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13 Exploring patient safety incidents arising from advance care planning for end of life patients: a mixed methods analysis of incident reports
  1. Toby Dinnen1,
  2. Huw Williams1,
  3. Simon Noble1,
  4. Adrian Edwards1,
  5. Joyce Kenkre2,
  6. Peter Hibbert3,
  7. Liam Donaldson4 and
  8. Andrew Carson-Stevens1
  1. 1Cardiff University, UK
  2. 2University of South UK
  3. 3Macquarie University, Australia
  4. 4London School of Hygiene and Tropical Medicine, UK


Introduction Advance Care Planning (ACP) is an important component of patient centred end-of-life care (Houben et al. 2014; Brinkman-Stoppelenburg et al. 2014). However there is little evidence available on the safety of the process and its impact on quality of care.

Aim To characterise the nature of patient safety incidents arising around the ACP process for patients approaching end-of-life.

Method The National Reporting and Learning System (NRLS) collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports between 2005 and 2015. A mixed methods process combining structured data coding and exploratory descriptive analysis was undertaken to describe incidents underlying causes and outcomes. A thematic analysis identified areas on which to focus improvement initiatives.

Results We identified 67 incident reports in which patients experienced inadequate care due to issues with implementation of ACP. The most common source of error was (mis)communication of ACP (n=27) where documentation was lost or verbal handover was inaccurate. Over one third of reports (n=24) described an ACP not being followed. In the remaining reports (n=16) an ACP was not completed despite being appropriate. The most common contributory factor was inadequate staff knowledge (n=18). Common outcomes were cardiopulmonary resuscitation attempts contrary to a patient’s wishes (n=18). Other outcomes included inappropriate treatment or transfer/admission.

Conclusion Our national level analysis identifies key priorities which should be explored in local contexts: specifically improving public and staff understanding and engagement with ACP and developing systems for recording and accessing ACP documentation across healthcare services.


  1. . Brinkman-Stoppelenburg A, Rietjens JA, Van Der Heide A. The effects of advance care planning on end-of-life care: A systematic review. Palliative Medicine2014;28:1000–25.

  2. . Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: A systematic review and meta-analysis. Journal of the American Medical Directors Association2014;15:477–89.

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