Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.
OBJECTIVE
To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm.


METHODS
Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009.


METHODS
52 preventable hospital deaths.


METHODS
England.


METHODS
The nature of problems in care and contributory factors underlying avoidable deaths in hospital.


RESULTS
The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability.


CONCLUSIONS
Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.
Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK helen.hogan@lshtm.ac.uk.
Helen
H
Hogan
Patient Safety Intelligence, NHS England, London W1T 5HD, UK.
Frances
F
Healey
Clinical Safety Research Unit, Imperial College, London W2 1NY, UK.
Graham
G
Neale
Institute of Health and Society, University of Newcastle, Newcastle upon Tyne NE2 4AX, UK.
Richard
R
Thomson
Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
Nick
N
Black
Department of Experimental Psychology, Oxford University, Oxford OX1 3UD, UK.
Charles
C
Vincent
D004739:England; D006760:Hospitalization; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D033262:Narration; D009313:National Health Programs; D015588:Observer Variation; D064406:Patient Harm / Q000401:mortality*; D011320:Primary Health Care; D036301:Qualitative Research; D011787:Quality of Health Care; D015203:Reproducibility of Results; D012189:Retrospective Studies; D063127:Secondary Health Care
content analysis; mortality review; narrative accounts; preventable death; problems in care