Medication | General care | Immediate care surroundings | Communication | Service management | Other | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
No. of patient reports | No. of classified PSIs | No. of patient reports | No. of classified PSIs | No. of patient reports | No. of classified PSIs | No. of patient reports | No. of classified PSIs | No. of patient reports | No. of classified PSIs | No. of patient reports | No. of classified PSIs | ||||||
1. Delayed administration of medication | 6 | 2 | 8. Lack of or problems with routine care procedures (eg, wound dressing, emptying of urine bottles) | 4 | 2 | 20. Problems with other patients or visitors (eg, due to speciality mix; antisocial behaviour—smoking etc) | 20 | 0 | 28. Staff not offering opportunity for patient involvement (eg, not discussing care/treatment with patient) | 3 | 2 | 32. Problems with whole ward or treatment area design (eg, side rooms—isolation; lack of orientating signs) | 9 | 0 | 36. Patient-reported positive instances of care | 5 | 0 |
2. Problems between home and hospital prescribed medication | 1 | 0 | 9. Problems with accessing staff when needed (eg, not being helped to bathe) | 2 | 0 | 21. Problems with equipment, equipment design or facilities (eg, call buzzer not working, shower door not closing, bed sheets full of holes) | 25 | 8 | 29. Staff not listening to patient's information or symptoms (eg, failure to acknowledge the ‘wider picture’) | 8 | 2 | 33. Existing systems prevent effective patient-centred action | 1 | 0 | 37. Patient suggestions for improving safety | 2 | 0 |
3. Missed medication | 1 | 1 | 10. Problems with mealtimes or diet (eg, missed meals, meals placed out of reach, no help with feeding) | 8 | 2 | 22. Lack of equipment or facilities (eg, too few keys for drug trolley; too few toilets; no patient line) | 6 | 1 | 30. Inadequate information sharing about condition, treatments or care | 12 | 0 | 34. Care and safety of patients outside immediate care surroundings (eg, patients using other hospital facilities or social areas when not capable as result of condition) | 4 | 0 | |||
4. Incorrect dose of medication | 1 | 1 | 11. Diagnostic or technical procedure delays or cancellations | 3 | 1 | 23. Problems with general hygiene (eg, lack of cleaning, dirty equipment; cleaning rota causing falls risk with wet floors) | 17 | 4 | 31. Inappropriate style of communication to patients | 4 | 0 | 35. Problems with staffing levels | 3 | 0 | |||
5. Incorrect medication administered | 1 | 1 | 12. Incorrect treatment or procedure undertaken | 2 | 2 | 24. Misuse of equipment (eg, drug trolley left open, bedrails not used) | 4 | 4 | |||||||||
6. Other issues with medication administration | 3 | 1 | 13. Problems with infection control (eg, staff or visitors not using gel/hand washing) | 9 | 6 | 25. Noise in ward environment | 9 | 0 | |||||||||
7. Delays to medication administration at discharge (eg, receipt of take home medication) | 1 | 0 | 14. Problems with access, storage or completion of patient documentation/records (eg, missing case notes; incorrectly completed notes) | 4 | 3 | 26. Problems with personal security, perceived or actual | 2 | 0 | |||||||||
15. Staff lacking condition-specific knowledge (eg, diabetes) | 3 | 0 | 27. Ambient temperature of ward or facilities | 1 | 0 | ||||||||||||
16. Problems with patient dignity and respect (eg, handled inappropriately; privacy not respected) | 3 | 0 | |||||||||||||||
17. Delayed diagnosis | 1 | 0 | |||||||||||||||
18. Inadequate consideration of emotional/social care needs | 5 | 0 | |||||||||||||||
19. Problems with transfer (eg, movement between wards or services) | 1 | 0 |
PSI, patient safety incident.