The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study

BMC Health Services Research

Sheila Hollins³  Steve Gillard³  Christine Edwards⁶  Nikoletta Giatras²  Elisabeth Abraham¹  Vanessa Gordon⁴  Lucy Goulding⁷  Irene Tuffrey-Wijne⁵ 

[1] Florence Nightingale Faculty of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UK;Cass Business School, City University London, London EC1Y 8TZ, UK;Institute of Population Health, St George’s University of London, Cranmer Terrace, London SW17 0RE, UK;NHS England Patent Safety Maple Street, London W1T 5HD, UK;Faculty of Health, Social Care and Education, St. George’s University of London and Kingston University, 2nd floor Grosvenor Wing, Cranmer Terrace, London SW17 0RE, UK;Institute of Leadership and Management in Health, Kingston University Business School, Kingston, UK;King’s Improvement Science, King’s College London, De Crespigny Park, London SE5 8AF, UK

关键词: Quality improvement;    Safety culture;    Health Services Research;    Hospital;    Patient safety;    Learning disability;    Intellectual disability;   

Others  :  1126164
DOI  :  10.1186/1472-6963-14-432

 received in 2013-12-16, accepted in 2014-08-19,  发布年份 2014

【 摘 要 】

Background

There has been evidence in recent years that people with intellectual disabilities in acute hospitals are at risk of preventable deterioration due to failures of the healthcare services to implement the reasonable adjustments they need. The aim of this paper is to explore the challenges in monitoring and preventing patient safety incidents involving people with intellectual disabilities, to describe patient safety issues faced by patients with intellectual disabilities in NHS acute hospitals, and investigate underlying contributory factors.

Methods

This was a 21-month mixed-method study involving interviews, questionnaires, observation and monitoring of incident reports to assess the implementation of recommendations designed to improve care provided for patients with intellectual disabilities and explore the factors that compromise or promote patient safety. Six acute NHS Trusts in England took part. Data collection included: questionnaires to clinical hospital staff (n = 990); questionnaires to carers (n = 88); interviews with: hospital staff including senior managers, nurses and doctors (n = 68) and carers (n = 37); observation of in-patients with intellectual disabilities (n = 8); monitoring of incident reports (n = 272) and complaints involving people with intellectual disabilities.

Results

Staff did not always readily identify patient safety issues or report them. Incident reports focused mostly around events causing immediate or potential physical harm, such as falls. Hospitals lacked effective systems for identifying patients with intellectual disabilities within their service, making monitoring safety incidents for this group difficult.

The safety issues described by the participants were mostly related to delays and omissions of care, in particular: inadequate provision of basic nursing care, misdiagnosis, delayed investigations and treatment, and non-treatment decisions and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders.

Conclusions

The events leading to avoidable harm for patients with intellectual disabilities are not always recognised as safety incidents, and may be difficult to attribute as causal to the harm suffered. Acts of omission (failure to give care) are more difficult to recognise, capture and monitor than acts of commission (giving the wrong care). In order to improve patient safety for this group, the reasonable adjustments needed by individual patients should be identified, documented and monitored.

【 授权许可】

   
2014 Tuffrey-Wijne et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]World Health Organisation: Patient safety. http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/patient-safety webcite (accessed 15/07/2014)
• [2]National Patient Safety Agency: What is a patient safety incident?. http://www.npsa.nhs.uk/nrls/reporting/what-is-a-patient-safety-incident/ webcite (accessed 15/07/2014)
• [3]Agency NPS: A risk matrix for managers. London: National Patient Safety Agency; 2008.
• [4]NHS England Patient safety Domain Team: The never events list; 2013/14 update. London: NHS England; 2013.
• [5]Vincent C: Adverse events in British hospitals: preliminary retrospective record review. Br Med J 2001, 322:517.
• [6]Leape L, Berwick D, Bates D: What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 2002, 288(4):501-507.
• [7]National Patient Safety Agency: Seven steps to patient safety The full reference guide. London: The National Patient Safety Agency; 2004.
• [8]Department of Health: Valuing People Now : A New Three-Year Strategy for people with learning disabilities. London: Department of Health; 2001.
• [9]Emerson E, Hatton C: People with Learning Disabilities in England. Centre for Disability Research: Lancaster; 2008.
• [10]Emerson E, Baines S, Allerton L, Welch V: Health Inequalities & People with Learning Disabilities in the UK: 2012. London: IHAL; 2012.
• [11]Prasher V, Janicki M: Physical health of adults with intellectual disabilities. Oxford: Wiley-Blackwell; 2002.
• [12]O’Hara J, McCarthy J, Bouras N: Intellectual disability and ill health: a review of the evidence. Cambridge: Cambridge University Press; 2010.
• [13]Disability Rights Commission: Equal treatment: closing the gap - a formal investigation into physical health inequalities experienced by people with learning disabilities and/or mental health problems. London: Disability Rights Commission; 2006.
• [14]Ouellette-Kuntz H: Understanding health disparities and inequities faced by individuals with intellectual disabilities. J Appl Res Intellect Disabil 2005, 18:113-121.
• [15]Mencap: Treat me right! Better healthcare for people with a learning disability. London: Mencap; 2004.
• [16]Department of Health: Expanding the list of “never events”: equality impact assessment. London: Department of Health; 2011.
• [17]National Patient Safety Agency: Safeguarding people with learning disabilities within the NHS: an agenda for the National Patient Safety Agency. London: National Patient Safety Agency; 2004.
• [18]National Patient Safety Agency: Understanding the patient safety issues for people with learning disabilities. London: National Patient Safety Agency; 2004.
• [19]Mencap: Death by indifference. London: Mencap; 2007.
• [20]Michael J: Healthcare for all: report of the independent inquiry into access to healthcare for people with learning disabilities. London: Aldridge Press; 2008.
• [21]Parliamentary and Health Service Ombudsman: Six lives: the provision of public services to people with learning disabilities. London: The Stationery Office; 2009.
• [22]Heslop P, Blair P, Fleming P, Hoghton M, Marriott A, Russ L: Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD): Final report. Norah Fry Research Centre: Bristol; 2013.
• [23]Heslop P, Blair PS, Fleming P, Hoghton M, Marriott A, Russ L: The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. Lancet 2013. [http://dx.doi.org/10.1016/S0140-6736(13)62026 webcite-7]
• [24]Tuffrey-Wijne I, Giatras N, Goulding L, Abraham E, Fenwick L, Edwards C, Hollins C: Identifying the factors affecting the implementation of strategies to promote a safer environment for patients with learning disabilities in NHS hospitals: a mixed-methods study. Health Serv Deliv Res 2013., 1(13) Available from: http://www.journalslibrary.nihr.ac.uk/hsdr/volume-1/issue-13 webcite
• [25]Care Quality Commission: Quality and risk profiles of NHS trusts in early 2010: a consultation of proposals. London: Care Quality Commission; 2010.
• [26]Department for Constitutional Affairs: Mental Capacity Act 2005 (Chapter 9). London: The Stationery Office; 2005. Available from: http://www.legislation.gov.uk/ukpga/2005/9/contents webcite
• [27]House of Lords Select Committee on the Mental Capacity Act 2005: Mental Capacity Act 2005: post-legislative scrutiny. Report of session 2013–14. London: The Stationery Office; 2014.
• [28]Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J: The Quality in Australian Healthcare Study. Med J Aust 1995, 163:458-471.
• [29]Agency for Healthcare Research and Quality Patient Safety Network: Patient safety network glossary. http://www.psnet.ahrq.gov/glossary.aspx?indexLetter=E webcite (accessed 15/07/2014)
• [30]Vincent C: Incident reporting and patient safety. Br Med J 2007, 334:51.
• [31]Tuffrey-Wijne I, Goulding L, Giatras N, Abraham E, Gillard S, White S, Edwards C, Hollins S: The barriers to and enablers of providing reasonably adjusted health services to people with intellectual disabilities in acute hospitals: evidence from a mixed-methods study. BMJ Open 2014. doi:10.1136/bmjopen-2013-004606