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Lookup NU author(s): Stephanie Mulrine, Professor Katie Brittain
This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.Objective: The purpose of this study was to further the understanding of reported patient safety events at the interface between hospital and care home including what active failings and latent conditions were present and how reporting helped learning. Methods: Two care home organizations, one in the North East and one in the South West of England, participated in the study. Reports relating to a transition and where a patient safety event had occurred were sought during the COVID-19 (SARS-CoV-2) virus prepandemic and intrapandemic periods. All reports were screened for eligibility and analyzed using content analysis. Results: Seventeen South West England care homes and 15 North East England care homes sent 114 safety incident reports and after screening 91 were eligible for review. A hospital discharge transition (n = 78, 86%) was most common. Pressure damage (n = 29, 32%), medication errors (n = 26, 29%) and premature discharge (n = 21, 23%) contributed to 84% of the total reporting. Many ‘active failings’ (n = 340) were identified with fewer latent conditions (failings) (n = 14, 15%) being reported. No examples of individual learning were identified. Organization and systems learning were identified in 12 reports (n = 12, 13%). Conclusions: The findings highlight potentially high levels of underreporting. The most common safety incidents reported were pressure damage, medication errors, and premature discharge. Many active failings causing numerous staff actions were identified emphasizing the cost to patients and services. Additionally, latent conditions (failings) were not emphasized; similarly, evidence of learning from safety incidents was not addressed.
Author(s): Newman C, Mulrine S, Brittain K, Dawson P, Mason C, Spencer M, Sykes K, Young-Murphy L, Waring J, Scott J
Publication type: Article
Publication status: Published
Journal: Journal of Patient Safety
Year: 2024
Volume: 20
Issue: 7
Pages: 478-489
Print publication date: 01/10/2024
Online publication date: 28/08/2024
Acceptance date: 02/04/2018
Date deposited: 25/09/2024
ISSN (print): 1549-8417
ISSN (electronic): 1549-8425
Publisher: Lippincott Williams and Wilkins
URL: https://doi.org/10.1097/PTS.0000000000001267
DOI: 10.1097/PTS.0000000000001267
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