,” each of which accounted for 10% of reported incidents.

Medication errors, classified under “deficient checking and oversight”, were responsible for 60 deaths, 3% of the total. However, many deaths classified as being due to other reasons may also have been medication-related – for example, inpatient falls, healthcare-associated infection and venous thromboembolism.

The findings emphasise the value of safe systems, says Bryony Dean Franklin, executive lead pharmacist (research) and director of the Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust and UCL School of Pharmacy. “Collectively, these cases highlight the risks associated with medication that is not used or monitored correctly.”

Dean Franklin says that, as with all studies based on incident report data, there is likely to be some underreporting and variation in data quality, meaning that the real safety risks may be greater.  But she adds: “It’s also very encouraging to see the data given to the national reporting and learning system being analysed and used to find ways to facilitate greater organisational learning.”

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.20065519

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