BMJ study: 5 % of patients exposed to preventable harm across medical settings

BMJ | 2019| Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

A systematic review with meta analysis observes that the prevalence of preventable patient harm across a range of settings, their analysis indicates that approximately 1 in 20 patients are exposed to preventable harm. The study findings suggest that preventable patient harm was more prevalent in advanced specialties such as intensive care or surgery. 

Abstract

Objective To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

Design Systematic review and meta-analysis.

Data sources Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

Review methods Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

Results Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

Conclusions Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

The article is available to read in full from the BMJ 

In the news: OnMedica One in 20 patients exposed to preventable harm in medical care

Patient Safety Strategy

The NHS patient safety strategy | NHS Improvement 

This strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety.  To do this the NHS will build on two foundations: a patient safety culture and a patient safety system.

Three strategic aims will support the development of both:
• improving understanding of safety by drawing intelligence from multiple
sources of patient safety information (Insight)
• equipping patients, staff and partners with the skills and opportunities to
improve patient safety throughout the whole system (Involvement)
• designing and supporting programmes that deliver effective and sustainable
change in the most important areas (Improvement).

Full document: The NHS Patient Safety Strategy. Safer culture, safer systems, safer
patients

See also: How data can shape a safer NHS|  Nuffield Trust blog

Investigation into recognising and responding to critically unwell patients

Healthcare Safety Investigation Branch | May 2019 |Investigation into recognising and responding to critically unwell patients

The Healthcare Safety Investigation Branch has published its final report: Investigation into recognising and responding to critically unwell patients, with two safety recommendations and three safety observations published 23 May 2019.

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Image source: hsib.org.uk

Final report 

Summary report

New report focuses on recommendations to make ambulance transfers safer

Healthcare Safety Investigation Branch | January 2019 | New report focuses on recommendations to make ambulance transfers safer

A new report from the Healthcare Safety Investigation Branch, Transfer of Critically Ill Adults shows that a lack of national guidance and standard practice for ambulance transfers could be putting patients at risk. 

The report puts forward key recommendations aimed at making transfers safer for adults that are critically ill.

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Image source: hsib.org.uk

This investigation was launched after the Healthcare Safety Investigation Branch were notified of the case of Richard, a 54-year old man, who died during an emergency transfer to a specialist care centre. He had been diagnosed with an acute aortic dissection after experiencing chest pain during exercise earlier that day. Aortic dissection occurs when the innermost layer of the wall of the aorta tears, allowing blood at high pressure to flow in between the layers forcing them apart.

Safety recommendations

The report sets out two safety recommendations:

Patient Safety Collaboratives

NHS Improvement| January 2019 | Patient Safety Collaboratives: A retrospective review 

Almost five years since the establishment of  Patient Safety  Collaboratives (PSCs), NHS Improvement  commissioned a review (in 2018) to better understand the mechanics of the delivery of PSCs, the impact of the programme, and to make recommendations for the recommissioning of the PSCs.

he operational delivery and impact of the Patient Safety Collaborative programme. This report gives its findings and recommendations to strengthen the programme, i.

This review makes 13 recommendations to strengthen the programme, including greater collective focus on priority workstreams and alignment to the forthcoming patient safety strategy, building on momentum achieved to date, and informs the future operating model and commission for the PSCs (Source: NHS England).

NHS Improvement Patient Safety Collaboratives A retrospective review

NHS Safety Culture: Opening the door to change

Care Quality Commission | December 2018 | NHS Safety Culture: Opening the door to change

The CQC collaborated with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place. These are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

 

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Image source: cqc.org.uk

Their review sought to answer 4 questions:

  • How do trusts regard existing guidance to prevent Never Events?
  • How effectively do trusts use safety guidance?
  • How do other system partners support the implementation of safety guidance?
  • What can we learn from other industries?

To this end the CQC visited 18 NHS trusts (both acute and mental health) during April and June 2018. They conducted one-to-one interviews, visited different services and reviewed policies and procedures.

CQC also consulted aviation, nuclear and fire and rescue industries to understand other safety-critical industries’ approach to safety.

Although patient safety alerts are generally seen as an effective way to share safety guidance, the context in which they are landing creates challenges for trusts. The report identifies challenges faced by trusts, by the health system as a whole, and in educating and training staff (Source: CQC).

Full news release from CQC 

Opening the door to change 

Opening the door to change Summary

Related:

NHS Improvement Never events data 

Consultation on a national patient safety strategy for the NHS

NHS Improvement| December 2018 | Consultation on a national patient safety strategy for the NHS

NHS Improvement are developing proposals for a new national patient safety strategy to support the NHS to be the safest healthcare system in the world. The strategy is being developed alongside the NHS Long Term Plan and will be relevant to all parts of the NHS, be that physical or mental health care, in or out of hospital and primary care. To make sure the strategy works for patients, NHS staff and providers, they are currently consulting on their proposals. 

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Consultation document and further details are available from the Consultation web page