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Harms from discharge to primary care: mixed methods analysis of incident reports.

ABSTRACT: Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice.A mixed methods analysis of 598 patient safety incident reports in England and Wales related to 'Discharge' from the National Reporting and Learning System.Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice.A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with 'safe discharge' checklists, discharge coordinators, and family involvement.Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.

SUBMITTER: Williams H

PROVIDER: S-EPMC4655737 | biostudies-other | 2015 Dec

REPOSITORIES: biostudies-other

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Project description:Rationale & objectiveWidespread delivery of high-quality care for acute kidney injury (AKI) survivors after hospital discharge requires a multidisciplinary team. We aimed to compare management approaches between nephrologists and primary care providers (PCPs) and explored strategies to optimize collaboration.Study designExplanatory sequential mixed-methods study using a case-based survey followed by semi-structured interviews.Setting & participantsNephrologists and PCPs providing AKI survivor care at 3 Mayo Clinic sites and the Mayo Clinic Health System were included.OutcomesSurvey questions and interviews elucidated participants' recommendations for post-AKI care.Analytical approachDescriptive statistics were used to summarize survey responses. Qualitative data analysis used deductive and inductive strategies. A connecting and merging approach was used for mixed-methods data integration.Results148 of 774 (19%) providers submitted survey responses (24/72 nephrologists and 105/705 PCPs). Nephrologists and PCPs recommended laboratory monitoring and follow-up with a PCP shortly after hospital discharge. Both indicated that the need for nephrology referral, and its timing should be dictated by clinical and non-clinical patient-specific factors. There were opportunities for improvement in medication and comorbid condition management in both groups. Incorporation of multidisciplinary specialists (eg, pharmacists) was recommended to expand knowledge, optimize patient-centered care, and alleviate provider workload.LimitationsSurvey findings may have been affected by non-response bias and the unique challenges facing clinicians and health systems during the COVID-19 pandemic. Participants were from a single health system, and their views or experiences may differ from those in other health systems or serving different populations.ConclusionsA multidisciplinary team-based model of post-AKI care may facilitate implementation of a patient-centered care plan, improve adherence to best practices, and reduce clinician and patient burden. Individualizing care for AKI survivors based on clinical and non-clinical patient-specific factors is needed to optimize outcomes for patients and health systems.

Project description:BackgroundThe COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context.MethodsWe conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript.ResultsWe identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose.ConclusionsWe have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Project description:BACKGROUND:Implementation of evidence-based programs (EBPs) for disease self-management and prevention is a policy priority. It is challenging to implement EBPs offered in community settings and to integrate them with healthcare. We sought to understand, categorize, and richly describe key challenges and opportunities related to integrating EBPs into routine primary care practice in the United States. METHODS:As part of a parent, participatory action research project, we conducted a mixed methods evaluation guided by the PRECEDE implementation planning model in an 11-county region of Southeast Minnesota. Our community-partnered research team interviewed and surveyed 15 and 190 primary care clinicians and 15 and 88 non-clinician stakeholders, respectively. We coded interviews according to pre-defined PRECEDE factors and by participant type and searched for emerging themes. We then categorized survey items-before looking at participant responses-according to their ability to generate further evidence supporting the PRECEDE factors and emerging themes. We statistically summarized data within and across responder groups. When consistent, we merged these with qualitative insight. RESULTS:The themes we found, "Two Systems, Two Worlds," "Not My Job," and "Seeing is Believing," highlighted the disparate nature of prescribed activities that different stakeholders do to contribute to health. For instance, primary care clinicians felt pressured to focus on activities of diagnosis and treatment and did not imagine ways in which EBPs could contribute to either. Quantitative analyses supported aspects of all three themes, highlighting clinicians' limited trust in community-placed activities, and the need for tailored education and system and policy-level changes to support their integration with primary care. CONCLUSIONS:Primary care and community-based programs exist in disconnected worlds. Without urgent and intentional efforts to bridge well-care and sick-care, interventions that support people's efforts to be and stay well in their communities will remain outside of-if not at odds with-healthcare.

Project description:INTRODUCTION:Poor quality communication between hospital doctors and GPs at the time of hospital discharge is associated with adverse patient outcomes. This may be more marked after an episode of critical illness, the complications of which can persist long after hospital discharge. AIMS:1. to evaluate information sharing between ICU staff and GPs after a critical illness 2. to identify factors influencing the flow and utilisation of this information. METHODS:Parallel mixed methods observational study in an Irish setting, with equal emphasis on quantitative and qualitative data. Descriptive analysis was performed on quantitative data derived from GP and ICU consultant questionnaires. Qualitative data came from semi-structured interviews with GPs and consultants, and were analysed using directed content analysis. Mixing of data occurred at the stage of interpretation. RESULTS:GPs rarely received information about an episode of critical illness directly from ICU staff, with most coming from patients and relatives. Information received from hospital sources was frequently brief and incomplete. Common communication barriers reported by consultants were insufficient time, low perceived importance and difficulty establishing GP contact. When provided information, GPs seldom actioned specific interventions, citing insufficient guidance in hospital correspondence and poor knowledge about critical illness complications and their management. A majority of all respondents thought that improved information sharing would benefit patients. Cultural influences on practice were identified in qualitative data. A priori qualitative themes were: (1) perceived benefits of information sharing, (2) factors influencing current practice and (3) strategies for optimal information sharing. Emergent themes were: (4) the central role of the GP in patient care, (5) the concept of the "whole patient journey" and (6) a culture of expectation around a GP's knowledge of hospital care. CONCLUSIONS:Practical and cultural factors contribute to suboptimal information sharing between ICU and primary care doctors around an episode of critical illness in ICU. We propose a three-milestone strategy to improve the flow and utilisation of information when patients are admitted, discharged or die within the ICU.

Project description:BackgroundChronic diseases are a significant public health concern, particularly in older adults. To address the delivery of health care services to optimally meet the needs of older adults with multiple chronic diseases, Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) uses a novel approach that involves patient home visits by trained volunteers to collect and transmit relevant health information using e-health technology to inform appropriate care from an inter-professional healthcare team. Health TAPESTRY was implemented, pilot tested, and evaluated in a randomized controlled trial (analysis underway). Knowledge translation (KT) interventions such as Health TAPESTRY should involve an investigation of their sustainability and scalability determinants to inform further implementation. However, this is seldom considered in research or considered early enough, so the objectives of this study were to assess the sustainability and scalability potential of Health TAPESTRY from the perspective of the team who developed and pilot-tested it.MethodsOur objectives were addressed using a sequential mixed-methods approach involving the administration of a validated, sustainability survey developed by the National Health Service (NHS) to all members of the Health TAPESTRY team who were actively involved in the development, implementation and pilot evaluation of the intervention (Phase 1: n = 38). Mean sustainability scores were calculated to identify the best potential for improvement across sustainability factors. Phase 2 was a qualitative study of interviews with purposively selected Health TAPESTRY team members to gain a more in-depth understanding of the factors that influence the sustainability and scalability Health TAPESTRY. Two independent reviewers coded transcribed interviews and completed a multi-step thematic analysis. Outcomes were participant perceptions of the determinants influencing the sustainability and scalability of Health TAPESTRY.ResultsTwenty Health TAPESTRY team members (53% response rate) completed the NHS sustainability survey. The overall mean sustainability score was 64.6 (range 22.8-96.8). Important opportunities for improving sustainability were better staff involvement and training, clinical leadership engagement, and infrastructure for sustainability. Interviews with 25 participants (response rate 60%) showed that factors influencing the sustainability and scalability of Health TAPESTRY emerged across two dimensions: I) Health TAPESTRY operations (development and implementation activities undertaken by the central team); and II) the Health TAPESTRY intervention (factors specific to the intervention and its elements). Resource capacity appears to be an important factor to consider for Health TAPESTRY operations as it was identified across both sustainability and scalability factors; and perceived lack of interprofessional team and volunteer resource capacity and the need for stakeholder buy-in are important considerations for the Health TAPESTRY intervention. We used these findings to create actionable recommendations to initiate dialogue among Health TAPESTRY team members to improve the intervention.ConclusionsOur study identified sustainability and scalability determinants of the Health TAPESTRY intervention that can be used to optimize its potential for impact. Next steps will involve using findings to inform a guide to facilitate sustainability and scalability of Health TAPESTRY in other jurisdictions considering its adoption. Our findings build on the limited current knowledge of sustainability, and advances KT science related to the sustainability and scalability of KT interventions.

Project description:BackgroundChildren are scheduled to receive 18-20 immunizations before their 18th birthday in England and Wales; this approximates to 13 million vaccines administered per annum. Each immunization represents a potential opportunity for immunization-related error and effective immunization is imperative to maintain the public health benefit from immunization. Using data from a national reporting system, this study aimed to characterize pediatric immunization-related safety incident reports from primary care in England and Wales between 2002 and 2013.MethodsA cross-sectional mixed methods study was undertaken. This comprised reading the free-text of incident reports and applying codes to describe incident type, potential contributory factors, harm severity, and incident outcomes. A subsequent thematic analysis was undertaken to interpret the most commonly occurring codes, such as those describing the incident, events leading up to it and reported contributory factors, within the contexts they were described.ResultsWe identified 1745 reports and most (n=1077, 61.7%) described harm outcomes including three deaths, 67 reports of moderate harm and 1007 reports of low harm. Failure of timely vaccination was the potential cause of three child deaths from meningitis and pneumonia, and described in a further 113 reports. Vaccine administration incidents included the wrong number of doses (n=476, 27.3%), wrong timing (n=294, 16.8%), and wrong vaccine (n=249, 14.3%). Documentation failures were frequently implicated. Socially and medically vulnerable children were commonly described.ConclusionThis is the largest examination of reported contributory factors for immunization-related patient safety incidents in children. Our findings suggest investments in IT infrastructure to support data linkage and identification of risk predictors, development of consultation models that promote the role of parents in mitigating safety incidents, and improvement efforts to adapt and adopt best practices from elsewhere, are needed to mitigate future immunization-related patient safety incidents. These priorities are particularly pressing for vulnerable patient groups.

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Harms from discharge to primary care: mixed methods analysis of incident reports.

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