Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK.
PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK.
J R Soc Med. 2023 Jul;116(7):236-245. doi: 10.1177/01410768231166138. Epub 2023 May 17.
Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities. We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons.
Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019.
Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare.
Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors.
Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n = 171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities.
This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.
囚犯使用医疗保健服务的频率是普通人群的三倍，健康状况较差。他们特殊的医疗保健需求常常给安全的医疗保健服务带来挑战。本研究旨在描述监狱中报告的患者安全事件，以指导实践改进，并确定卫生政策重点。我们对 2018 年 4 月至 2019 年 3 月期间英格兰监狱向国家报告和学习系统报告的安全事件进行了探索性的多方法分析。
安全事件已由英格兰监狱向国家报告和学习系统报告。
审查报告以确定任何意外或意外事件（s），这些事件可能导致或已经导致接受医疗保健的囚犯受到伤害。
对自由文本描述进行检查，以确定安全事件的类型和性质、结果和伤害严重程度。通过结构化研讨会，与主题专家一起对分析进行了背景解释，以解释最常见事件和促成因素之间的关系。
在 4112 份报告中，最常观察到的事件是与药物相关的（n=1167，33%），特别是在给药时（n=626，54%）。其次是与获得相关的（n=559，15%），包括患者延迟获得医疗保健专业人员（n=236，42%）和管理医疗预约（n=171，31%）。研讨会将涉及促成因素的事件（n=1529，28%）纳入三个关键主题，即医疗保健的获得、护理的连续性以及监狱和医疗保健重点之间的平衡。
本研究强调了改善囚犯药物安全和获得医疗保健服务的重要性。我们建议进行人员配备水平审查，以确保医疗预约得到参加，并审查处理错过预约的程序、患者转移期间的沟通以及药物处方。
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