Table 2

Patient-derived safety categories by rank, with definitions and examples

RankCategoryPatient incident reports, n (%)Examples of patient incident reports that were not classified as patient safety incidentsExample of patient incident reports classified as patient safety incidents
  1. Staff to patient

  2. Staff to staff

  3. Patient to staff

251 (21.7%)Staff to patient:
Patient went for a scan, X-ray, without any warning or information about why the scan was being done.
Staff to staff:
One nurse said I could go home after an X-ray and a possible dressing change, the doctor said that I would go home as I was and have the X-ray as an outpatient and go home as I am.
Patient to staff:
Patient concerned about fire procedures in case a fire started. The patient is partially sighted and felt that in an emergency he would be left. The side bars to the bed are up and he felt that he would be unable to get out of the bed. Fire procedures have not been explained to him.
Staff to patient:
Patient feels there has been some confusion about when they were going to surgery and when they could eat. This has led to them not being able to eat properly for up to 2.5 days at one point.
Staff to staff:
On some occasions, the night staff do not seem to be aware of the patient’s medication, he has to let them know what he should be taking.
Patient to staff:
When patient overhears staff talking they assume she is not in pain, but she is, they didn’t ask her and assume that as they have given her painkillers they have worked.
145 (12.6%)
93 (8%)
13 (1.1%)
2Staff issues
For example, staff availability, insufficient staff, not prioritising, buzzers not answered, avoiding work
153 (13.2%)Staff seemed overworked and that meant things sometimes were not done on time.I had a cannula replacement to be done and instead of it being done at 18:00 when asked I was knocked awake at 02:00 for it to be done. Because there was no trained doctor available.
For  example, light at night, noise from staff/other patients/equipment, fixtures and fittings, general cleanliness, temperature, loneliness (single rooms), missing equipment
141 (12.2%)Night staff were noisy—talking loudly, shoes—made it difficult to fall asleep. Doors slam.The bath is very difficult to access because the side is high. I have to use a step which is dangerous when you are wet.
For example, inappropriate conduct from staff, confidentiality breaches, poor staff attitude, patients not being treated with dignity, overheard private conversation
135 (11.6%)Consultants need to remember that there is a patient as well as an illness.On a night time, struggled getting out of bed. The call bell was put out of reach, and couldn’t get out of bed and second night the call bell was again out of reach and the patient had to crawl out of bed as the side railings were put up, and when patient got out the staff were sat around eating take away.
5Medication issues
For example, medicine unavailable, late medication, missed or wrong medication
114 (9.9%)Patient stated that there were delays in getting anti-sickness tablets following admission. Patient needed them before meals but on several occasions got them too late.Patient was almost given anticoagulant twice in same day, but stopped nurse and told them that he had already had it.
For example, feeling like one is waiting too long, having to reschedule/postpone, results not available, waiting for treatment/investigation, equipment not available
102 (8.3%)It takes a long time for the discharge process to happen once discharge has been decided, up to 8 hours.When I came in they told me I would be able to have an operation on Thursday, then changed until Saturday then Sunday and now not till Thursday.
7Staff training
For example, staff not knowing how to do things, staff not trained how to do things, misdiagnosis
63 (5.5%)Electrically operated bed: staff don’t know how to use it, patient knows more.Another patient in the bay has dementia and has been aggressive towards the staff. He was punching and grabbing the staff and they were unable to get out of his grasp. A senior nurse came and showed the staff what to do in this situation.
8Food and drink/nutrition
For example, timing of meals and drinks, communication about food requirements, frequent starving for surgery, specific dietary needs, lack of help with eating
54 (4.7%)Patient has been unable to eat anything but breakfast for the last three days as the food is unpleasant.Patient opposite cannot communicate her needs or feed herself. She has not had a drink today or had more than two spoons of soup to eat. I felt that the staff feeding her gave up too soon.
9Ward management
For example, lack of consistency, lack of overview, not adhering to a standard, inappropriate ward for patient, missing/mislaid documents
44 (3.8%)Went to nurses desk to ask a question, and while I was gone they put someone else in my cubicle. Had to sit on chairs for around 30 min—until porter took me to the surgical assessment ward.File with the notes has been missing from the bedside for the morning—the staff nurse was looking for it, and now the doctor is also looking for it.
10Equipment and systems failure
For example, ward/medical equipment, systems not working or failing
32 (2.8%)The night lights have been flickering, it gives me a headache.PCAS machine for pain relief stopped working, two further machines were not working either and they had to get a technician out to come and repair it.
11Infection risk
For example, spills not cleaned up, poor hygiene practice, full bedpans, inappropriate glove use, dirty facilities (visible bodily fluids)
27 (2.3%)Bed pans (full) had been left in the toilets for hours and smell from one of them was horrendous.Patient went into toilet last night and noticed faeces on toilet roll holder, she told a member of staff at the time but it was still there following day.
12Health and safety
For example, slips/trips/ falls, clutter, space, safety and security, safeguarding, supervision
27 (2.3%)Patient described a patient in the same bay who has dementia and causes some disruption—trying to get in bed with another patient. Sometimes patient woke up and saw her standing over her and it is quite scary, especially as quite poorly herself.There are fire doors at the end of the bay that lead directly outside. In the middle of the night an elderly confused man walked out of them with his Zimmer frame.
13Repeat procedure/complication
For example, something that should not have needed to be done again, unexpected complication
11 (1%)Came in about 6 weeks ago with abdominal pain—went for scan. Said all fine and sent me home even though I was still not well, as was sick at home. Then readmitted for same problem and now finally having treatment.I had a blood test that went missing in the laboratory, it had to be repeated.
14Not a concern1 (0.09%)The patient was moved from an orthopaedic ward to a surgical ward because of bed shortages. The move was made once her care needs were appropriate for being moved to a non-specialist area. A nurse from the trauma ward will have to attend to make adjustments to knee brace. (Not a concern, the patient was involved in the decision to move her.)
  • PCAS: Patient-Controlled Analgesia System.