Abstract
Hospital mortality is increasingly being regarded as a key indicator of patient safety, yet methodologies for assessing mortality are frequently contested and seldom point directly to areas of risk and solutions. The aim of our study was to classify reports of deaths due to unsafe care into broad areas of systemic failure capable of being addressed by stronger policies, procedures, and practices. The deaths were reported to a patient safety incident reporting system after mandatory reporting of such incidents was introduced. The UK National Health Service database was searched for incidents resulting in a reported death of an adult over the period of the study. The study population comprised 2,010 incidents involving patients aged 16 y and over in acute hospital settings. Each incident report was reviewed by two of the authors, and, by scrutinising the structured information together with the free text, a main reason for the harm was identified and recorded as one of 18 incident types. These incident types were then aggregated into six areas of apparent systemic failure: mismanagement of deterioration (35%), failure of prevention (26%), deficient checking and oversight (11%), dysfunctional patient flow (10%), equipment-related errors (6%), and other (12%). The most common incident types were failure to act on or recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%). Analysis of these 2,010 fatal incidents reveals patterns of issues that point to actionable areas for improvement. Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives.
Highlights
Inpatient deaths are an inevitable outcome for some acutely and chronically ill patients admitted to hospital
Our approach demonstrates the potential utility of patient safety incident reports in identifying areas of service failure and highlights opportunities for corrective action to save lives
The study population was all adult deaths reported by National Health Service (NHS) staff as patient safety incidents from hospitals in England over the period 1 June 2010 to 31 October 2012, 17 mo in total
Summary
Inpatient deaths are an inevitable outcome for some acutely and chronically ill patients admitted to hospital. In England, such analyses led to the following: the recognition of major failures in the standards of care in the children’s heart surgery service at the Bristol Royal Infirmary [5], the identification of disturbing levels of poor care and neglect of elderly patients at Stafford Hospital (Mid Staffordshire NHS Foundation Trust) [6], and an urgent review of quality of care in 14 hospitals with high mortality rates [7] Metrics such as the hospital standardised mortality ratio and the Summary Hospital-Level Mortality Indicator are used to identify hospitals with potential patient safety problems [4]. To identify areas of service failure amenable to improvement through strengthened clinical policies, procedures, and practices, the researchers undertake a thematic analysis of deaths in hospitals in England that were reported by healthcare staff to a mandatory patient-safety-related incident reporting system. A thematic analysis examines patterns (‘‘themes’’) within nonnumerical (qualitative) data
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