Prehospital care is an established element of the healthcare system, encompassing the emergency medical care given to patients at the scene of illness or injury, during transfer and prior to their arrival at a healthcare facility (Wilson et al, 2015). The undifferentiated presentation of patients to prehospital care services and the varied environments in which they present entails that decision-making is complex. Those decisions made in the prehospital period, and subsequent actions and interventions, can impact upon safe and effective patient outcomes (Bijani et al, 2021). However, the provision of healthcare services has been demonstrated to be associated with harm being caused to patients (Panagioti et al, 2019). The World Health Organization (WHO) defines patient harm as ‘an incident that results in harm to a patient such as impairment of structure or function of the body and/or any deleterious effect arising there from or associated with plans or actions taken during the provision of healthcare, rather than an underlying disease or injury, and may be physical, social or psychological (e.g. disease, injury, suffering, disability and death)’ (WHO, 2009: 16). These occurrences may be termed ‘patient safety incidents’ (PSIs), themselves defined as ‘unintended or unexpected incidents which could have, or did, lead to harm for one or more patients receiving healthcare’ (NHS Improvement, 2019). Acknowledging that compared to primary or secondary care, little is known about the extent of patient harm caused by the provision of prehospital care, the systematic review undertaken by O'Connor et al (2021) seeks to establish the prevalence and harm associated with PSIs in the prehospital setting.
Aim of commentary
This commentary aims to critically appraise the methods used within the review by O'Connor et al (2021) and expand upon the findings in the context of clinical practice.
Methods
A comprehensive multi-database search was carried out on Medline, Web of Science, PsycINFO, CINAHL and Academic Search Complete, with grey literature also being examined (January 2001 to October 2020). Any English language, prehospital study that reported numerical form data with a useable denominator for calculating PSI frequency on at least one of the following: the number/frequency of PSIs; the harm associated with PSIs; and/or included PSIs that occurred during routine care, were included. Consideration of the exclusion criteria reveals that studies looking at patients with specific conditions/procedures; the performance of a single or small number of drug/devices; and incidences of providers deciding not to perform a treatment, were all excluded. These areas all appear to be part of normal or expected prehospital practices and all are very relevant to the topic of PSIs; their exclusion from this review is therefore contentious.
Title and abstract screening were undertaken by only one reviewer with full-text screening completed by the research team. However, it was not stipulated if this was done in duplicate or if blinding of the screening took place. Two reviewers undertook a quality assessment of the included studies using the Quality Assessment Tool for Studies with Diverse Designs, but it is unclear if this was done independently or collaboratively. Data extraction was conducted independently by two reviewers with a third reviewer involved to resolve any disagreements. Data synthesis raised some concerns: due to a lack of heterogeneity between studies, descriptive and narrative synthesis was instead undertaken but this appears to have been inappropriate in some cases; as an indicative example, frequency data for PSIs per 100 transports was combined with a non-equivalent comparator of PSIs per 100 medication doses.
Results
The search strategy identified 3264 papers. After full screening, 22 studies were included (1 study was qualitative, 1 was a mixed-methods design and 20 were quantitative). Most of the studies were based in Europe (12), with 6 from the USA, 2 from Australia and 2 from the Middle East. Of the studies included in the review, the majority (86.4%) were assessed to be of medium quality following application of the Quality Assessment Tool for Studies with Diverse Designs.
The review found the frequency of patient safety incidents (PSIs) to vary greatly from 0 to 71.2 per 100 records/transports/patients/medication doses. Although the review considered subgroup analyses of these findings, due to a lack of standardisation in how PSIs are classified within the studies included in the review, a low level of confidence can be put in the combined PSI frequency rates.
The authors of this review did provide supplement information on PSIs for each included study which allowed the direct comparison of consistent denominators for measuring PSIs. Greatest consistency was found when looking at rates of PSIs per 100 dispatches, which ranged from 0.4 to 1.7; and greatest variation was found when looking at PSIs associated with medications with a range from 0.2 to 71.2 per 100 doses.
Similarly, to the frequency of PSIs, the presence of harm occurring during PSIs was found to have great variation from 0 to 80.6% in the studies that focused on this. The severity of this harm caused was determined within four of the included studies with around 10% of PSIs estimated to result in severe harm; between 19.4–25.8% resulting in moderate harm and 19.5–54.8% resulting in low harm.
The review highlighted that the process through which PSIs are identified may impact on the information obtained about them, with different frequency rates and reports of harm being recorded through incident reporting systems compared to processes involving record review. There also appears to be a lack of focus on the preventability of PSIs, with the only study that included this as a focus identifying that 45.3% of PSIs were preventable.
Key Points
CPD Reflection Questions
Commentary
Using the Joanna Briggs Institute Critical Appraisal Tool for Systematic Reviews, 7 out of the 10 applicable criteria were deemed to be satisfactory for this review. The comprehensiveness of the review is likely limited due to an unclear review question; some contention around the methodology and criteria of the excluded and included studies in the review, and some potential for bias identified through the critical appraisal not being conducted by two or more reviewers independently. However, this review is still of value.
When considering PSIs in prehospital care, it is important that systems are implemented to accurately capture the prevalence and associated harm caused by these incidents, given the potential impact on patients. It is not clear from this review whether incident reporting systems or, instead, processes involving record review, result in a more accurate capture of PSI data. Including a focus on the preventability of PSIs identified through current systems for capturing PSI information, may be beneficial for then implementing strategies to prevent further similar incidents from occurring.
A further review of the literature, using more robust methods, including more appropriate combining of data, would likely be beneficial to obtain a more accurate and thorough understanding of PSIs in the prehospital setting. Additionally, further research into the topic of prehospital PSIs is needed. This should include: examining what system works best to most accurately identify PSIs; the harm associated with PSIs; and the preventability of PSIs in this setting. This research is needed to be able to make further recommendations for ambulance service practice on this topic.