TABLE 2.

Cross Tabulation of Incident Classifications and Active Failures With Exemplar Quotes From Incident Reports

		n (%)	Active Failures	Exemplar Quotes
Incident classification	Pressure ulcer	101 (36)	• Skin bundle documentation inaccurate • Nonadherence/lack of follow-up to treatment of pressure ulcer in skin bundle • No mention of pressure ulcer in transfer documents • No skin assessment undertaken before transition • Skin assessment not thoroughly undertaken • Incorrect location of pressure sore in documentation • Pressure sore graded incorrectly in documentation • Tissue viability nurse was not alerted • Pressure ulcer worsening	• Patient transfered [sic] from [name of sending ward] to [name of receiving ward] found to have a stage 1 pressure sore on right buttock however skin bundle stated it was normal • Patient transfered [sic] into the care on our ward and stated on handover that skin was intact and has a grade 2 • Patient was handed over to have skin intact but fragile. on skin inspection this was not the case, patient had grade 2 spine; scab to forehead; grade 3 to left calf-sloughy; grade 2 to left calf, scabbed; dry cracked skin to both heels and arms; grade 2 to right forearm, • Nothing has been documented or handed over. No body map already in place and patient has been in hospital for a few days already. • Telephone handover given but no mention of any issues with skin damage
	Falls	32 (12)	• Inadequate moving and handling • Failure to use equipment available • Failure to check patient understood instructions • Information in patient notes overlooked • Inadequate observation/monitoring of patient • Fall not documented in transfer notes • No medical review after previous falls	• OT and physiotherapy joint transfer assessment. Sliding transfer from bed to chair. Somehow the wheelchair was pushed away. Patient fell to the floor. • Staff sat at nurse’s station having handover when heard a loud bang [sic]. when we stood up we saw pt on floor [sic] at doorway to bay 4. Pt had been walking out of bay when she fell but staff had not seen her due to board round screen blocking the view of bay 4 (falls bay). • Bank HCA C reports to me that she was supervising the patient transferring from bed to chair, on route to the bathroom when his legs gave way and he crumbled to his knees. • About to transfer [patient name] from the bed to a wheel chair to sit out. I had placed his slippers on and dropped the bed rail ready for him to move his legs out. I went to the end of the bed to get a Zimmer frame, to assist with the transfer, when I turned round Mr C coughed and his legs moved and he turned and rolled out of bed. He landed on the floor next to his bed
	Medication	31 (11)	• Discharge medication prescription incomplete • Discharged without prescribed medication • Incorrect medication prescribed • Incorrect medication prescribed (other patient) • Medication not administered • Unsigned for controlled medication • Prescription illegible/unclear • Lost medication • Medication labeled incorrectly • Incorrect medication dosage in discharge notes • Medication not checked on arrival to ward	• The ward then checked their drug cupboard and it came to light that 1 vial (10 g) had gone missing so they could not make up the full 30 gram dose • I came onto shift onto [date] and was administering the 8 a.m. medications. Noticed on drug chart, 22:00 medications had not been given • Following handover checked prescription which was very unclear. • When discharging patient and gathering TTOs together it was noticed that patients insulin had not been prescribed on TTOs
	Documentation	29 (10)	• Patient documentation not signed • Missing information on patient documentation • Required documentation not completed • Lost/misplaced documentation • Incorrect (other patient’s) information	• Patient discharged to [name of hospital] this p.m. [name of hospital] contacted ward at 17:00 stating no notes for the patient had been received • Patient transferred to [name of receiving ward] from [name of sending ward], and found to have another patient’s PPM checklist in their notes • When speaking to staff and reading medical notes from [name of sending ward] there has been no documentation [sic] around the wound • No postop instructions or postop care written by staff from previous day when patient returned rom theater
	Delayed transition	15 (5)	• Transport failed to arrive on time • Ambulance personnel not willing to wait • Ambulance arrived with no room for nurse escort • Miscommunication with ambulance service • Miscommunication between staff about availability of bed • Poor communication with family members • Delay in obtaining test results • Take home medications not documented or signed off	• The patient was made ready for transport at 10:00 h. The patient’s transport finally arrived at 16:30 h. • Patient then turned up unannounced by hospital transport, but bed was unavailable • Patient should have been discharged today all TTOS and paperwork completed, patient needed pacing check before discharge. We understand the technician was busy and there were emergency’s he had to attend to • Patient was ready for collection 2 ambulance men arrived on the ward at 18:30 the patient had about 8 bags of property. I explained they were not going with her. As I was on the phone arranging for the bags to be collected the ambulance man shouted he had aborted it and I would have to rebook.
	Communication	15 (5)	• Failed to inform at handover that patient required cohorting • Not informed at transfer about deprivation of liberty being in place • No verbal handover took place • No handover of patient history/symptoms# • Not referred for advice/treatment/follow-up • Miscommunication between ward staff	• Stroke Outreach Service (SOS) had been told that her discharge was planned for [date]. No [Information System] referral had been made to SOS on [later date]. • Theater coordinator was not aware of this patient and theater was not booked. • Routine telephone call to nursing home after discharge – they report that recommendations were not passed over on transfer from nursing staff. • Patient transferred to [name of ward], with an inappropriate handover, was not informed that that the patient needed to be cohorted as gets confused during the night, although this question was specifically asked.
	Device/equipment	12 (4)	• Sutures not removed • Cannula left in situ • Catheter left in situ • IV in situ not replaced • IV pump running at incorrect rate	• Patient sent home with Venflon still in situ. • On exam it was found that patient had 2 embedded sutures still in place from surgery undertaken in [location of hospital] over 6 weeks ago • Pt found to have catheter in situ, which was full and was drained of 1500 ml urine. • During bad side hand over, 7:20 a.m. (approx) an IV pump with Furosemide alarmed to say it had finished, was not due to finish until 1 p.m. approx, the pump display showed it was running at 24 mL/h. It was prescribed to be running at 1.5 mL/h
	Infection control	11 (4)	• Failure to implement infection control procedures • Poor communication at handover/transfer between staff • Suboptimal patient isolation • Suboptimal ward cleaning • MRSA swab test not undertaken	• Patient was being nursed in a closed bay due to Diarrhea and Vomiting Outbreak. Phone call received from site manager over at the [name of hospital] that patient was to outlie on [name of receiving ward] as identified as medically stable for transfer. Therefore patient was transferred over resulting that other patients on [name of ward] were put at risk. Another patient transferred into empty bed space. • This meant that patient had been exposed to a side room environment, which had previously been occupied by a patient who had been very symptomatic with C. diff., without it being HPV • Patient transferred to [name of ward and date]. It was handed over that this patient was clear of C. diff. [date] infection control came to ward and explained that patient was not clear of Cdiff and had not been made clear initially. • Pt transferred from [name of ward] to [name of ward] from a side room into a side room with active diarrhea [sic] and vomiting within the previous 48 h? why transfer to ward 35 and with these symptoms
	Potentially unsafe transition	11 (4)	• Transition without cardiac monitoring • Nonadherence to treatment protocols • Inaccurate handover of patient history • Failure to take into account well-being of patient • Patient transferred with chest pain	• Staff Nurse from [name of ward] phoned, and advised that they have an admission coming in from [other ward name], but they prefer us admitting the patient while they take one of our patients instead. The patient they want is having on going chest pain, he was on cardiac monitor and was to have Angiogram done the following day at 11:00 h. The Staff Nurse insisted on having the patient moved to [name of ward] that night, despite the fact that no procedure was scheduled for him during the night. • Patient transferred [sic] from Catheter Lab without monitoring. Patient previously had HR 22, on arrival to Recovery, pre procedure, HR 36. Nil heart monitoring on transfer, additionally, no nurse attended during transfer. • Mr J H was transferred to [name of ward] from [name of ward] on the 03/01/15, Stoke Rehab, with a 1–1 carer and still needing Specialist Stroke Rehab, felt to be an inappropriate transfer and was in fact transferred back on the 05/01/15 • Pt handed over as being pleasantly muddled and just in hospital with increased confusion and was fine to go into the main ay. Explained that we had 3 pts already on the ward who required 1–1 care and we had no 1–1 carers. When pt arrived on the ward she immediately started climbing out of bed and becoming very aggressive
	Patient self-transfer	10 (4)	• Delayed diagnostic test • Mental health issues not addressed • Suboptimal patient observation	• Following a conversation with the medical team in which pt was informed that he was medically fit for discharge pt voiced to the Dr that he had suicidal thoughts and may wish to harm himself if he went home. Shortly after the conversation pt left the ward without informing staff and without any discharge papers or medication. As pt had communicated that he felt suicidal and had left the ward abruptly concerns were felt for his safety. • Patient found reading own notes and taking photos of script on phone. Patient very unhappy about what he had read, and started to remove electrodes, tried to diffuse and calm patient to stay in hospital appeared shaky not angry, saying wasting his time in hospital if no one believes these are epileptic seizures, explained that does not mean he isn’t having seizures. Refused to listen, statement supplied regarding conversion. Patient self-discharged, without waiting for Dr to see.
	Staff-related issues	4 (2)	• Poor communication between transferring and receiving ward staff • Inadequate staffing levels/staff shortages	• Staff transfered [sic] patient to ward and was told by staff nurse that patient was not expected, no hand over given and they did not have mattress for the patient. The receiving staff on the ward was very unwelcoming to the patient stating that she was not supposed to be coming to their ward. • Short staffed with ×2 RN’s and 1 HCA. bed manager informed an 2nd HCA sent to ward. Lots of confused high falls risk patients. Very loud on ward all night with patients using call bell, patients not using call bells and just getting up, lots of patients unwell, short of breath chest, pains, etc. All staff on ward constantly attending patients. One patient especially noisy shouting out an wake other patients or making it so other patients couldn’t sleep at all, which is exacerbating [sic] other high falls risks patient to get up and be unsettled. • Short staff – 6 members of staff working [date] Late shift. Discharging many patients – discharge meds (controlled drugs) not going with the pt as ambulances arrive and want a quick discharge. Spending 35 min on the phone booking ambulances which left patients without staff to provide care.
	Suboptimal treatment	4 (2)	• Temperature probe used incorrectly • Patient on incorrect SLT fluid regimen • BM not taken according to protocol • Patient returned from x-ray without neck collar	• Patient met discharge protocol, oral temperature being 36.3°C. When arriving on the ward, the ward nurse failed to take an accurate reading, due to the fact they did not insert the probe all the way down the ear canal. • Pt had an unstable neck fracture and was sent to x-ray for imaging with neck collar in situ. On pts return to the ward she was found to have been transferred back to the ward without the collar on. • I’m not sure whether the error occurred with [sending ward name] handing over SLT recs or with [name of ward] receiving them but the pt was put on out of date SLT recommendations. • Patient transferred from [name of ward] after having had a lumbar puncture. It was noted that his BM had not been taken since 17:10 h.
	Patient injury	2 (1)	• Staff failed to notice an injury had occurred during transfer • Suboptimal use of bed hoist	• Noticed a bump and small bruise to the patient’s left eyebrow, and according to the husband, the patient bumped her left eyebrow on the hoist while being transferred from wheelchair to bed, and again according to the husband, it seems that the day staff did not notice what she had done • Whilst patient being transfered [sic] off hoist sling on bed, patient suffered skin tear to left forearm.
	Patient violence	1 (<1)	• Information about patient mental health and behavioral history not handed over	• Documented in the nursing notes “can become aggressive and angry very quickly... this puts others at risk” information that was not handed over before transfer…. The patient was verbally aggressive to staff immediately on arrival to [name of ward] she was wandering around the ward threatening to hit staff and other patients
	Overall	278 (100)

BM = bone marrow, HR = heart rate, HPV = hydrogen peroxide vapour, MRSA = methicillin-resistant staphylococcus aureus; OT = occupational therapist, Pt = Patient, SLT = speech and Language therapist, TTO = to take out.