Advance care planning (ACP) is essential for patient centred care in the last phase of life. This study characterises and explores patient safety incidents arising from the ACP process reported in the National Reporting and Learning System. Searching over a 10 year period - 2005 - 2015 the study found 70 reports in which an ACP caused a patient safety incident across 3 areas: ACP's not completed despite being appropriate (23%); ACP completed but not accessible or miscommunicated between professionals (40%); and ACP completed and accessible but not followed(37%). Reasons for this included lack of staff knowledge, lack of confidence, and trust in prior documentation to create or enact the ACP. The authors conclude that staff related causes should be explored in local contexts along side system development for ACP documentation.
Dinnen, T. et al. 2019. Patient safety incidents in advance care planning for serious illness: a mixed-method analysis. BMJ: Supportive and Palliative Care. epub ahead of print. August 2019
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