1 Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK.
2 King's College, London, UK.
Palliat Med. 2018 Sep;32(8):1353-1362. doi: 10.1177/0269216318776846. Epub 2018 Jun 1.
Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population.
To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care.
A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms.
Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014.
A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death.
Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.
接受姑息治疗的患者容易发生患者安全事件，但人们对该人群中不安全护理造成的伤害程度或不安全护理的根源知之甚少。
定量和定性分析严重事件报告，以了解接受姑息治疗的人群中不安全护理的原因和影响。
采用混合方法。在对事件类型及其位置进行量化后，使用修改后的框架方法进行定性分析，以解释报告中的主题，从而检查不安全护理的根本原因和由此产生的伤害性质。
报告涉及英格兰国民保健服务（NHS）中接受姑息治疗的患者在 12 年期间（2002 年 4 月至 2014 年 3 月）发生的“需要调查的严重事件”的国家数据库。
共确定了 475 份报告：266 份与压疮有关，91 份与用药错误有关，46 份与跌倒有关，21 份与医疗保健相关感染（HAI）有关，18 份与其他异常死亡有关，14 份与卫生专业人员有关，8 份与转移事件有关，6 例自杀和 5 例其他关注。报告类型的频率因护理环境而异。根本原因包括缺乏姑息治疗经验、资源不足和服务协调不善。由此产生的伤害包括症状恶化、死亡过程中断、严重伤害和加速死亡。
不安全的护理对接受姑息治疗的患者构成了重大伤害风险。改善护理服务的协调以及更广泛地提供专业姑息治疗支持可能会降低这种风险。
