Patient safety in prisons: a multi-method analysis of reported incidents in England

McFadzean, Isobel J., Davies, Kate ORCID: https://orcid.org/0000-0002-9807-1231, Purchase, Thomas ORCID: https://orcid.org/0000-0002-4504-2111, Edwards, Adrian ORCID: https://orcid.org/0000-0002-6228-4446, Hellard, Stuart, Ashcroft, Darren M., Avery, Anthony J., Flynn, Sandra, Hewson, Tom, Jordan, Melanie, Keers, Richard, Panagioti, Maria, Wainwright, Verity, Walter, Florian, Shaw, Jenny and Carson-Stevens, Andrew ORCID: https://orcid.org/0000-0002-7580-7699 2023. Patient safety in prisons: a multi-method analysis of reported incidents in England. Journal of the Royal Society of Medicine 116 (7) , pp. 236-245. 10.1177/01410768231166138

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Abstract

Objectives Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities. Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons. Setting Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019. Participants Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare. Main outcome measures Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors. Results Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n =  171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities. Conclusions This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.

Item Type:	Article
Date Type:	Publication
Status:	Published
Schools:	Medicine Prime Centre Wales (PRIME)
Publisher:	SAGE Publications
ISSN:	0141-0768
Date of First Compliant Deposit:	23 May 2023
Date of Acceptance:	12 May 2023
Last Modified:	28 Sep 2023 22:34
URI:	https://orca.cardiff.ac.uk/id/eprint/159882

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