A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

Benjamin T Bremner; Carl J. Heneghan; Jeffrey K Aronson; Georgia C Richards

Review

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

November 1, 2023

Bremner BT, Heneghan CJ, Aronson JK, et al. J Patient Saf Risk Manag. 2023;28(5):227-236.

View more articles from the same authors.

Autopsies and coronial investigations provide important learning opportunities. In the UK, coroners may issue Prevention of Future Death reports (PFD) when they determine taking actions could prevent future deaths. This review summarizes studies that use PFDs to investigate patient safety, such as medication- or diagnosis-related deaths. The authors conclude the impact of PFDs could be strengthened by improving the reporting and dissemination system and enforcing the requirement that hospitals submit a response.

Free full text

Related website

Related Resources From the Same Author(s)

Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care.

January 13, 2016

Early diagnosis of cancer: systems approach to support clinicians in primary care.

April 5, 2023

Quality gaps identified through mortality review.

February 1, 2017

Communication-and-resolution programs: the challenges and lessons learned from six early adopters.

January 15, 2014

Implementation of diagnostic pauses in the ambulatory setting.

February 14, 2018

Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.

November 5, 2008

Assessing the impact of teaching patient safety principles to medical students during surgical clerkships.

July 20, 2011

What causes delays in diagnosing blood cancers? A rapid review of the evidence.

July 5, 2023

The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.

April 20, 2011

Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria.

July 13, 2016

"It's not our ass": medical resident sense-making regarding lawsuits.

July 19, 2006

Using an interactive voice response system to improve patient safety following hospital discharge.

August 1, 2007

Improving safety for hospitalized patients: much progress but many challenges remain.

August 17, 2016

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

August 10, 2005

Confidential clinician-reported surveillance of adverse events among medical inpatients.

March 27, 2005

Interventional procedures outside of the operating room: results from the National Anesthesia Clinical Outcomes Registry.

March 7, 2018

Pathology trainees rarely report safety incidents: a review of 13,722 safety reports and a call to action.

September 21, 2022

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Introduction to the STS National Database Series: outcomes analysis, quality improvement, and patient safety.

November 18, 2015

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

How teams work—or don’t—in primary care: a field study on internal medicine practices.

June 2, 2010

Investigation of mental and physical health of nurses associated with errors in clinical practice.

October 26, 2022

Developing a learning health system: insights from a qualitative process evaluation of a pharmacist-led electronic audit and feedback intervention to improve medication safety in primary care.

November 14, 2018

Should medical errors be disclosed to pediatric patients? Pediatricians' attitudes toward error disclosure.

September 23, 2015

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

January 11, 2023

Improving patient safety: moving beyond the "hype" of medical errors.

October 26, 2005

Six habits to enhance MET performance under stress: a discussion paper reviewing team mechanisms for improved patient outcomes.

September 30, 2015

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

October 27, 2010

Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.

June 5, 2019

Governing the safety of artificial intelligence in healthcare.

May 8, 2019

Remembering to learn: the overlooked role of remembrance in safety improvement.

December 7, 2016

Imitating incidents: how simulation can improve safety investigation and learning from adverse events.

June 27, 2018

Early warnings, weak signals and learning from healthcare disasters.

April 9, 2014

The problem with incident reporting.

October 28, 2015

Learning from patient safety incidents: creating participative risk regulation in healthcare.

February 27, 2008

Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study.

April 22, 2020

Quality improvement and patient safety activities in academic departments of medicine.

October 31, 2012

Adverse events following an emergency department visit.

February 28, 2007

Reporting trends in a regional medication error data-sharing system.

May 12, 2010

Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.

October 5, 2011

"Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk.

April 24, 2019

Medication errors and patient complications with continuous renal replacement therapy.

May 3, 2006

Optimizing situation awareness to reduce emergency transfers in hospitalized children.

October 20, 2021

Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study.

July 6, 2022

Measuring adverse events in hospitalized patients: an administrative method for measuring harm.

September 7, 2016

Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior.

February 3, 2010

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

January 30, 2005

What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records.

December 21, 2011

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

October 13, 2010

The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.

November 10, 2010

Barriers and facilitators to patient engagement in patient safety from patients and healthcare professionals' perspectives: a systematic review and meta-synthesis.

August 25, 2021

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emergency department.

September 8, 2021

How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?

January 13, 2010

Patient perspectives on test result communication in primary care: a qualitative study.

April 29, 2015

Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification.

August 29, 2007

Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture.

July 1, 2009

A systematic review to evaluate the accuracy of electronic adverse drug event detection.

January 4, 2012

The association between sepsis and potential medical injury among hospitalized patients.

September 19, 2012

Can we import improvements from industry to healthcare?

May 1, 2019

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

July 10, 2019

Does the concept of safety culture help or hinder systems thinking in safety?

January 22, 2014

Human and organizational biases affecting the management of safety.

October 12, 2011

Systematic biases in group decision-making: implications for patient safety.

November 5, 2014

Confronting racism in pediatric care.

January 11, 2023

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

September 9, 2015

Test result communication in primary care: a survey of current practice.

August 19, 2015

Case study research: the view from complexity science.

May 4, 2005

Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space.

September 27, 2023

The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.

June 27, 2018

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review.

October 28, 2015

Evaluating service delivery interventions to enhance patient safety.

January 14, 2009

Learning from failure: the need for independent safety investigation in healthcare.

November 19, 2014

A human factors subsystems approach to trauma care.

August 27, 2014

Safe use of the EHR by medical scribes: a qualitative study.

November 18, 2020

The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.

November 17, 2010

A 38-year-old woman with fetal loss and hysterectomy.

August 17, 2005

Extraneous tissue a potential source for diagnostic error in surgical pathology.

January 4, 2012

Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".

August 5, 2020

A review of medical error reporting system design considerations and a proposed cross-level systems research framework.

April 4, 2007

Computer physician order entry: benefits, costs, and issues.

March 27, 2005

July 20, 2022

Medication errors resulting from computer entry by nonprescribers.

May 6, 2009

Inpatient suicide: preventing a common sentinel event.

March 25, 2009

Improving heparin safety: a multidisciplinary invited conference.

July 23, 2008

Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment.

December 14, 2005

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

April 22, 2009

How providers can optimize effective and safe scribe use: a qualitative study.

February 1, 2023

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

February 10, 2021

Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety movement.

February 16, 2022

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013-20: an observational study of NHS privatisation.

July 20, 2022

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

March 8, 2017

The federal government's oversight of CT safety: regulatory possibilities.

April 4, 2012

Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse drug events in the intensive care unit and general ward.

August 1, 2018

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

June 4, 2014

Clinical pharmacists and inpatient medical care: a systematic review.

May 17, 2006

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

The effect of external inspections on safety in acute hospitals in the National Health Service in England: a controlled interrupted time-series analysis.

August 14, 2019

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.

April 10, 2013

Related Resources

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

November 8, 2023

Adverse Events.

November 8, 2023

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

November 7, 2023

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

Adverse Health Events in Minnesota: Annual Reports.

September 30, 2023

Annual Speak Up Data Reports.

September 6, 2023

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Underreporting of quality measures and associated facility characteristics and racial disparities in US nursing home ratings.

June 7, 2023

Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database.

May 17, 2023

More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA.

May 3, 2023

Association of past and future paid medical malpractice claims.

March 1, 2023

Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls.

January 25, 2023

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

November 9, 2022

Medicare fines for high hospital readmissions drop, but nearly 2,300 facilities are still penalized.

November 9, 2022

Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States.

October 12, 2022

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Hospitals will still have to share safety data publicly—CMS will publish scorecard of avoidable patient harm after all.

August 17, 2022

Independent Neurology Inquiry.

July 20, 2022

The evidence base for US joint commission hospital accreditation standards: cross sectional study.

July 13, 2022

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

July 6, 2022

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

June 1, 2022

20 years after To Err Is Human: a bibliometric analysis of ‘the IOM report’s’ impact on research on patient safety.

January 26, 2022

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

November 17, 2021

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

October 13, 2021

Association of hospital public quality reporting with electronic health record medication safety performance.

October 6, 2021

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

A Thematic Analysis of HSIB's First 22 Investigations.

September 29, 2021

Ripped apart: medical misdiagnosis and malpractice.

August 18, 2021

See More About The Topic

Hospitals

Medicine

Public Reporting

Governmental Reporting

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site