Table 3

Categorisation of patient-reported safety concerns by number of reports and classified PSIs

MedicationGeneral careImmediate care surroundingsCommunicationService managementOther
No. of patient reportsNo. of classified PSIsNo. of patient reportsNo. of classified PSIsNo. of patient reportsNo. of classified PSIsNo. of patient reportsNo. of classified PSIsNo. of patient reportsNo. of classified PSIsNo. of patient reportsNo. of classified PSIs
1. Delayed administration of medication628. Lack of or problems with routine care procedures (eg, wound dressing, emptying of urine bottles)4220. Problems with other patients or visitors (eg, due to speciality mix; antisocial behaviour—smoking etc)20028. Staff not offering opportunity for patient involvement (eg, not discussing care/treatment with patient)3232. Problems with whole ward or treatment area design (eg, side rooms—isolation; lack of orientating signs)9036. Patient-reported positive instances of care50
2. Problems between home and hospital prescribed medication109. Problems with accessing staff when needed (eg, not being helped to bathe)2021. Problems with equipment, equipment design or facilities (eg, call buzzer not working, shower door not closing, bed sheets full of holes)25829. Staff not listening to patient's information or symptoms (eg, failure to acknowledge the ‘wider picture’)8233. Existing systems prevent effective patient-centred action1037. Patient suggestions for improving safety20
3. Missed medication1110. Problems with mealtimes or diet (eg, missed meals, meals placed out of reach, no help with feeding)8222. Lack of equipment or facilities (eg, too few keys for drug trolley; too few toilets; no patient line) 6130. Inadequate information sharing about condition, treatments or care12034. 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)40
4. Incorrect dose of medication1111. Diagnostic or technical procedure delays or cancellations3123. Problems with general hygiene (eg, lack of cleaning, dirty equipment; cleaning rota causing falls risk with wet floors)17431. Inappropriate style of communication to patients4035. Problems with staffing levels30
5. Incorrect medication administered1112. Incorrect treatment or procedure undertaken2224. Misuse of equipment (eg, drug trolley left open, bedrails not used) 44
6. Other issues with medication administration3113. Problems with infection control (eg, staff or visitors not using gel/hand washing)9625. Noise in ward environment 90
7. Delays to medication administration at discharge (eg, receipt of take home medication)1014. Problems with access, storage or completion of patient documentation/records (eg, missing case notes; incorrectly completed notes)4326. Problems with personal security, perceived or actual20
15. Staff lacking condition-specific knowledge (eg, diabetes)3027. Ambient temperature of ward or facilities10
16. Problems with patient dignity and respect (eg, handled inappropriately; privacy not respected)30
17. Delayed diagnosis10
18. Inadequate consideration of emotional/social care needs50
19. Problems with transfer (eg, movement between wards or services)10
  • PSI, patient safety incident.