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  1. Adhnan Omar1,
  2. Philippa Rees1,
  3. Huw Prosser Evans1,
  4. Huw Williams1,
  5. Alison Cooper1,
  6. Sophie Banerjee1,
  7. Peter Hibbert2,
  8. Meredith Makeham2,
  9. Gareth Parry3,
  10. Liam Donaldson4,
  11. Adrian Edwards1,
  12. Andrew Carson-Stevens1
  1. 1Cardiff University, United Kingdom-Wales
  2. 2University of New South Wales, United Kingdom-Wales
  3. 3Institute for Healthcare Improvement, United States
  4. 4Imperial College London, United Kingdom-England


Background Globally, two in five children are deemed vulnerable by virtue of their physical, psychological and social characteristics. These children are at increased risk of sub-optimal care and disproportionate levels of iatrogenic harm. There remains a paucity of literature describing initiatives for practice improvement for these children.

Objectives Identify safety reports describing vulnerable children in the England and Wales National Reporting and Learning System (NRLS). Characterise reports in terms of what happened and reported causative issues, in order to identify key change concepts (drivers) and related interventions (change ideas) for improvement.

Methods An operational definition of ‘vulnerability in children’, including key domains and related keywords (Appendix 1, 2), was empirically informed by a scoping review of the published and grey literature. Relevant reports were descriptively analysed. The free text of the four most frequent incident types (Pareto principle) was discussed by a multi-disciplinary team to identify key concepts for improvement.

Results 2,015 reports were identified involving vulnerable children. The problem areas identified primarily resulted from a fragmentation of care services. This included inefficient transfer of information between primary care services; failure to operationalise care plans in practice; and inconsistent access to healthcare services. Reported causes are outlined in an Ishikawa diagram (figure 1) and summarized in the related driver diagram (figure 2) to mitigate problem areas.

Conclusions Analysis of patient safety incident reports assisted in the pragmatic identification of key concepts for healthcare professionals to begin more informed discussions about improving the care delivered to vulnerable children.

Figure 1

Ishikawa diagram illustrating causative factors contributing to patient safety incidents.

Figure 2

Driver diagram for improved safety and quality of healthcare of vulnerable children in primary care.

Appendix 1

Process of generating key terms.

Appendix 2

Process of generating key terms (continued).

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