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Table 3 Incidents involving patients with intellectual disabilities, reported through the hospitals’ Incident Reporting Systems

From: The challenges in monitoring and preventing patient safety incidents for people with intellectual disabilities in NHS acute hospitals: evidence from a mixed-methods study

Number of incidents Type of incident Example
106 Falls “Patient calling out and when entered room found patient on floor.”
34 Physical or verbal abuse to staff “When going to do an assessment of the patient he grabbed a nurse by the hands and then went to punch me. Security phoned when speaking to the patient after he went for me again. Security had to hold the patient down to the bed so he did not hit anyone.”
29 Patient to staff
5 Family/friend to staff
30 Pressure sores “Patient was admitted with stage 2/stage 3 pressure ulcers to her sacrum and a grade 2 pressure ulcer to her ( R ) elbow.”
12 Medication-related “Drug chart checked prior to administration of Baclofen tablets. Route section of drug chart filled in as oral (O) medication needed to be given via gastrostomy.”
12 Patients absconding / discharging against medical advice “Patient found wandering around [name of railway station] in underpants and dressing gown with no shoes on.”
10 Feeding-related “I set a feed up. At the end of his feed I realised that I had given him the wrong feed. He is prescribed [name of feed] and I had actually given him [name of different feed].”
8 Accidents and injuries “Patient very agitated, nursed on the floor as high falls risk, patient continuously repositioned and nursed in side ward with door open in view of nurses bay. Patient managed to crawl onto floor from floor mattress and hit arm and leg, skin tear to both.”
7 Tracheostomy-related “Patient has a tracheostomy tube in situ and there was no evidence of tracheostomy care that has been done by the nurses from 2:00 am until the time I saw the patient around 10:00 am. Nothing was documented in the tracheostomy care checklist.”
7 Safeguarding alerts “Staff within the department raised concerns relating to the patients presenting condition and where concerned that there were issues of self-neglect or neglect by the carers.”
6 Relating to family or community staff
1 Relating to hospital staff
7 Inappropriate clinical area/ward “Patient with learning difficulties transferred from CDU to [ward X] despite clear admission criteria regarding [ward X] taking such patients.”
7 Delays to treatment “Patient with learning difficulties had been admitted due to increasing breathlessness from a large pleural effusion. Due to agitation, it was not safe to perform pleural aspiration or chest drainage under conscious sedation. A decision was taken to perform this under general anaesthesia on the day of admission. The patient was kept nil by mouth for four consecutive days whilst awaiting this procedure. Despite daily communications with the anaesthetic department, the patient did not have this procedure until 5 days post admission.”
3 Capacity and consent issues described as reason for delays “Patient arrived in dept for Colonoscopy. Patient restless and wandering around despite carer. No consent filled by home or next of kin and referral does not make clear that the patient has dementia. Carer unable to consent. Patient cancelled as unsafe to do procedure. Patient not understanding anything told to her.”
5 Delays to diagnostic tests “Ten patients in CDU waiting for x rays. One patient with learning difficulties and aspiration pneumonia has been waiting 3 days for a chest x ray!!! This is not really defensible!!!”
5 Epileptic seizures “Patient had a seizure attack, fell backwards, fall was broken, fell on bottom.”
16 Other Includes: poor record keeping; unavailability of equipment; theft/loss of patient property; patient is upset/shouting; delays in clerking/admission; self harm “No ECG monitor available in the [theatre X] anaesthetic room to record the ECG tracing when a patient condition deteriorated.”
   “The above patient was a one hour ambulance breach. She arrived in the dept at 15.23 and was not transferred on to a trolley until 16.12.”