The Most Common Serious Safety Errors in NHS Hospital Wards Over a 10 Year Period

The study by Alexandra Urquhart et al aimed to learn from and understand the most frequent patient safety incidences involving acutely sick adults that have resulted in severe harm or death. The study reviewed 370 instances of either death or severe harm in NHS hospitals in a 10-year period (2005–2015) based on acute medical assessment units in both England and Wales. Acute medical units were championed by the Royal College of Physicians in 2004 to reduce the load on the A&E departments.

According to the study:

Patient safety incidents occur in 6% of patient cases acutely admitted to hospital, with 12% resulting in severe or fatal outcomes.”

This is despite the fact that in 2004, the Royal College of Physicians urged acute medical units to relieve pressure on emergency departments in a bid to improve patient outcomes. However, a decade later the study noted:

Only a single Irish hospital study has reported decreased mortality since the introduction of an acute medical unit (a 60% reduction in relative risk for individual patients). It is still the case that, despite major redesign of care delivery, little is known about patient safety incidents occurring in acute medical units.”

The objectives of the study were to understand the characteristics of the incidents, including the contributing factors and outcomes, to interpret those factors in relation to the types of incidents, and to identify any priorities for improvement.

The study made use of the National Reporting and Learning System database. Incident reports received from staff in NHS hospitals in England and Wales have both structured and unstructured sections. The structured section includes a breakdown of the type of incident, severity of harm, incident location, as well as any specialty and medication used. The free-text (unstructured) section includes any preceding events and a detailing of the incident. The reports were over a period of 10 years, from 2005 to 2015.

The Most Frequent Incidences Reported

The research, published on the 4th of August, 2021 in the Journal of the Royal Society of Medicine, revealed the most frequent incidences reported by hospital staff include:

1.Errors made during arrival in an acute medical unit to diagnosis

“Common errors that occurred immediately after patients arrived in an acute medical unit included problems identifying significant illnesses early, especially if presentations were atypical. Errors involved ‘routine’ investigations that are commonly requested for all patients, the results of which were often not acted upon or false reassurance was gained from negative results when the most appropriate investigation may not have been requested.”

With regard to misdiagnosis errors:

“Delayed diagnosis was the most common (n = 36) diagnostic error, and cancer was the most commonly missed diagnosis (n = 11)” and “Staff mistakes were frequently identified as having led up to diagnostic errors (n = 15), and these were most often mistakes interpreting investigations, including ECGs and imaging tests (n = 9)”

2. Medication related errors

Medication errors were the second most common incident occurring, representing 16% (n = 61) of severe harm and death reports. The commonest contributory factors were failure to follow protocol (n = 8) and staff mistakes (n = 6).”

“Within the medication error reports, the main theme was human factors issues, including errors with handwriting or allergies not being checked or documented appropriately. One-fifth of the medication errors resulted in patient death (n = 13); these commonly occurred overnight (n = 6). The most common medication type associated with death following a medication error was antibiotics (n = 5)”

3. Errors in continuity of care

These included:
  • The lack of necessary treatment
  • Failure to follow management plans
  • Failure to follow-ups on results
  • Observations not done or acted upon.

“Errors commonly occurred when the care of patients was being transferred from an acute medical unit to the community or another specialty. Errors in continuity of medication, care plans and follow-up for patients after discharge were common themes. Patient care was often delayed due to a lack of available beds, delaying access to specialist care.”

Summary

The report stated:

A total of 377 reports of severe harm or death were confirmed. The most common incident types were diagnostic errors (n = 79), medication-related errors (n = 61), and failures in monitoring patients (n = 57). Incidents commonly stemmed from lack of active decision-making during patient admissions and communication failures between teams. Patients were at heightened risk of unsafe care during handovers and transfers of care.”

A list of the primary incident types

Table 1. The primary incident types from the included reports and the harm outcomes
from the a priori coding using the PISA classification.

The Contributory Factors to the Incidents

Table 2. Contributory factors by incident type (see supplemental Appendix 1 for a more detailed breakdown).

As well as the risks of mistakes occurring during handovers, the risks to patients being transferred to other hospitals and the lack of continuous care between different hospital locations was highlighted in 36 of the assessed reports, most frequently overnight.

The report noted:

“It highlights poor communication between staff during patient care handovers and an ineffectively large ratio of patients to doctors, with less staff being available after work hours.”

Patients being assessed by inexperienced staff

According to the report:

Our analysis shows the system relies on the most junior doctors and staff members seeing patients first. A lack of experience led to problems recognising acutely unwell patients, selecting appropriate proformas to use or accessing senior help.”

University College London and Cardiff University researchers stated that safety improvement efforts should prioritise increasing the after work-hours support for junior doctors and employing the use of more electronic prescribing systems to reduce medication errors.

Patients at risk overnight

The medication errors are mostly being made overnight, with out-of-hours pharmacy support said to be relatively non-existent. Coupled with the higher patients to doctor ratios during the night, it explains the increase in likelihood of the severe harm or death incidents during those hours. Patients are generally at an increased risk overnight.

Cardiff University’s Dr Andrew Carson-Stevens, the lead researcher and clinical reader in patient safety and quality improvement commented:

“The reports in this study came from frontline healthcare professionals over a 10-year period and our detailed analysis highlights where acute medical units can review their existing systems to ensure they are as safe as possible.”

Vulnerable patients at risk

Researchers add that the patients who are unable to speak up for themselves could be most at risk. One of the key conclusions throughout the assessed reports was the general dependence on certain individuals and the patients themselves to remind the staff about necessary and/or scheduled tests and referrals. If a patient is unaware of what should happen, or does not speak in spite of this knowledge, they are at a greater risk of going through the undesirable incidences stemming from lack of proper care.

The University of London’s Sarah Yardley highlighted this worrying fact, saying:

“Patients who were unable to self-advocate due to their illness or other vulnerabilities were often overlooked due to system pressures and may be most at risk.”

The conclusions of the report

In its conclusion, the report recommends improvements to patient safety following the 10-year analysis of incidence reports. These recommendations include:

  • The introduction of electronic drug prescription and monitoring systems and access to a pharmacist

“Medication errors can be reduced by the presence of an additional medical admission pharmacist seven days a week, as this can improve the number of full medication histories taken on admission.21 Many of the medication errors occurring in the acute medical unit could be reduced with wider implementation of electronic prescribing systems.”

  • Enforcing checklists to reduces misdiagnosis

“These errors can be prevented by using checklists which provide a layout for assessing patients, this can alert clinicians to any areas where more information needs to be collected”

  • Electronic handover systems

“Electronic handover systems allow doctors to provide up-to-date patient information, including monitoring, and create lists of outstanding tasks, improving the safety of handovers.15 Problems during handover were a common cause of errors in patient monitoring and many of these errors occurred overnight”.

  • Increase in the number of senior staff overnight and during weekends.

“Our analysis shows the system relies on the most junior doctors and staff members seeing patients first. A lack of experience led to problems recognising acutely unwell patients, selecting appropriate proformas to use or accessing senior help.”


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