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PSNet: Patient Safety Network
Journal Article

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

Tuffrey-Wijne I, Goulding L, Gordon V, et al. BMC health services research. 2014;14:432.

Patients with physical limitations are known to be at increased risk of experiencing adverse events, but the quality and safety of care for patients with learning disabilities has been less studied. As the prevalence of learning disabilities—particularly autism spectrum disorder—is increasing, this mixed-methods study from the United Kingdom is an important advance in understanding the risks faced by this vulnerable group of patients. The authors found that patients with intellectual disabilities face numerous safety threats, often related to poor communication that can lead to errors of omission. These included missed nursing care, delayed or missed diagnoses, and concerns over inappropriate limitations on the intensity of care. The study also demonstrates the importance of using multiple methods to identify safety hazards, as the formal incident reporting system yielded only a few cases, but many themes emerged from interviews with clinicians, caregivers, and patients.