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NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

OBJECTIVES: To review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths. INTRODUCTION: Potentially preventable deaths occur worldwide within healthcare organisations. In Englan...

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Autores principales: Brummell, Zoe, Vindrola-Padros, Cecilia, Braun, Dorit, Moonesinghe, S Ramani
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2021
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264864/
https://www.ncbi.nlm.nih.gov/pubmed/34233980
http://dx.doi.org/10.1136/bmjopen-2020-046619
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author Brummell, Zoe
Vindrola-Padros, Cecilia
Braun, Dorit
Moonesinghe, S Ramani
author_facet Brummell, Zoe
Vindrola-Padros, Cecilia
Braun, Dorit
Moonesinghe, S Ramani
author_sort Brummell, Zoe
collection PubMed
description OBJECTIVES: To review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths. INTRODUCTION: Potentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on ‘LfDs’ in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and LfDs’. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths. METHOD: We undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222). RESULTS: All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families. CONCLUSIONS: The wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.
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spelling pubmed-82648642021-07-23 NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme Brummell, Zoe Vindrola-Padros, Cecilia Braun, Dorit Moonesinghe, S Ramani BMJ Open Health Policy OBJECTIVES: To review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths. INTRODUCTION: Potentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on ‘LfDs’ in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and LfDs’. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths. METHOD: We undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222). RESULTS: All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families. CONCLUSIONS: The wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries. BMJ Publishing Group 2021-07-07 /pmc/articles/PMC8264864/ /pubmed/34233980 http://dx.doi.org/10.1136/bmjopen-2020-046619 Text en © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
spellingShingle Health Policy
Brummell, Zoe
Vindrola-Padros, Cecilia
Braun, Dorit
Moonesinghe, S Ramani
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title_full NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title_fullStr NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title_full_unstemmed NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title_short NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
title_sort nhs ‘learning from deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme
topic Health Policy
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264864/
https://www.ncbi.nlm.nih.gov/pubmed/34233980
http://dx.doi.org/10.1136/bmjopen-2020-046619
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