Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

Age and Ageing
Alison CooperAndrew Carson-Stevens

Abstract

older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting. to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care. a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013. 1,591 primary care patient safety incident reports regarding patients aged 65 years and older. we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care. the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serio...Continue Reading

References

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Citations

Nov 24, 2017·International Journal of Older People Nursing·Melissa WilloughbyLyndal Bugeja
Jul 10, 2018·Nature Reviews. Neurology·Maria Teresa FerrettiUNKNOWN Women’s Brain Project and the Alzheimer Precision Medicine Initiative
Mar 8, 2019·Journal of Trauma Nursing : the Official Journal of the Society of Trauma Nurses·Linda Nancy Roney, Mary C Acri
Oct 20, 2018·BMJ Quality & Safety·Sally J GilesAndrea L Hernan
Oct 6, 2019·BMC Family Practice·Andrew Carson-StevensAnthony Avery
Nov 14, 2017·Journal of Wound Care·R Samuriwo
May 30, 2020·The British Journal of General Practice : the Journal of the Royal College of General Practitioners·Rachel Ann Spencer
Sep 21, 2018·Pharmacy : Journal of Pharmacy, Education and Practice·Sue JordanDavid Hughes
Jun 20, 2019·Scientific Reports·Marta MarquiéMercè Boada
Mar 2, 2018·British Journal of Community Nursing·Lucy Sitton-KentPhillip Miller
Jul 3, 2018·Bulletin of the World Health Organization·Jennifer CooperAndrew Carson-Stevens
Jan 16, 2021·Patient Education and Counseling·Rachel Ann Spencer, Harjot Singh Punia

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