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Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis
  1. Toby Dinnen1,
  2. Huw Williams1,
  3. Sarah Yardley2,
  4. Simon Noble3,
  5. Adrian Edwards1,
  6. Peter Hibbert4,
  7. Joyce Kenkre5 and
  8. Andrew Carson-Stevens1,4
  1. 1Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
  2. 2Marie Curie Palliative Care Research Department, University College London, London, UK
  3. 3Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
  4. 4Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  5. 5Faculty of Life Sciences and Education, University of South Wales, Pontypridd, Wales
  1. Correspondence to Dr Andrew Carson-Stevens, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK; carson-stevensap{at}


Objectives Advance care planning (ACP) is essential for patient-centred care in the last phase of life. There is little evidence available on the safety of ACP. This study characterises and explores patient safety incidents arising from ACP processes in the last phase of life.

Methods The National Reporting and Learning System collates patient safety incident reports across England and Wales. We performed a keyword search and manual review to identify relevant reports, April 2005–December 2015. Mixed-methods, combining structured data coding, exploratory and thematic analyses were undertaken to describe incidents, underlying causes and outcomes, and identify areas for improvement.

Results We identified 70 reports in which ACP caused a patient safety incident across three error categories: (1) ACP not completed despite being appropriate (23%, n=16). (2) ACP completed but not accessible or miscommunicated between professionals (40%, n=28). (3) ACP completed and accessible but not followed (37%, n=26). Themes included staff lacking the knowledge, confidence, competence or belief in trustworthiness of prior documentation to create or enact ACP. Adverse outcomes included cardiopulmonary resuscitation attempts contrary to ACP, other inappropriate treatment and/or transfer or admission.

Conclusion This national analysis identifies priority concerns and questions whether it is possible to develop strong system interventions to ensure safety and quality in ACP without significant improvement in human-dependent issues in social programmes such as ACP. Human-dependent issues (ie, varying patient, carer and professional understanding, and confidence in enacting prior ACP when required) should be explored in local contexts alongside systems development for ACP documentation.

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  • Funding This research was funded by Marie Curie and by the Scientific Foundation Board of the Royal College of General Practitioners (Grant No MC 2016-06). The funders had no involvement in the study design, data analysis, writing of the report or decision to publish.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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