Department of Targeted Intervention, University College London, London, UK
Advisor/Lived experience, London, UK.
BMJ Open Qual. 2023 Feb;12(1). doi: 10.1136/bmjoq-2022-002093.
The imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched in the National Health Service (NHS) in England. NHS Secondary Care Trusts (NSCTs) are legally required to publish quantitative and qualitative information relating to deaths due to problems in care within their organisation, including any learning derived from these deaths.
All LfDs report from 2017 to 2020 were reviewed and evaluated, quantitatively and qualitatively using sequential content and reflexive thematic analysis, through a critical realist lens to understand what we can learn from LfDs reporting and the mechanisms enabling or preventing engagement with the LfDs programme.
The majority of NSCTs have identified learning, actions and, to a lesser degree, assessed the impact of these actions. The most frequent learning relates to missed/delayed/uncoordinated care and communication/cultural issues. System issues and lack of resources feature infrequently. There is significant variation among NSCTs as to what 'learning' in this context actually means and a lack of oversight combining patient safety initiatives.
Engagement of NSCTs with the LfDs programme varies significantly. Learning as a result of the LfDs programme is occurring. The ability, significance or value of this learning in preventing future patient deaths remains unclear. Consensus about what constitutes effective learning with regard to patient safety needs to be defined and agreed on.
当患者因护理问题而死亡时，学习是绝对必要的。2017 年，学习死亡事件（LfDs）框架作为一项全国性的患者安全计划，在英格兰的国民保健服务（NHS）中推出。NHS 二级保健信托（NSCT）有法律义务公布与其组织内因护理问题导致的死亡相关的定量和定性信息，包括从这些死亡中获得的任何学习。
对 2017 年至 2020 年期间的所有 LfDs 报告进行了回顾和评估，使用顺序内容分析和反思性主题分析进行定量和定性分析，并通过批判现实主义视角来理解我们可以从 LfDs 报告中学习到什么，以及促成或阻碍参与 LfDs 计划的机制。
大多数 NSCT 已经确定了学习、行动，以及在较小程度上评估了这些行动的影响。最常见的学习涉及到遗漏/延迟/不协调的护理以及沟通/文化问题。系统问题和资源匮乏的情况很少出现。各 NSCT 之间在这方面的“学习”实际上意味着什么，以及缺乏结合患者安全举措的监督方面存在显著差异。
NSCT 对 LfDs 计划的参与程度存在显著差异。由于 LfDs 计划而产生的学习正在发生。但在预防未来患者死亡方面，这种学习的能力、重要性或价值尚不清楚。需要定义并就患者安全方面的有效学习达成共识。
