Paediatric safety in primary care: a cross-sectional mixed methods study of national incident report data

Abstract

Primary care is responsible for the majority of children’s healthcare contact, yet there is a dearth of research into the safety of care provided to children in this setting. Confidential Enquiries highlight the need for improved vaccination, better recognition of seriously unwell children, and improved management of children with chronic conditions. This thesis therefore aimed to explore deficiencies in the vaccination process and in the primary care provided to ‘unwell’ children. A cross-sectional mixed methods study of paediatric safety incidents involving vaccination or ‘unwell’ children, from primary care between 2002-2013 was conducted. The free-texts of 3913 reports submitted to the National Reporting and Learning System were classified to describe: incident types, contributory factors, incident outcomes, and severity of harm outcomes. Additionally, a literature review was conducted to identify potential interventions to address problem areas identified. Key vaccination-related failures included vaccination with the wrong number of doses, at the wrong time, or with the wrong vaccine. Documentation failures and staff mistakes frequently underpinned these incidents, and vulnerable groups appeared more prone to incidents. Key incidents involving ‘unwell’ children were related to: medication provision; and failures of diagnosis, assessment, referral, and communication, primarily related to telephone assessments. Medication errors were often the result of staff mistakes and failing to follow protocols. Incidents related to telephone assessment of ‘unwell’ children were often precipitated by protocol problems such as failing to assess children using the appropriate protocol. The findings presented in this thesis provide an overview of paediatric safety problems in primary care, in addition to offering recommendations for improvement. Example recommendations include building IT infrastructure to address vaccination-related documentation discrepancies; electronic transmission of prescriptions to community pharmacies to reduce dispensing errors; and adapting clinical decision software to improve paediatric telephone-based assessments. The hypotheses generated from this work will form the basis of future work