Patient safety in eye care: a multi-method analysis of reported incidents involving implementation of care and clinical assessment in England and Wales

Abstract

Patient safety is a global health priority, yet there is limited research into how ophthalmology is responding to this. There is evidence that a review of patient harm related to eye care and the associated patient safety incidents is needed. We aimed to characterise patient safety incidents involving eye care by: identifying the most frequently reported incidents involving clinical care; and characterising the nature of incidents leading to severe vision loss. The data comprised patient safety incidents reported between 2018 and 2022 to the National Reporting and Learning System and the NHS England Learn from Patient Safety Events system. Reports were searched for eye-related terms (ICD-11) and those reports relating to implementation of care and clinical assessment were included. A descriptive analysis was undertaken to characterise the most frequent incident types and their contributory factors, followed by a thematic analysis of incidents relating to severe vision loss. Of the 836 reports identified, insufficient care (n = 416) and delayed diagnosis (n = 234) featured most. Patient harm occurred related to vision loss (n = 449), delays in treatment (n = 182), and disease progression (n = 121). Among 220 reports that resulted in severe vision loss, patients with Glaucoma and Age-related Macular Degeneration were impacted by delays in monitoring and management, loss to follow-up, disease progression due to insufficient care and system failures. In this characterisation of eye-related incident reports in a national population, potential areas of interest toward safer eye care include addressing delays in patients receiving care and insufficient care such as inconsistent monitoring in glaucoma.