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1.  Pediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database 
Vaccine  2015;33(32):3873-3880.
Children are scheduled to receive 18–20 immunizations before their 18th birthday in England and Wales; this approximates to 13 million vaccines administered per annum. Each immunization represents a potential opportunity for immunization-related error and effective immunization is imperative to maintain the public health benefit from immunization. Using data from a national reporting system, this study aimed to characterize pediatric immunization-related safety incident reports from primary care in England and Wales between 2002 and 2013.
A cross-sectional mixed methods study was undertaken. This comprised reading the free-text of incident reports and applying codes to describe incident type, potential contributory factors, harm severity, and incident outcomes. A subsequent thematic analysis was undertaken to interpret the most commonly occurring codes, such as those describing the incident, events leading up to it and reported contributory factors, within the contexts they were described.
We identified 1745 reports and most (n = 1077, 61.7%) described harm outcomes including three deaths, 67 reports of moderate harm and 1007 reports of low harm. Failure of timely vaccination was the potential cause of three child deaths from meningitis and pneumonia, and described in a further 113 reports. Vaccine administration incidents included the wrong number of doses (n = 476, 27.3%), wrong timing (n = 294, 16.8%), and wrong vaccine (n = 249, 14.3%). Documentation failures were frequently implicated. Socially and medically vulnerable children were commonly described.
This is the largest examination of reported contributory factors for immunization-related patient safety incidents in children. Our findings suggest investments in IT infrastructure to support data linkage and identification of risk predictors, development of consultation models that promote the role of parents in mitigating safety incidents, and improvement efforts to adapt and adopt best practices from elsewhere, are needed to mitigate future immunization-related patient safety incidents. These priorities are particularly pressing for vulnerable patient groups.
PMCID: PMC4518472  PMID: 26122580
Health services; Patient safety; Primary care; Public health; Quality improvement; NRLS, National Reporting and Learning System; WHO, World Health Organization
2.  The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach 
BMJ Open  2013;3(11):e003448.
The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery.
Cross-sectional study (retrospective analysis of records in a database).
The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties.
We extracted all orthopaedic error reports from the system over 1 year (2009–2010).
Outcome measures
The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention.
155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively.
The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.
PMCID: PMC3840344  PMID: 24270831
3.  Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise 
PLoS Medicine  2013;10(11):e1001554.
Using a modified Delphi exercise, Aziz Sheikh and colleagues identify research priorities for patient safety research in primary care contexts.
Please see later in the article for the Editors' Summary
PMCID: PMC3833831  PMID: 24260028
4.  How Asking Patients a Simple Question Enhances Care at the Bedside: Medical Students as Agents of Quality Improvement 
The Permanente Journal  2013;17(4):27-31.
Medical students have traditionally played a passive role in the delivery of health care. The Institute for Healthcare Improvement Open School members and leaders initiated the Ask One Question project in December 2011. Through a commitment to the project, students are learning to assume a unique position in health care settings, as both learners and caregivers. They are improving care at the bedside by asking a simple question: “How can I improve your stay today?” Using the Model for Improvement to adapt the Ask One Question concept for local use, medical students at Cardiff University (United Kingdom) asked 120 patients. A content analysis of those responses identified 89 issues across 4 broad areas for improvement, including communication issues (uncertainty about their care management and desire for more time with their health care professional); practical issues (assistance with tasks made difficult because of ill health); wider organizational and National Health Services requests; and medical needs (requiring medical or nursing intervention). A medical student, a clinical colleague, or the hospital organization could act on those issues. Actions ranged from attending to simple tasks (eg, finding spectacles) or basic care needs (eg, giving a drink) to suggestions requiring wider institutional change. On a simple but effective level, Ask One Question reflects good manners and is a demonstrable competency of patient-centered practice. It is a vehicle for enabling students to seek improvements in health care and initiate relevant actions to improve the patient experience at the bedside.
PMCID: PMC3854805  PMID: 24361017
5.  Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors 
With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error.
Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs).
The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward.
Conclusion and level of evidence
Despite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.
PMCID: PMC3615848  PMID: 23569398
orthopedic surgery; patient safety incident; iatrogenic harm; error
6.  Mortality as an indicator of patient safety in orthopaedics: lessons from qualitative analysis of a database of medical errors 
Orthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005–2009), using a qualitative approach.
Reports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created.
A total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey – 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths – 32% were related to severe infections; (3) reported quality of medical interventions – 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals – 44% of deaths had a failure in non-technical skills.
Most complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.
PMCID: PMC3416713  PMID: 22682470
Patient safety; Errors; Orthopaedics; Trauma surgery; Quality improvement
7.  Minimising drug errors in critically ill patients 
Critical Care  2011;15(1):401.
PMCID: PMC3222016  PMID: 21235830

Results 1-7 (7)