Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers, and Discharges: Do They Serve Organizations, Staff, or Patients?

Objective: The aim of the study was to analyze content of incident reports during patient transitions in the context of care of older people, cardiology, orthopedics, and stroke.

Methods: A structured search strategy identified incident reports involving patient transitions (March 2014-August 2014, January 2015-June 2015) within 2 National Health Service Trusts (in upper and lower quartiles of incident reports/100 admissions) in care of older people, cardiology, orthopedics, and stroke. Content analysis identified the following: incident classifications; active failures; latent conditions; patient/relative involvement; and evidence of individual or organizational learning. Reported harm was interpreted with reference to National Reporting and Learning System criteria.

Results: A total 278 incident reports were analyzed. Fourteen incident classifications were identified, with pressure ulcers the modal category (n = 101,36%), followed by falls (n = 32, 12%), medication (n = 31, 11%), and documentation (n = 29, 10%). Half (n = 139, 50%) of incident reports related to interunit/department/team transfers. Latent conditions were explicit in 33 (12%) reports; most frequently, these related to inadequate resources/staff and concomitant time pressures (n = 13). Patient/family involvement was explicit in 61 (22%) reports. Patient well-being was explicit in 24 (9%) reports. Individual and organizational learning was evident in 3% and 7% of reports, respectively. Reported harm was significantly lower than coder-interpreted harm (P < 0.0001).

Conclusions: Incident report quality was suboptimal for individual and organizational learning. Underreporting level of harm suggests reporter bias, which requires reducing as much as practicable. System-level interventions are warranted to encourage use of staff reflective skills, emphasizing joint ownership of incidents. Co-producing incident reports with other clinicians involved in the transition and patients/relatives could optimize organizational learning.