ArticleJournal of the Royal Society of Medicine2021
Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.
Article in Journal of the Royal Society of Medicine, 2021. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 11 papers, 1 of them a synthesis that pooled it.
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Who cites it
11 citing papers in PubMed, 1 synthesis or guideline pooled it, 17 citations in OpenAlex.
- Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis.BMJ quality & safety · 2022Pooled it
- Learning from end-of-life injectable medication patient safety incidents in the community: a mixed-methods analysis.The British journal of general practice : the journal of the Royal College of General Practitioners · 2026Article
- Article
- Multiple points of system failure underpin continuous subcutaneous infusion safety incidents in palliative care: A mixed methods analysis.Palliative medicine · 2025Article
- Article
- The benefits and opportunities: Engaging patients in identifying and reporting patient safety incidents.Healthcare management forum · 2024Article
- Barriers and Facilitators to Coping with Second Victim Experiences: Insights from Nurses and Nurse Managers.Journal of nursing management · 2024Article
- Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.Chiropractic & manual therapies · 2023Article
- Investigating the clinical decision-making of nursing students using high-fidelity simulation, observation and think aloud: A mixed methods research study.Journal of advanced nursing · 2023Article
- Prioritising health and wellbeing: the hope we cling to in 2021.Journal of the Royal Society of Medicine · 2021Article
- Article
Corrections and comments
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Authors and funding
5 authors at 3 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveSix per cent of hospital patients experience a patient safety incident, of which 12% result in severe/fatal outcomes. Acutely sick patients are at heightened risk. Our aim was to identify the most frequently reported incidents in acute medical units and their characteristics.
designRetrospective mixed methods methodology: (1) an a priori coding process, applying a multi-axial coding framework to incident reports; and, (2) a thematic interpretative analysis of reports.
settingPatient safety incident reports (10 years, 2005-2015) collected from the National Reporting and Learning System, which receives reports from hospitals and other care settings across England and Wales.
participantsReports describing severe harm/death in acute medical unit were identified.
main outcome measuresIncident type, contributory factors, outcomes and level of harm were identified in the included reports. During thematic analysis, themes and metathemes were synthesised to inform priorities for quality improvement.
resultsA total of 377 reports of severe harm or death were confirmed. The most common incident types were diagnostic errors (
conclusionThis 10-year national analysis of incident reports provides recommendations to improve patient safety including: introduction of electronic prescribing and monitoring systems; forcing checklists to reduce diagnostic errors; and increased senior presence overnight and at weekends.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.