Professor Andrew Carson-Stevens
(he/him)
BSc (Hons) MB BCh MPhil PhD HonMFPH FRSA FRCGP
Professor of Patient Safety
- Carson-StevensAP@cardiff.ac.uk
- +44 29206 87779
- Neuadd Meirionnydd, Floor 8th, Room 808E, University Hospital of Wales, Heath Park, Cardiff, CF14 4YS
Overview
Overview
I am an academic general practitioner leading research into how health and social care organisations learn from unsafe care experienced by patients and families.
I convene the Patient Safety Research Group (the 'PISA group') in the Division of Population Medicine, School of Medicine, Cardiff University, and our expertise includes:
- investigating the nature and burden of avoidable harm in healthcare;
- identifying patient safety priority areas from analysis of routine patient safety data (e.g., case note review, incident reports, complaints, patient-reported questionnaires);
- patient safety measurement (taxonomy/typology development); and,
- development and implementation of interventions to minimise harm to patients in health and social care settings.
I am co-Director of the Marie Curie Research Centre in the Division of Population Medicine.
Across Cardiff University, I convene the Welsh Ergonomics and Safer Patients Alliance (WESPA), an interdisciplinary group of researchers (School of Medicine, Cardiff Business School, School of Engineering) and clinicians undertaking research and service evaluation to enable innovation and implementation of practices to improve patient safety in healthcare.
National academic leadership
I am the Wales Primary Care Research Specialty Lead at Health and Care Research Wales where I have led the development of inclusive centralised approaches to community-based clinical research delivery.
I am the Patient Safety Work Package Lead at the Wales Centre for Primary and Emergency Care Research (PRIME Centre Wales).
International academic leadership
I am a long-standing adviser to the World Health Organization on patient safety and a methodological adviser to the OECD Working Group for Patient-reported Safety Outcomes.
I was on the expert panel for WHO's international review of Patient Safety Incident Reporting and Learning Systems culminating in a technical report and guidance. In February 2020, I co-chaired the working group for 'Measurement, reporting, learning and surveillance' at a Global WHO Consultation in Geneva, and was subsequently one of three senior academics responsible for formulating the content and recommendations for measurement included in the WHO's Global Patient Safety Action Plan (2020-2030). My research group closely supported WHO to prepare the first WHO Global Patient Safety Report 2024 for the World Health Assembly charting Member State progress to implement the WHO Global Patient Safety Action Plan.
I am Honorary Professor at the Australian Institute of Health Innovation, Macquarie University, Australia (2016 –) and Adjunct Professor at Queen's University, Canada (2019 –) where I supervise doctoral students.
Publication
2024
- Sagua, N., Carson-Stevens, A. and James, K. L. 2024. Characterizing medication safety incidents in surgical patients: a retrospective cross-sectional analysis of incident reports. Therapeutic Advances in Drug Safety 2024(15) (10.1177/20420986241271881)
- Png, M. E. et al. 2024. Cost-utility analysis of molnupiravir plus usual care versus usual care alone as early treatment for community-based adults with COVID-19 and increased risk of adverse outcomes in the UK PANORAMIC trial. British Journal of General Practice 74(745), pp. e570-e579. (10.3399/BJGP.2023.0444)
- Deere, R. et al. 2024. Multi-domain self-management in older people with osteoarthritis and multimorbidities: protocol for the TIPTOE randomised controlled trial. Trials 25, article number: 557. (10.1186/s13063-024-08380-7)
- Ball, E. et al. 2024. 6637 How do families mitigate paediatric safety incidents in emergency departments? A multi-method national analysis of incident reports. Archives of Disease in Childhood 109, pp. A400-A401. (10.1136/archdischild-2024-rcpch.629)
- Hibbert, P. D. et al. 2024. Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study. BMJ Open 14(7), article number: e085854. (10.1136/bmjopen-2024-085854)
- Edwards, P. J., Finnikin, S. J., Wilson, F., Bennett-Britton, I., Carson-Stevens, A., Barnes, R. and Payne, R. A. 2024. Safety-netting advice documentation out-of-hours: a retrospective cohort from 2013 to 2020.. British Journal of General Practice (10.3399/BJGP.2024.0057)
- Rawlings, A. et al. 2024. The burden of acute eye conditions on different healthcare providers: a retrospective population-based study. British Journal of General Practice 74, pp. e264-e274. (10.3399/BJGP.2022.0616)
- Davies, F. et al. 2024. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed methods realist evaluation. Health and Social Care Delivery Research 12(10) (10.3310/JWQZ5348)
- de Andrade, F. K. et al. 2024. Validated medication deprescribing instruments for patients with palliative care needs a systematic review. Hospital Pharmacy 48(2), pp. 83-89. (10.1016/j.farma.2023.08.004)
- Cooper, A. et al. 2024. Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation. Emergency Medicine Journal 41(5), pp. 287-295. (10.1136/emermed-2023-213426)
- Pereira, N. et al. 2024. Methods for studying medication safety following electronic health record implementation in acute care: a scoping review. Journal of the American Medical Informatics Association 31(2), pp. 499-508. (10.1093/jamia/ocad231)
- Hibbert, P. D. et al. 2024. The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study). BMC Medicine 22(1), article number: 22. (10.1186/s12916-023-03224-8)
2023
- Sewell, B. et al. 2023. The cost of implementing the COVID-19 shielding policy in Wales. BMC Public Health 23, article number: 2342. (10.1186/s12889-023-17169-3)
- Purchase, T., Bowie, P., Hibbert, P., Krishnan, R. G. and Carson-Stevens, A. 2023. Human factors to improve patient safety. In: Patient Safety. Cham, Switzerland: Springer, pp. 45-60., (10.1007/978-3-031-35933-0_4)
- Purchase, T. et al. 2023. Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study. BMC Medical Research Methodology 23(1), article number: 234. (10.1186/s12874-023-02057-6)
- Anderson, N. et al. 2023. Mapping processes in the emergency department using the functional resonance analysis method. Annals of Emergency Medicine 82(3), pp. 288-297. (10.1016/j.annemergmed.2022.12.029)
- Gbinigie, O. et al. 2023. Platform adaptive trial of novel antivirals for early treatment of COVID-19 In the community (PANORAMIC): protocol for a randomised, controlled, open-label, adaptive platform trial of community novel antiviral treatment of COVID-19 in people at increased risk of more severe disease. BMJ Open 13, article number: e069176. (10.1136/bmjopen-2022-069176)
- Porter, A. et al. 2023. Rationale for the shielding policy for clinically vulnerable people in the UK during the COVID-19 pandemic: a qualitative study. BMJ Open 13, article number: e073464. (10.1136/bmjopen-2023-073464)
- McFadzean, I. J. et al. 2023. Patient safety in prisons: a multi-method analysis of reported incidents in England. Journal of the Royal Society of Medicine 116(7), pp. 236-245. (10.1177/01410768231166138)
- Evans, S., Farnell, D. J. J., Carson-Stevens, A. and Kemp, A. 2023. Survey of practices for documenting evidence of bruises from physical abuse during child protection proceedings. BMJ Paediatrics Open 7(1), article number: e002047. (10.1136/bmjpo-2023-002047)
- Sivell, S., Price, D. and Carson-Stevens, A. 2023. The challenges and experiences of providing end-of-life care in primary care: online survey and semi-structured interviews with UK primary care professionals.. Presented at: RCGP Annual Conference 2023, Glasgow, 19-20 October 2023, Vol. 73. Vol. Suppl. Royal College of General Practitioners, (10.3399/bjgp23X733833)
- Rees, P. et al. 2023. Family role in paediatric safety incidents: a retrospective study protocol. BMJ Open 13(7), article number: e075058. (10.1136/bmjopen-2023-075058)
- Hibbert, P. D., Molloy, C. J., Schultz, T. J., Carson-Stevens, A. and Braithwaite, J. 2023. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. International Journal for Quality in Health Care 35(3) (10.1093/intqhc/mzad056)
- Snooks, H. et al. 2023. Did the UK's public health Shielding policy protect the clinically extremely vulnerable during the Covid-19 pandemic in Wales? Results of EVITE Immunity, a link data retrospective study. Public Health 218, pp. 12-20. (10.1016/j.puhe.2023.02.008)
- Alqenae, F. A., Steinke, D., Carson-Stevens, A. and Keers, R. N. 2023. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. Therapeutic Advances in Drug Safety 14 (10.1177/20420986231154365)
- Keers, R. N. et al. 2023. Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. PLoS ONE 18(3), article number: e0282021. (10.1371/journal.pone.0282021)
- Sivell, S. et al. 2023. Protocol to evaluate the implementation of the royal college of general practitioners and Marie Curie Daffodil Standards in UK general practice. Presented at: The Marie Curie Research Conference 2023, Virtual, 6-10 February 2023, Vol. 13. BMJ Publishing Group pp. A8., (10.1136/spcare-2023-MCRC.19)
- Sivell, S., Price, D. and Carson-Stevens, A. 2023. Understanding the experiences of providing end-of-life care in UK general practices; preliminary data from an independent evaluation of the daffodil standards.. Presented at: The Marie Curie Research Conference 2023, Virtual, 6-10 February 2023, Vol. 13. BMJ Supportive and Palliative Care: BMJ Publishing Group pp. A8-A9., (10.1136/spcare-2023-MCRC.20)
- Butler, C. C. et al. 2023. Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. The Lancet 401(10373) (10.1016/S0140-6736(22)02597-1)
- Bowie, P., Ross, A., Purchase, T., McNab, D., Hughes, H., Donovan, L. and Carson-Stevens, A. 2023. Patient safety learning for healthcare improvement: considering the "system context" in medico-legal cases?. Journal of Personal Injury Law
- Hibbert, P. D. et al. 2023. Unsafe care in residential settings for older adults. A content analysis of accreditation reports. International Journal for Quality in Health Care 35(4), article number: mzad085. (10.1093/intqhc/mzad085)
2022
- MacFarlane, E., Carson-Stevens, A., North, R., Ryan, B. and Acton, J. 2022. A mixed-methods characterisation of patient safety incidents by primary eye care practitioners. Ophthalmic and Physiological Optics 42(6), pp. 1304-1315. (10.1111/opo.13030)
- Evans, B. A. et al. 2022. Implementing public involvement throughout the research process - experience and learning from the GPs in EDs study. Health Expectations 25(5), pp. 2471-2484. (10.1111/hex.13566)
- Evans, B. A. et al. 2022. Evaluation of the shielding initiative in Wales (EVITE Immunity): protocol for a quasi-experimental study. BMJ Open 12, article number: e059813. (10.1136/bmjopen-2021-059813)
- Dinnen, T. et al. 2022. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Supportive and Palliative Care 12(e3), pp. e403-e410. (10.1136/bmjspcare-2019-001824)
- Edwards, M. et al. 2022. The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – a realist evaluation. International Emergency Nursing 62, article number: 101155. (10.1016/j.ienj.2022.101155)
- Slater, D., Hollnagel, E., MacKinnon, R., Sujan, M., Carson-Stevens, A., Ross, A. and Bowie, P. 2022. A systems analysis of the COVID-19 pandemic response in the United Kingdom-Part 1-The overall context. Safety Science 146, article number: 105525. (10.1016/j.ssci.2021.105525)
- Yardley, S., Williams, H., Bowie, P., Edwards, A., Noble, S., Donaldson, L. and Carson-Stevens, A. 2022. Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory. BMJ Open 12(1) (10.1136/bmjopen-2020-048045)
- Price, D. et al. 2022. Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation. BMC Emergency Medicine 22(12) (10.1186/s12873-021-00562-9)
- Hibbert, P. D. et al. 2022. Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study. International Journal for Quality in Health Care 34(2), article number: mzac033. (10.1093/intqhc/mzac033)
- McFadzean, I. et al. 2022. Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'. BMC Emergency Medicine 22(1), article number: 155. (10.1186/s12873-022-00709-2)
- Sewell, B. et al. 2022. P3 How Much Did the COVID-19 Shielding Policy Cost in Wales? Results of a Cost Analysis Within the EVITE Immunity Evaluation. Value in Health 25(12) (10.1016/j.jval.2022.09.015)
2021
- Ensaldo-Carrasco, E., Sheikh, A., Cresswell, K., Bedi, R., Carson-Stevens, A. and Sheikh, A. 2021. Patient safety incidents in primary care dentistry in England and Wales: a mixed-methods study. Journal of Patient Safety 17(8), pp. e1383-e1393. (10.1097/PTS.0000000000000530)
- Avery, A. J. et al. 2021. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Quality and Safety 30, pp. 961-976. (10.1136/bmjqs-2020-011405)
- Cooper, A. et al. 2021. Identifying safe care processes when GPs work in or alongside emergency departments: realist evaluation. British Journal of General Practice 71(713), pp. e931-e940. (10.3399/BJGP.2021.0090)
- Lazarus, R. et al. 2021. Safety and immunogenicity of concomitant administration of COVID-19 vaccines (ChAdOx1 or BNT162b2) with seasonal influenza vaccines in adults in the UK (ComFluCOV): a multicentre, randomised, controlled, phase 4 trial. The Lancet 398(10318), pp. 2277-2287. (10.1016/S0140-6736(21)02329-1)
- Urquhart, A., Yardley, S., Thomas, E., Donaldson, L. and Carson-Stevens, A. 2021. Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. Journal of the Royal Society of Medicine 14(12), pp. 563-574. (10.1177/01410768211032589)
- Cooper, A. et al. 2021. Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis. BMC Emergency Medicine 21, article number: 139. (10.1186/s12873-021-00537-w)
- Bennett-Britton, I., Banks, J., Carson-Stevens, A. and Salisbury, C. 2021. Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations. British Journal of General Practice 71(711), pp. e797-e805. (10.3399/BJGP.2021.0076)
- Yardley, S., Francis, S., Chuter, A., Hellard, S., Abernethy, J. and Carson-Stevens, A. 2021. Mixed methods study protocol: Do national reporting and learning system medication incidents in palliative care reflect patient and carer concerns about medication management and safety?. BMJ Open 11(9) (10.1136/bmjopen-2021-048696)
- Alshehri, G. H., Keers, R. N., Carson-Stevens, A. and Ashcroft, D. M. 2021. Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System. Journal of Patient Safety 17, pp. 341-351. (10.1097/PTS.0000000000000815)
- Snooks, H. et al. 2021. Call volume, triage outcomes and protocols during the first wave of the COVID-19 pandemic in the UK: results of a national survey. Journal of the American College of Emergency Physicians Open (JACEP Open) 2(4), article number: e12492. (10.1002/emp2.12492)
- Ensaldo-Carrasco, E., Suarez-Ortegon, M. F., Carson-Stevens, A., Cresswell, K., Bedi, R. and Sheikh, A. 2021. Patient safety incidents and adverse events in ambulatory dental care: A systematic scoping review. Journal of Patient Safety 17(5), pp. 381-391. (10.1097/PTS.0000000000000316)
- Fournier, J. et al. 2021. Patient-safety incidents during COVID-19 health crisis in France: an exploratory sequential multi-method study in primary care. European Journal of General Practice 27(1), pp. 142-151. (10.1080/13814788.2021.1945029)
- Alghamdi, A. A., Keers, R. N., Sutherland, A., Carson-Stevens, A. and Ashcroft, D. M. 2021. A mixed-methods analysis of medication safety incidents reported in neonatal and children's intensive care. Pediatric Drugs 23, pp. 287-297. (10.1007/s40272-021-00442-6)
- Edwards, M. et al. 2021. A classification of primary care streaming pathways in UK emergency departments: findings from a multi-methods study comprising cross-sectional survey; site visits with observations, semi-structured and informal interviews. International Emergency Nursing 56, article number: 101000. (10.1016/j.ienj.2021.101000)
- Choudhry, M. et al. 2021. Senior clinical and business managers' perspectives on the influence of different funding mechanisms, and barriers and enablers to implementing models of employing General Practitioners in or alongside emergency departments: qualitative study. Health Policy 125, pp. 482-488. (10.1016/j.healthpol.2020.11.016)
- Hernan, A. L., Giles, S., Carson-Stevens, A., Morgan, M., Lewis, P., Hind, J. and Versace, V. L. 2021. Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England. BMJ Open 11(4), article number: e042551. (10.1136/bmjopen-2020-042551)
- Disbeschl, S. et al. 2021. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot and Feasibility Studies 7(1), article number: 100. (10.1186/s40814-021-00834-y)
- Emary, K. R. W. et al. 2021. Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 variant of concern 202012/01 (B.1.1.7): an exploratory analysis of a randomised controlled trial. The Lancet 397(10282), pp. 1351-1362. (10.1016/S0140-6736(21)00628-0)
- Voysey, M. et al. 2021. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four randomised trials. Lancet 397(10277), pp. 881-891. (10.1016/S0140-6736(21)00432-3)
- Vaismoradi, M. et al. 2021. Nobody ever questions-Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative. PLoS ONE 16(1), article number: e0244519. (10.1371/journal.pone.0244519)
- Bowie, P. et al. 2021. Is the "never event?"concept a useful safety management strategy in complex primary healthcare systems?. International Journal for Quality in Health Care 33(S1), pp. 25-30. (10.1093/intqhc/mzaa101)
- Voysey, M. et al. 2021. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 397(10269), pp. 99-111. (10.1016/S0140-6736(20)32661-1)
2020
- Evans, H. P. et al. 2020. Automated classification of primary care patient safety incident report content and severity using supervised Machine Learning (ML) approaches. Health Informatics Journal 26(4), pp. 3123-3139. (10.1177/1460458219833102)
- Hibbert, P. D. et al. 2020. Characterising the types of paediatric adverse events detected by the global trigger tool - CareTrack Kids. Journal of Patient Safety and Risk Management 25(6), pp. 239-249. (10.1177/2516043520969329)
- Gibson, R. et al. 2020. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Addiction 115(11), pp. 2066-2076. (10.1111/add.15039)
- Evans, A., Hinchliffe, A., Hood, K. and Carson-Stevens, A. 2020. Use of prescribing indicators as a means of identifying variation in the prevalence of valproate prescribing between health communities: a cross-sectional study. Integrated Healthcare Journal 2(1), article number: e000022. (10.1136/ihj-2019-000022)
- Omar, A. et al. 2020. Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports. Archives of Disease in Childhood 105, pp. 731-737. (10.1136/archdischild-2019-318406)
- Edwards, M. et al. 2020. Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study. BMC Emergency Medicine 20(1), article number: 62. (10.1186/s12873-020-00358-3)
- Price, D. et al. 2020. Challenges of recruiting emergency department patients to a qualitative study: a thematic analysis of researchers? experiences. BMC Medical Research Methodology 20(1), article number: 151. (10.1186/s12874-020-01039-2)
- Hibbert, P., Thomas, M., Deakin, A., Runciman, W., Carson-Stevens, A. and Braithwaite, J. 2020. A qualitative content analysis of retained surgical items: Learning from root cause analysis investigations. International Journal for Quality in Health Care 32(3), pp. 184-189. (10.1093/intqhc/mzaa005)
- Cooper, A., Carson-Stevens, A., Hughes, T. and Edwards, A. 2020. Is streaming patients in emergency departments to primary care services effective and safe?. BMJ 368, article number: m462. (10.1136/bmj.m462)
- Mitchell, R. et al. 2020. Using the WHO international classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths. Applied Ergonomics 82, article number: 102920. (10.1016/j.apergo.2019.102920)
- Young, S., Deslandes, P., Cooper, J., Williams, H., Kenkre, J. and Carson-Stevens, A. 2020. A mixed methods analysis of lithium-related patient safety incidents in primary care. Therapeutic Advances in Drug Safety 11, pp. 1-8. (10.1177/2042098620922748)
2019
- Hussain, F., Cooper, A., Carson-Stevens, A., Donaldson, S. L., Hibbert, P., Hughes, T. and Edwards, A. 2019. Diagnostic error in the emergency department: learning from national patient safety incidents report analysis. BMC Emergency Medicine 19, article number: 77. (10.1186/s12873-019-0289-3)
- Carson-Stevens, A. et al. 2019. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Family Practice 20, article number: 134. (10.1186/s12875-019-0990-z)
- Cooper, A. et al. 2019. Taxonomy of the form and function of primary care services in or alongside emergency departments: concepts paper. Emergency Medicine Journal 36(10), pp. 625-630. (10.1136/emermed-2018-208305)
- Cooper, A. et al. 2019. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 9(4), article number: e024501. (10.1136/bmjopen-2018-024501)
- Williams, H. et al. 2019. Quality improvement identifying priorities for safer out- of- hours palliative care: lessons from a mixed methods analysis of a national incident reporting database. Palliative Medicine 33(3), pp. 346-356. (10.1177/0269216318817692)
2018
- Carson-Stevens, A., McNab, D., Freestone, J., Black, C. and Bowie, P. 2018. Participatory design of a complex improvement intervention for the primary care management of Sepsis using the Functional Resonance Analysis Method. BMC Medicine 16, article number: 174. (10.1186/s12916-018-1164-x)
- Stanciu, M. A. et al. 2018. Development of an intervention to expedite cancer diagnosis through primary care: a protocol. BJGP Open 2(3), article number: 18X101595. (10.3399/bjgpopen18X101595)
- Doran, N., Bethune, R., Watson, J., Finucane, K. and Carson-Stevens, A. 2018. Empowering junior doctors: a qualitative study of a QI programme in South West England. Postgraduate Medical Journal 94(1116), pp. 571-577.
- Yardley, I., Yardley, S., Williams, H., Carson-Stevens, A. and Donaldson, L. J. 2018. Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents. Palliative Medicine 32(8), pp. 1353-1362. (10.1177/0269216318776846)
- Carson-Stevens, A., Donaldson, L. and Sheikh, A. 2018. The rise of patient safety-II: should we give up hope on safety-I and extracting value from patient safety incidents? Comment on "false dawns and new horizons in patient safety research and practice". International Journal of Health Policy and Management 7(7), article number: 12. (10.15171/ijhpm.2018.23)
- Carson-Stevens, A., Hayes, J., Evans, A. and Donaldson, L. 2018. Wales: Realizing a data-drive healthcare improvement agenda: a manifesto for world class patient safety. In: Braithwaite, J. et al. eds. Health Care Systems: Future Predictions of Global Care.. CRC Press Taylor and Francis Group, pp. 275-280.
- Ensaldo-Carrasco, E., Carson-Stevens, A., Cresswell, K., Bedi, R. and Sheikh, A. 2018. Developing agreement on never events in primary care dentistry: an international eDelphi study. British Dental Journal 224, pp. 733-740. (10.1038/sj.bdj.2018.351)
- Cooper, J. et al. 2018. Classification of patient-safety incidents in primary care. Bulletin of the World Health Organization 96(7), pp. 498-505. (10.2471/BLT.17.199802)
- Stuttaford, L., Chakraborty, M., Carson-Stevens, A. and Powell, C. 2018. G190 Patient safety incidents in neonatology: a 10-year descriptive analysis of reports from NHS England and Wales. Archives of Disease in Childhood 103(S1), article number: A78. (10.1136/archdischild-2018-rcpch.185)
- Yardley, I. E., Carson-Stevens, A. and Donaldson, L. J. 2018. Serious incidents after death: content analysis of incidents reported to a national database. Journal of the Royal Society of Medicine 111(2), pp. 57-64. (10.1177/0141076817744561)
2017
- Cooper, J. et al. 2017. Nature of blame in patient safety incident reports: mixed methods analysis of a national database. Annals of Family Medicine 15(5), pp. 455-461. (10.1370/afm.2123)
- Cooper, A. et al. 2017. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age and Ageing 46(5), pp. 833-839. (10.1093/ageing/afx044)
- Cork, N., Rooney, K. D. and Carson-Stevens, A. 2017. When I say? quality improvement. Medical Education 51(5), pp. 467-468. (10.1111/medu.13244)
- Lazenby, S., Edwards, A. G., Samuriwo, R., Riley, S. G., Murray, M. A. and Carson-Stevens, A. 2017. End-of-life care decisions for haemodialysis patients – ‘We only tend to have that discussion with them when they start deteriorating’. Health Expectations 20(2), pp. 260-273. (10.1111/hex.12454)
- Carson-Stevens, A. and Donaldson, L. 2017. Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners.. Manual. Royal College of General Practitioners. Available at: http://www.rcgp.org.uk/-/media/Files/CIRC/Patient-Safety/Reporting-and-learning-from-patient-safety-incidents.ashx?la=en
- Bell, B. G. et al. 2017. Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study. BMJ Open 7(2), article number: e013786. (10.1136/bmjopen-2016-013786)
- Cooper, J., MacLeod, N., Williams, H. and Carson-Stevens, A. 2017. Learning from excellence and patient safety incidents. Archives of Disease in Childhood 102(3), pp. 295-296. (10.1136/archdischild-2016-312445)
- Gibson, R. et al. 2017. Unsafe opioid replacement therapy in England and Wales: a mixed-methods study. The Lancet 389(S1), pp. S38. (10.1016/S0140-6736(17)30434-8)
- Rees, P. et al. 2017. Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis. Plos Medicine 14(1), article number: e1002217. (10.1371/journal.pmed.1002217)
- Carson-Stevens, A. 2017. Generating learning from patient safety incident reports from general practice. PhD Thesis, Cardiff University.
2016
- Makeham, M., Dovey, S., Zwar, N. and Carson-Stevens, A. 2016. Administrative errors: technical series on safer primary care. Technical Report.
- Samuriwo, R., Williams, H., Cooper, J. and Carson-Stevens, A. 2016. Improving skin care through data: a pitch for patient safety incident reporting. Journal of Wound Care 25(12), pp. 691. (10.12968/jowc.2016.25.12.691)
- Carson-Stevens, A. et al. 2016. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Health Services and Delivery Research 4(27), pp. 1-76. (10.3310/hsdr04270)
- Panesar, S. S. et al. 2016. How safe is primary care? A systematic review. BMJ Quality & Safety 25(7), pp. 544-553. (10.1136/bmjqs-2015-004178)
- Wood, F., Martin, S. M., Carson-Stevens, A., Elwyn, G., Precious, E. and Kinnersley, P. R. 2016. Doctors’ perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study. Health Expectations 19(3), pp. 751-761. (10.1111/hex.12258)
- Samuriwo, R., Evans, H. P., Williams, H., Rees, P., Hibbert, P., Makeham, M. and Carson-Stevens, A. 2016. Primary Care Patient Safety (PISA) Research Group - Identifying priorities for pressure ulcer prevention in primary care.. EWMA Journal 16(1), pp. 25-26.
- Evans, H. P., Cooper, A., Williams, H. and Carson-Stevens, A. 2016. Improving the safety of vaccine delivery. Human Vaccines & Immunotherapeutics 12(5), pp. 1280-1281. (10.1080/21645515.2015.1137404)
- Williams, H., Cooper, A. and Carson-Stevens, A. 2016. Opportunities for incident reporting. Response to: 'The problem with incident reporting' by Macrae et al. BMJ Quality & Safety 25(2), pp. 133-134. (10.1136/bmjqs-2015-004962)
2015
- Williams, H. et al. 2015. Harms from discharge to primary care: mixed methods analysis of incident reports. British Journal of General Practice (BJGP) 65(641), pp. e829-e837. (10.3399/bjgp15X687877)
- Carson-Stevens, A. et al. 2015. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open 5(12), article number: e009079. (10.1136/bmjopen-2015-009079)
- Omar, A. et al. 2015. Vulnerable children and their care quality issues: a descriptive analysis of a national database [Abstract]. BMJ Quality and Safety 24(11), pp. 732-733., article number: 588. (10.1136/bmjqs-2015-IHIabstracts.18)
- Rees, P. et al. 2015. Identifying priorities for improved child healthcare: a mixed methods analysis of safety incident reports [Abstract]. BMJ Quality and Safety 24(11), pp. 730-731., article number: 579. (10.1136/bmjqs-2015-IHIabstracts.16)
- Rees, P. et al. 2015. Pediatric immunization-related safety incidents in primary care: a mixed methods analysis of a national database. Vaccine 33(32), pp. 3873-3880. (10.1016/j.vaccine.2015.06.068)
- Rees, P. et al. 2015. Safety incidents in the primary care office setting. Pediatrics 135(6), pp. 1027-1035. (10.1542/peds.2014-3259)
- Carson-Stevens, A., Edwards, A. G., Panesar, S., Parry, G., Rees, P., Sheikh, A. and Donaldson, L. 2015. Reducing the burden of iatrogenic harm in children. The Lancet 385(9978), pp. 1593-1594. (10.1016/S0140-6736(14)61739-6)
- Dahill, M. et al. 2015. First-year doctors' attitudes and beliefs relating to quality improvement and patient safety. Clinical Risk 21(2-3), pp. 47-49. (10.1177/1356262215585270)
- Rees, P., Edwards, A., Powell, C., Evans, H. P., Panesar, S. and Carson-Stevens, A. 2015. Disparities in the quality of primary healthcare for socially deprived children. Archives of Disease in Childhood 100(3), pp. 299-300. (10.1136/archdischild-2014-307618)
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Priorities for pressure ulcer prevention: mixed methods analysis of patient safety incidents reports from primary care in England and Wales (2003-2013).. Presented at: PRIME Centre Wales 1st Annual Meeting, Cardiff, Wales, 22 September 2015.
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Primary care pressure ulcer related patient safety incidents reports from England and Wales: a mixed methods analysis. Presented at: 18th Annual Meeting of the European Pressure Ulcer Advisory Panel (EPUAP 2015), Ghent, Belgium, 16-18 September 2015.
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Primary care pressure ulcer related patient safety incidents reports from England and Wales: A mixed methods analysis.. Presented at: 25th Conference of the European Wound Management Association (EWMA 2015), London, England, 13 May 2015.
- Samuriwo, R. et al. 2015. How do we prevent pressure ulcers in primary care? Galvanising insights from healthcare professionals. Presented at: 21st Annual Institute for Healthcare Improvement Scientific Symposium (IHI 2015), Orlando, FL, USA, 7 December 2015.
2014
- Rees, P., Edwards, A., Panesar, S. and Carson-Stevens, A. 2014. Child mortality in the UK. The Lancet 384(9958), pp. 1923-1924. (10.1016/S0140-6736(14)62272-8)
- Rees, P., Evans, H. P., Panesar, S., Llewelyn, M., Edwards, A. and Carson-Stevens, A. 2014. Contraindicated BCG vaccination in "at risk" infants. BMJ 349, article number: g5388. (10.1136/bmj.g5388)
- Panesar, S., Carson-Stevens, A., Salvilla, S. and Sheikh, A. Panesar, S. et al. eds. 2014. Patient safety and healthcare improvement at a glance. Wiley-Blackwell.
- Rees, P., Carson-Stevens, A., Williams, H., Panesar, S. and Edwards, A. 2014. Quality improvement informed by a reporting and learning system. Archives of Disease in Childhood 99(7), pp. 702-703. (10.1136/archdischild-2014-306198)
- Madhok, R. et al. 2014. Promoting patient safety in India: situational analysis and the way forward. National Medical Journal of India 27(4), pp. 217-223.
- Jones, A. and Carson-Stevens, A. 2014. Patient stories in improvement. In: Panesar, S. S. et al. eds. Patient Safety and Healthcare Improvement at a Glance. Chichester, UK: Wiley, pp. 90-92.
2013
- Panesar, S. S. et al. 2013. The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach. BMJ Open 3(11), pp. e003448. (10.1136/bmjopen-2013-003448)
- Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E. and Goldmann, D. A. 2013. Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics 13(6), pp. S23-S30. (10.1016/j.acap.2013.04.007)
- Cresswell, K. M. et al. 2013. Global research priorities to better understand the burden of iatrogenic harm in primary care: An international delphi exercise. PLoS Medicine 10(11), pp. e1001554. (10.1371/journal.pmed.1001554)
- Ward, H. O., McIldowie, B., Kibble, S., Squire, A. and Carson-Stevens, A. 2013. Financial implications for survivors of stroke. British Medical Journal 347, article number: f4999. (10.1136/bmj.f4999)
- Carson-Stevens, A., Patel, E., Nutt, S. L., Bhatt, J. and Panesar, S. S. 2013. The social movement drive: a role for junior doctors in healthcare reform. Journal of the Royal Society of Medicine 106(8), pp. 305-309. (10.1177/0141076813489677)
- Mustafa, M., Carson-Stevens, A., Gillespie, D. and Edwards, A. G. 2013. Psychological interventions for women with metastatic breast cancer. Cochrane Library 2013(6), article number: CD004253. (10.1002/14651858.CD004253.pub4)
- Panesar, S., Carson-Stevens, A., Salvilla, S., Patel, B., Mirza, S. and Mann, B. 2013. Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors. Drug, Healthcare and Patient Safety 2013(5), pp. 57-65. (10.2147/DHPS.S40887)
- Carson-Stevens, A., Davies, M. M., Jones, R., Pawan Chik, A. D., Robbé, I. J. and Fiander, A. N. 2013. Framing patient consent for student involvement in pelvic examination: a dual model of autonomy: Table 1.. Journal of Medical Ethics 39(11), pp. 676-680. (10.1136/medethics-2012-100809)
- Carson-Stevens, A. P., Jones, A., Hansen, A. S., Printz, A., Patel, E., Bhatt, J. and Panesar, S. S. 2013. Q-Tip: "What can I do to improve your care today?" -One question closer to patient-centered care. American Journal of Medical Quality 28(2), pp. 174-174. (10.1177/1062860612470782)
2011
- Carson-Stevens, A., Hingston, C. D. and Wise, M. P. 2011. Minimising drug errors in critically ill patients. Critical Care 15(1), article number: 401. (10.1186/cc9366)
2010
- Panesar, S. S., Carson-Stevens, A., Fitzgerald, J. E. and Emerton, M. 2010. The WHO surgical safety checklist - junior doctors as agents for change. International Journal of Surgery 8(6), pp. 414-416. (10.1016/j.ijsu.2010.06.004)
Articles
- Sagua, N., Carson-Stevens, A. and James, K. L. 2024. Characterizing medication safety incidents in surgical patients: a retrospective cross-sectional analysis of incident reports. Therapeutic Advances in Drug Safety 2024(15) (10.1177/20420986241271881)
- Png, M. E. et al. 2024. Cost-utility analysis of molnupiravir plus usual care versus usual care alone as early treatment for community-based adults with COVID-19 and increased risk of adverse outcomes in the UK PANORAMIC trial. British Journal of General Practice 74(745), pp. e570-e579. (10.3399/BJGP.2023.0444)
- Deere, R. et al. 2024. Multi-domain self-management in older people with osteoarthritis and multimorbidities: protocol for the TIPTOE randomised controlled trial. Trials 25, article number: 557. (10.1186/s13063-024-08380-7)
- Ball, E. et al. 2024. 6637 How do families mitigate paediatric safety incidents in emergency departments? A multi-method national analysis of incident reports. Archives of Disease in Childhood 109, pp. A400-A401. (10.1136/archdischild-2024-rcpch.629)
- Hibbert, P. D. et al. 2024. Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study. BMJ Open 14(7), article number: e085854. (10.1136/bmjopen-2024-085854)
- Edwards, P. J., Finnikin, S. J., Wilson, F., Bennett-Britton, I., Carson-Stevens, A., Barnes, R. and Payne, R. A. 2024. Safety-netting advice documentation out-of-hours: a retrospective cohort from 2013 to 2020.. British Journal of General Practice (10.3399/BJGP.2024.0057)
- Rawlings, A. et al. 2024. The burden of acute eye conditions on different healthcare providers: a retrospective population-based study. British Journal of General Practice 74, pp. e264-e274. (10.3399/BJGP.2022.0616)
- Davies, F. et al. 2024. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed methods realist evaluation. Health and Social Care Delivery Research 12(10) (10.3310/JWQZ5348)
- de Andrade, F. K. et al. 2024. Validated medication deprescribing instruments for patients with palliative care needs a systematic review. Hospital Pharmacy 48(2), pp. 83-89. (10.1016/j.farma.2023.08.004)
- Cooper, A. et al. 2024. Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation. Emergency Medicine Journal 41(5), pp. 287-295. (10.1136/emermed-2023-213426)
- Pereira, N. et al. 2024. Methods for studying medication safety following electronic health record implementation in acute care: a scoping review. Journal of the American Medical Informatics Association 31(2), pp. 499-508. (10.1093/jamia/ocad231)
- Hibbert, P. D. et al. 2024. The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study). BMC Medicine 22(1), article number: 22. (10.1186/s12916-023-03224-8)
- Sewell, B. et al. 2023. The cost of implementing the COVID-19 shielding policy in Wales. BMC Public Health 23, article number: 2342. (10.1186/s12889-023-17169-3)
- Purchase, T. et al. 2023. Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study. BMC Medical Research Methodology 23(1), article number: 234. (10.1186/s12874-023-02057-6)
- Anderson, N. et al. 2023. Mapping processes in the emergency department using the functional resonance analysis method. Annals of Emergency Medicine 82(3), pp. 288-297. (10.1016/j.annemergmed.2022.12.029)
- Gbinigie, O. et al. 2023. Platform adaptive trial of novel antivirals for early treatment of COVID-19 In the community (PANORAMIC): protocol for a randomised, controlled, open-label, adaptive platform trial of community novel antiviral treatment of COVID-19 in people at increased risk of more severe disease. BMJ Open 13, article number: e069176. (10.1136/bmjopen-2022-069176)
- Porter, A. et al. 2023. Rationale for the shielding policy for clinically vulnerable people in the UK during the COVID-19 pandemic: a qualitative study. BMJ Open 13, article number: e073464. (10.1136/bmjopen-2023-073464)
- McFadzean, I. J. et al. 2023. Patient safety in prisons: a multi-method analysis of reported incidents in England. Journal of the Royal Society of Medicine 116(7), pp. 236-245. (10.1177/01410768231166138)
- Evans, S., Farnell, D. J. J., Carson-Stevens, A. and Kemp, A. 2023. Survey of practices for documenting evidence of bruises from physical abuse during child protection proceedings. BMJ Paediatrics Open 7(1), article number: e002047. (10.1136/bmjpo-2023-002047)
- Rees, P. et al. 2023. Family role in paediatric safety incidents: a retrospective study protocol. BMJ Open 13(7), article number: e075058. (10.1136/bmjopen-2023-075058)
- Hibbert, P. D., Molloy, C. J., Schultz, T. J., Carson-Stevens, A. and Braithwaite, J. 2023. Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review. International Journal for Quality in Health Care 35(3) (10.1093/intqhc/mzad056)
- Snooks, H. et al. 2023. Did the UK's public health Shielding policy protect the clinically extremely vulnerable during the Covid-19 pandemic in Wales? Results of EVITE Immunity, a link data retrospective study. Public Health 218, pp. 12-20. (10.1016/j.puhe.2023.02.008)
- Alqenae, F. A., Steinke, D., Carson-Stevens, A. and Keers, R. N. 2023. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. Therapeutic Advances in Drug Safety 14 (10.1177/20420986231154365)
- Keers, R. N. et al. 2023. Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. PLoS ONE 18(3), article number: e0282021. (10.1371/journal.pone.0282021)
- Butler, C. C. et al. 2023. Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial. The Lancet 401(10373) (10.1016/S0140-6736(22)02597-1)
- Bowie, P., Ross, A., Purchase, T., McNab, D., Hughes, H., Donovan, L. and Carson-Stevens, A. 2023. Patient safety learning for healthcare improvement: considering the "system context" in medico-legal cases?. Journal of Personal Injury Law
- Hibbert, P. D. et al. 2023. Unsafe care in residential settings for older adults. A content analysis of accreditation reports. International Journal for Quality in Health Care 35(4), article number: mzad085. (10.1093/intqhc/mzad085)
- MacFarlane, E., Carson-Stevens, A., North, R., Ryan, B. and Acton, J. 2022. A mixed-methods characterisation of patient safety incidents by primary eye care practitioners. Ophthalmic and Physiological Optics 42(6), pp. 1304-1315. (10.1111/opo.13030)
- Evans, B. A. et al. 2022. Implementing public involvement throughout the research process - experience and learning from the GPs in EDs study. Health Expectations 25(5), pp. 2471-2484. (10.1111/hex.13566)
- Evans, B. A. et al. 2022. Evaluation of the shielding initiative in Wales (EVITE Immunity): protocol for a quasi-experimental study. BMJ Open 12, article number: e059813. (10.1136/bmjopen-2021-059813)
- Dinnen, T. et al. 2022. Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis. BMJ Supportive and Palliative Care 12(e3), pp. e403-e410. (10.1136/bmjspcare-2019-001824)
- Edwards, M. et al. 2022. The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety – a realist evaluation. International Emergency Nursing 62, article number: 101155. (10.1016/j.ienj.2022.101155)
- Slater, D., Hollnagel, E., MacKinnon, R., Sujan, M., Carson-Stevens, A., Ross, A. and Bowie, P. 2022. A systems analysis of the COVID-19 pandemic response in the United Kingdom-Part 1-The overall context. Safety Science 146, article number: 105525. (10.1016/j.ssci.2021.105525)
- Yardley, S., Williams, H., Bowie, P., Edwards, A., Noble, S., Donaldson, L. and Carson-Stevens, A. 2022. Which human factors design issues are influencing system performance in out-of-hours community palliative care? Integration of realist approaches with an established systems analysis framework to develop mid-range programme theory. BMJ Open 12(1) (10.1136/bmjopen-2020-048045)
- Price, D. et al. 2022. Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation. BMC Emergency Medicine 22(12) (10.1186/s12873-021-00562-9)
- Hibbert, P. D. et al. 2022. Designing clinical indicators for common residential aged care conditions and processes of care: the CareTrack Aged development and validation study. International Journal for Quality in Health Care 34(2), article number: mzac033. (10.1093/intqhc/mzac033)
- McFadzean, I. et al. 2022. Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'. BMC Emergency Medicine 22(1), article number: 155. (10.1186/s12873-022-00709-2)
- Sewell, B. et al. 2022. P3 How Much Did the COVID-19 Shielding Policy Cost in Wales? Results of a Cost Analysis Within the EVITE Immunity Evaluation. Value in Health 25(12) (10.1016/j.jval.2022.09.015)
- Ensaldo-Carrasco, E., Sheikh, A., Cresswell, K., Bedi, R., Carson-Stevens, A. and Sheikh, A. 2021. Patient safety incidents in primary care dentistry in England and Wales: a mixed-methods study. Journal of Patient Safety 17(8), pp. e1383-e1393. (10.1097/PTS.0000000000000530)
- Avery, A. J. et al. 2021. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Quality and Safety 30, pp. 961-976. (10.1136/bmjqs-2020-011405)
- Cooper, A. et al. 2021. Identifying safe care processes when GPs work in or alongside emergency departments: realist evaluation. British Journal of General Practice 71(713), pp. e931-e940. (10.3399/BJGP.2021.0090)
- Lazarus, R. et al. 2021. Safety and immunogenicity of concomitant administration of COVID-19 vaccines (ChAdOx1 or BNT162b2) with seasonal influenza vaccines in adults in the UK (ComFluCOV): a multicentre, randomised, controlled, phase 4 trial. The Lancet 398(10318), pp. 2277-2287. (10.1016/S0140-6736(21)02329-1)
- Urquhart, A., Yardley, S., Thomas, E., Donaldson, L. and Carson-Stevens, A. 2021. Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. Journal of the Royal Society of Medicine 14(12), pp. 563-574. (10.1177/01410768211032589)
- Cooper, A. et al. 2021. Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis. BMC Emergency Medicine 21, article number: 139. (10.1186/s12873-021-00537-w)
- Bennett-Britton, I., Banks, J., Carson-Stevens, A. and Salisbury, C. 2021. Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations. British Journal of General Practice 71(711), pp. e797-e805. (10.3399/BJGP.2021.0076)
- Yardley, S., Francis, S., Chuter, A., Hellard, S., Abernethy, J. and Carson-Stevens, A. 2021. Mixed methods study protocol: Do national reporting and learning system medication incidents in palliative care reflect patient and carer concerns about medication management and safety?. BMJ Open 11(9) (10.1136/bmjopen-2021-048696)
- Alshehri, G. H., Keers, R. N., Carson-Stevens, A. and Ashcroft, D. M. 2021. Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System. Journal of Patient Safety 17, pp. 341-351. (10.1097/PTS.0000000000000815)
- Snooks, H. et al. 2021. Call volume, triage outcomes and protocols during the first wave of the COVID-19 pandemic in the UK: results of a national survey. Journal of the American College of Emergency Physicians Open (JACEP Open) 2(4), article number: e12492. (10.1002/emp2.12492)
- Ensaldo-Carrasco, E., Suarez-Ortegon, M. F., Carson-Stevens, A., Cresswell, K., Bedi, R. and Sheikh, A. 2021. Patient safety incidents and adverse events in ambulatory dental care: A systematic scoping review. Journal of Patient Safety 17(5), pp. 381-391. (10.1097/PTS.0000000000000316)
- Fournier, J. et al. 2021. Patient-safety incidents during COVID-19 health crisis in France: an exploratory sequential multi-method study in primary care. European Journal of General Practice 27(1), pp. 142-151. (10.1080/13814788.2021.1945029)
- Alghamdi, A. A., Keers, R. N., Sutherland, A., Carson-Stevens, A. and Ashcroft, D. M. 2021. A mixed-methods analysis of medication safety incidents reported in neonatal and children's intensive care. Pediatric Drugs 23, pp. 287-297. (10.1007/s40272-021-00442-6)
- Edwards, M. et al. 2021. A classification of primary care streaming pathways in UK emergency departments: findings from a multi-methods study comprising cross-sectional survey; site visits with observations, semi-structured and informal interviews. International Emergency Nursing 56, article number: 101000. (10.1016/j.ienj.2021.101000)
- Choudhry, M. et al. 2021. Senior clinical and business managers' perspectives on the influence of different funding mechanisms, and barriers and enablers to implementing models of employing General Practitioners in or alongside emergency departments: qualitative study. Health Policy 125, pp. 482-488. (10.1016/j.healthpol.2020.11.016)
- Hernan, A. L., Giles, S., Carson-Stevens, A., Morgan, M., Lewis, P., Hind, J. and Versace, V. L. 2021. Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England. BMJ Open 11(4), article number: e042551. (10.1136/bmjopen-2020-042551)
- Disbeschl, S. et al. 2021. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot and Feasibility Studies 7(1), article number: 100. (10.1186/s40814-021-00834-y)
- Emary, K. R. W. et al. 2021. Efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine against SARS-CoV-2 variant of concern 202012/01 (B.1.1.7): an exploratory analysis of a randomised controlled trial. The Lancet 397(10282), pp. 1351-1362. (10.1016/S0140-6736(21)00628-0)
- Voysey, M. et al. 2021. Single-dose administration and the influence of the timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine: a pooled analysis of four randomised trials. Lancet 397(10277), pp. 881-891. (10.1016/S0140-6736(21)00432-3)
- Vaismoradi, M. et al. 2021. Nobody ever questions-Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative. PLoS ONE 16(1), article number: e0244519. (10.1371/journal.pone.0244519)
- Bowie, P. et al. 2021. Is the "never event?"concept a useful safety management strategy in complex primary healthcare systems?. International Journal for Quality in Health Care 33(S1), pp. 25-30. (10.1093/intqhc/mzaa101)
- Voysey, M. et al. 2021. Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK. Lancet 397(10269), pp. 99-111. (10.1016/S0140-6736(20)32661-1)
- Evans, H. P. et al. 2020. Automated classification of primary care patient safety incident report content and severity using supervised Machine Learning (ML) approaches. Health Informatics Journal 26(4), pp. 3123-3139. (10.1177/1460458219833102)
- Hibbert, P. D. et al. 2020. Characterising the types of paediatric adverse events detected by the global trigger tool - CareTrack Kids. Journal of Patient Safety and Risk Management 25(6), pp. 239-249. (10.1177/2516043520969329)
- Gibson, R. et al. 2020. A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales. Addiction 115(11), pp. 2066-2076. (10.1111/add.15039)
- Evans, A., Hinchliffe, A., Hood, K. and Carson-Stevens, A. 2020. Use of prescribing indicators as a means of identifying variation in the prevalence of valproate prescribing between health communities: a cross-sectional study. Integrated Healthcare Journal 2(1), article number: e000022. (10.1136/ihj-2019-000022)
- Omar, A. et al. 2020. Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports. Archives of Disease in Childhood 105, pp. 731-737. (10.1136/archdischild-2019-318406)
- Edwards, M. et al. 2020. Emergency department clinical leads' experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study. BMC Emergency Medicine 20(1), article number: 62. (10.1186/s12873-020-00358-3)
- Price, D. et al. 2020. Challenges of recruiting emergency department patients to a qualitative study: a thematic analysis of researchers? experiences. BMC Medical Research Methodology 20(1), article number: 151. (10.1186/s12874-020-01039-2)
- Hibbert, P., Thomas, M., Deakin, A., Runciman, W., Carson-Stevens, A. and Braithwaite, J. 2020. A qualitative content analysis of retained surgical items: Learning from root cause analysis investigations. International Journal for Quality in Health Care 32(3), pp. 184-189. (10.1093/intqhc/mzaa005)
- Cooper, A., Carson-Stevens, A., Hughes, T. and Edwards, A. 2020. Is streaming patients in emergency departments to primary care services effective and safe?. BMJ 368, article number: m462. (10.1136/bmj.m462)
- Mitchell, R. et al. 2020. Using the WHO international classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths. Applied Ergonomics 82, article number: 102920. (10.1016/j.apergo.2019.102920)
- Young, S., Deslandes, P., Cooper, J., Williams, H., Kenkre, J. and Carson-Stevens, A. 2020. A mixed methods analysis of lithium-related patient safety incidents in primary care. Therapeutic Advances in Drug Safety 11, pp. 1-8. (10.1177/2042098620922748)
- Hussain, F., Cooper, A., Carson-Stevens, A., Donaldson, S. L., Hibbert, P., Hughes, T. and Edwards, A. 2019. Diagnostic error in the emergency department: learning from national patient safety incidents report analysis. BMC Emergency Medicine 19, article number: 77. (10.1186/s12873-019-0289-3)
- Carson-Stevens, A. et al. 2019. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Family Practice 20, article number: 134. (10.1186/s12875-019-0990-z)
- Cooper, A. et al. 2019. Taxonomy of the form and function of primary care services in or alongside emergency departments: concepts paper. Emergency Medicine Journal 36(10), pp. 625-630. (10.1136/emermed-2018-208305)
- Cooper, A. et al. 2019. The impact of general practitioners working in or alongside emergency departments: a rapid realist review. BMJ Open 9(4), article number: e024501. (10.1136/bmjopen-2018-024501)
- Williams, H. et al. 2019. Quality improvement identifying priorities for safer out- of- hours palliative care: lessons from a mixed methods analysis of a national incident reporting database. Palliative Medicine 33(3), pp. 346-356. (10.1177/0269216318817692)
- Carson-Stevens, A., McNab, D., Freestone, J., Black, C. and Bowie, P. 2018. Participatory design of a complex improvement intervention for the primary care management of Sepsis using the Functional Resonance Analysis Method. BMC Medicine 16, article number: 174. (10.1186/s12916-018-1164-x)
- Stanciu, M. A. et al. 2018. Development of an intervention to expedite cancer diagnosis through primary care: a protocol. BJGP Open 2(3), article number: 18X101595. (10.3399/bjgpopen18X101595)
- Doran, N., Bethune, R., Watson, J., Finucane, K. and Carson-Stevens, A. 2018. Empowering junior doctors: a qualitative study of a QI programme in South West England. Postgraduate Medical Journal 94(1116), pp. 571-577.
- Yardley, I., Yardley, S., Williams, H., Carson-Stevens, A. and Donaldson, L. J. 2018. Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents. Palliative Medicine 32(8), pp. 1353-1362. (10.1177/0269216318776846)
- Carson-Stevens, A., Donaldson, L. and Sheikh, A. 2018. The rise of patient safety-II: should we give up hope on safety-I and extracting value from patient safety incidents? Comment on "false dawns and new horizons in patient safety research and practice". International Journal of Health Policy and Management 7(7), article number: 12. (10.15171/ijhpm.2018.23)
- Ensaldo-Carrasco, E., Carson-Stevens, A., Cresswell, K., Bedi, R. and Sheikh, A. 2018. Developing agreement on never events in primary care dentistry: an international eDelphi study. British Dental Journal 224, pp. 733-740. (10.1038/sj.bdj.2018.351)
- Cooper, J. et al. 2018. Classification of patient-safety incidents in primary care. Bulletin of the World Health Organization 96(7), pp. 498-505. (10.2471/BLT.17.199802)
- Stuttaford, L., Chakraborty, M., Carson-Stevens, A. and Powell, C. 2018. G190 Patient safety incidents in neonatology: a 10-year descriptive analysis of reports from NHS England and Wales. Archives of Disease in Childhood 103(S1), article number: A78. (10.1136/archdischild-2018-rcpch.185)
- Yardley, I. E., Carson-Stevens, A. and Donaldson, L. J. 2018. Serious incidents after death: content analysis of incidents reported to a national database. Journal of the Royal Society of Medicine 111(2), pp. 57-64. (10.1177/0141076817744561)
- Cooper, J. et al. 2017. Nature of blame in patient safety incident reports: mixed methods analysis of a national database. Annals of Family Medicine 15(5), pp. 455-461. (10.1370/afm.2123)
- Cooper, A. et al. 2017. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age and Ageing 46(5), pp. 833-839. (10.1093/ageing/afx044)
- Cork, N., Rooney, K. D. and Carson-Stevens, A. 2017. When I say? quality improvement. Medical Education 51(5), pp. 467-468. (10.1111/medu.13244)
- Lazenby, S., Edwards, A. G., Samuriwo, R., Riley, S. G., Murray, M. A. and Carson-Stevens, A. 2017. End-of-life care decisions for haemodialysis patients – ‘We only tend to have that discussion with them when they start deteriorating’. Health Expectations 20(2), pp. 260-273. (10.1111/hex.12454)
- Bell, B. G. et al. 2017. Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study. BMJ Open 7(2), article number: e013786. (10.1136/bmjopen-2016-013786)
- Cooper, J., MacLeod, N., Williams, H. and Carson-Stevens, A. 2017. Learning from excellence and patient safety incidents. Archives of Disease in Childhood 102(3), pp. 295-296. (10.1136/archdischild-2016-312445)
- Gibson, R. et al. 2017. Unsafe opioid replacement therapy in England and Wales: a mixed-methods study. The Lancet 389(S1), pp. S38. (10.1016/S0140-6736(17)30434-8)
- Rees, P. et al. 2017. Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis. Plos Medicine 14(1), article number: e1002217. (10.1371/journal.pmed.1002217)
- Samuriwo, R., Williams, H., Cooper, J. and Carson-Stevens, A. 2016. Improving skin care through data: a pitch for patient safety incident reporting. Journal of Wound Care 25(12), pp. 691. (10.12968/jowc.2016.25.12.691)
- Carson-Stevens, A. et al. 2016. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Health Services and Delivery Research 4(27), pp. 1-76. (10.3310/hsdr04270)
- Panesar, S. S. et al. 2016. How safe is primary care? A systematic review. BMJ Quality & Safety 25(7), pp. 544-553. (10.1136/bmjqs-2015-004178)
- Wood, F., Martin, S. M., Carson-Stevens, A., Elwyn, G., Precious, E. and Kinnersley, P. R. 2016. Doctors’ perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study. Health Expectations 19(3), pp. 751-761. (10.1111/hex.12258)
- Samuriwo, R., Evans, H. P., Williams, H., Rees, P., Hibbert, P., Makeham, M. and Carson-Stevens, A. 2016. Primary Care Patient Safety (PISA) Research Group - Identifying priorities for pressure ulcer prevention in primary care.. EWMA Journal 16(1), pp. 25-26.
- Evans, H. P., Cooper, A., Williams, H. and Carson-Stevens, A. 2016. Improving the safety of vaccine delivery. Human Vaccines & Immunotherapeutics 12(5), pp. 1280-1281. (10.1080/21645515.2015.1137404)
- Williams, H., Cooper, A. and Carson-Stevens, A. 2016. Opportunities for incident reporting. Response to: 'The problem with incident reporting' by Macrae et al. BMJ Quality & Safety 25(2), pp. 133-134. (10.1136/bmjqs-2015-004962)
- Williams, H. et al. 2015. Harms from discharge to primary care: mixed methods analysis of incident reports. British Journal of General Practice (BJGP) 65(641), pp. e829-e837. (10.3399/bjgp15X687877)
- Carson-Stevens, A. et al. 2015. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open 5(12), article number: e009079. (10.1136/bmjopen-2015-009079)
- Omar, A. et al. 2015. Vulnerable children and their care quality issues: a descriptive analysis of a national database [Abstract]. BMJ Quality and Safety 24(11), pp. 732-733., article number: 588. (10.1136/bmjqs-2015-IHIabstracts.18)
- Rees, P. et al. 2015. Identifying priorities for improved child healthcare: a mixed methods analysis of safety incident reports [Abstract]. BMJ Quality and Safety 24(11), pp. 730-731., article number: 579. (10.1136/bmjqs-2015-IHIabstracts.16)
- Rees, P. et al. 2015. Pediatric immunization-related safety incidents in primary care: a mixed methods analysis of a national database. Vaccine 33(32), pp. 3873-3880. (10.1016/j.vaccine.2015.06.068)
- Rees, P. et al. 2015. Safety incidents in the primary care office setting. Pediatrics 135(6), pp. 1027-1035. (10.1542/peds.2014-3259)
- Carson-Stevens, A., Edwards, A. G., Panesar, S., Parry, G., Rees, P., Sheikh, A. and Donaldson, L. 2015. Reducing the burden of iatrogenic harm in children. The Lancet 385(9978), pp. 1593-1594. (10.1016/S0140-6736(14)61739-6)
- Dahill, M. et al. 2015. First-year doctors' attitudes and beliefs relating to quality improvement and patient safety. Clinical Risk 21(2-3), pp. 47-49. (10.1177/1356262215585270)
- Rees, P., Edwards, A., Powell, C., Evans, H. P., Panesar, S. and Carson-Stevens, A. 2015. Disparities in the quality of primary healthcare for socially deprived children. Archives of Disease in Childhood 100(3), pp. 299-300. (10.1136/archdischild-2014-307618)
- Rees, P., Edwards, A., Panesar, S. and Carson-Stevens, A. 2014. Child mortality in the UK. The Lancet 384(9958), pp. 1923-1924. (10.1016/S0140-6736(14)62272-8)
- Rees, P., Evans, H. P., Panesar, S., Llewelyn, M., Edwards, A. and Carson-Stevens, A. 2014. Contraindicated BCG vaccination in "at risk" infants. BMJ 349, article number: g5388. (10.1136/bmj.g5388)
- Rees, P., Carson-Stevens, A., Williams, H., Panesar, S. and Edwards, A. 2014. Quality improvement informed by a reporting and learning system. Archives of Disease in Childhood 99(7), pp. 702-703. (10.1136/archdischild-2014-306198)
- Madhok, R. et al. 2014. Promoting patient safety in India: situational analysis and the way forward. National Medical Journal of India 27(4), pp. 217-223.
- Panesar, S. S. et al. 2013. The orthopaedic error index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach. BMJ Open 3(11), pp. e003448. (10.1136/bmjopen-2013-003448)
- Parry, G. J., Carson-Stevens, A., Luff, D. F., McPherson, M. E. and Goldmann, D. A. 2013. Recommendations for evaluation of health care improvement initiatives. Academic Pediatrics 13(6), pp. S23-S30. (10.1016/j.acap.2013.04.007)
- Cresswell, K. M. et al. 2013. Global research priorities to better understand the burden of iatrogenic harm in primary care: An international delphi exercise. PLoS Medicine 10(11), pp. e1001554. (10.1371/journal.pmed.1001554)
- Ward, H. O., McIldowie, B., Kibble, S., Squire, A. and Carson-Stevens, A. 2013. Financial implications for survivors of stroke. British Medical Journal 347, article number: f4999. (10.1136/bmj.f4999)
- Carson-Stevens, A., Patel, E., Nutt, S. L., Bhatt, J. and Panesar, S. S. 2013. The social movement drive: a role for junior doctors in healthcare reform. Journal of the Royal Society of Medicine 106(8), pp. 305-309. (10.1177/0141076813489677)
- Mustafa, M., Carson-Stevens, A., Gillespie, D. and Edwards, A. G. 2013. Psychological interventions for women with metastatic breast cancer. Cochrane Library 2013(6), article number: CD004253. (10.1002/14651858.CD004253.pub4)
- Panesar, S., Carson-Stevens, A., Salvilla, S., Patel, B., Mirza, S. and Mann, B. 2013. Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors. Drug, Healthcare and Patient Safety 2013(5), pp. 57-65. (10.2147/DHPS.S40887)
- Carson-Stevens, A., Davies, M. M., Jones, R., Pawan Chik, A. D., Robbé, I. J. and Fiander, A. N. 2013. Framing patient consent for student involvement in pelvic examination: a dual model of autonomy: Table 1.. Journal of Medical Ethics 39(11), pp. 676-680. (10.1136/medethics-2012-100809)
- Carson-Stevens, A. P., Jones, A., Hansen, A. S., Printz, A., Patel, E., Bhatt, J. and Panesar, S. S. 2013. Q-Tip: "What can I do to improve your care today?" -One question closer to patient-centered care. American Journal of Medical Quality 28(2), pp. 174-174. (10.1177/1062860612470782)
- Carson-Stevens, A., Hingston, C. D. and Wise, M. P. 2011. Minimising drug errors in critically ill patients. Critical Care 15(1), article number: 401. (10.1186/cc9366)
- Panesar, S. S., Carson-Stevens, A., Fitzgerald, J. E. and Emerton, M. 2010. The WHO surgical safety checklist - junior doctors as agents for change. International Journal of Surgery 8(6), pp. 414-416. (10.1016/j.ijsu.2010.06.004)
Book sections
- Purchase, T., Bowie, P., Hibbert, P., Krishnan, R. G. and Carson-Stevens, A. 2023. Human factors to improve patient safety. In: Patient Safety. Cham, Switzerland: Springer, pp. 45-60., (10.1007/978-3-031-35933-0_4)
- Carson-Stevens, A., Hayes, J., Evans, A. and Donaldson, L. 2018. Wales: Realizing a data-drive healthcare improvement agenda: a manifesto for world class patient safety. In: Braithwaite, J. et al. eds. Health Care Systems: Future Predictions of Global Care.. CRC Press Taylor and Francis Group, pp. 275-280.
- Jones, A. and Carson-Stevens, A. 2014. Patient stories in improvement. In: Panesar, S. S. et al. eds. Patient Safety and Healthcare Improvement at a Glance. Chichester, UK: Wiley, pp. 90-92.
Books
- Panesar, S., Carson-Stevens, A., Salvilla, S. and Sheikh, A. Panesar, S. et al. eds. 2014. Patient safety and healthcare improvement at a glance. Wiley-Blackwell.
Conferences
- Sivell, S., Price, D. and Carson-Stevens, A. 2023. The challenges and experiences of providing end-of-life care in primary care: online survey and semi-structured interviews with UK primary care professionals.. Presented at: RCGP Annual Conference 2023, Glasgow, 19-20 October 2023, Vol. 73. Vol. Suppl. Royal College of General Practitioners, (10.3399/bjgp23X733833)
- Sivell, S. et al. 2023. Protocol to evaluate the implementation of the royal college of general practitioners and Marie Curie Daffodil Standards in UK general practice. Presented at: The Marie Curie Research Conference 2023, Virtual, 6-10 February 2023, Vol. 13. BMJ Publishing Group pp. A8., (10.1136/spcare-2023-MCRC.19)
- Sivell, S., Price, D. and Carson-Stevens, A. 2023. Understanding the experiences of providing end-of-life care in UK general practices; preliminary data from an independent evaluation of the daffodil standards.. Presented at: The Marie Curie Research Conference 2023, Virtual, 6-10 February 2023, Vol. 13. BMJ Supportive and Palliative Care: BMJ Publishing Group pp. A8-A9., (10.1136/spcare-2023-MCRC.20)
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Priorities for pressure ulcer prevention: mixed methods analysis of patient safety incidents reports from primary care in England and Wales (2003-2013).. Presented at: PRIME Centre Wales 1st Annual Meeting, Cardiff, Wales, 22 September 2015.
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Primary care pressure ulcer related patient safety incidents reports from England and Wales: a mixed methods analysis. Presented at: 18th Annual Meeting of the European Pressure Ulcer Advisory Panel (EPUAP 2015), Ghent, Belgium, 16-18 September 2015.
- Samuriwo, R., Hibbert, P., Makeham, M., Evans, H. P. and Carson-Stevens, A. 2015. Primary care pressure ulcer related patient safety incidents reports from England and Wales: A mixed methods analysis.. Presented at: 25th Conference of the European Wound Management Association (EWMA 2015), London, England, 13 May 2015.
- Samuriwo, R. et al. 2015. How do we prevent pressure ulcers in primary care? Galvanising insights from healthcare professionals. Presented at: 21st Annual Institute for Healthcare Improvement Scientific Symposium (IHI 2015), Orlando, FL, USA, 7 December 2015.
Monographs
- Carson-Stevens, A. and Donaldson, L. 2017. Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners.. Manual. Royal College of General Practitioners. Available at: http://www.rcgp.org.uk/-/media/Files/CIRC/Patient-Safety/Reporting-and-learning-from-patient-safety-incidents.ashx?la=en
- Makeham, M., Dovey, S., Zwar, N. and Carson-Stevens, A. 2016. Administrative errors: technical series on safer primary care. Technical Report.
Thesis
- Carson-Stevens, A. 2017. Generating learning from patient safety incident reports from general practice. PhD Thesis, Cardiff University.
Research
Overview of Research
Learning from unsafe health and social care outcomes experienced by patients and their families
I have developed a mixed-methods approach for measuring the frequency and avoidability of harm, and identifying priorities for safety improvement.
The Patient Safety (PISA) classification system, inclusive of multi-axial coding frameworks is aligned to the WHO International Classification for Patient Safety, and was empirically developed during a national agenda setting study of patient safety incidents in General Practice (funded by NIHR Health Services and Delivery Research programme and colloquially known as the 'PISA study').
The PISA study was the largest characterisation of patient safety incidents in general practice worldwide. The PISA classification system has since provided a foundation for other researchers to replicate and extend the research, and advance the primary care patient safety agenda, internationally. Within the UK, for example, PISA has been applied to identify 'significant avoidable harm' in General Practices in England (funded by the NIHR Policy Research Programme), the NIHR-funded study to investigate avoidable harm in prison healthcare services in England, and the Cancer Research Wales-funded Think Cancer! Trial exploring causes of the longest delays for cancer diagnoses.
The PISA group has a vast portfolio of completed studies that have identified safety improvement priorities across the health and social care continuum, including: unsafe discharge from secondary to primary care settings and safety incidents experienced by children in primary care, older adults, patients receiving palliative care, advanced care planning, patients with dementia, adults receiving mental health services in primary care, and adults receiving opiate replacement.
Example areas of completed studies:
Healthcare in prisons
- Patient safety incidents in prisons – published in the Journal of the Royal Society of Medicine https://doi.org/10.1177/01410768231166138
Paediatric care in community contexts
- Patient safety incidents involving sick children in primary care in England and Wales: A mixed methods analysis – published in PLOS Medicine https://doi.org/10.1371/journal.pmed.1002217
- Safety incidents involving children in general practice – published in Pediatrics https://doi.org/10.1542/peds.2014-3259
- Paediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database– published in Vaccine https://doi.org/10.1016/j.vaccine.2015.06.068
Acute care settings
- Harms from discharge to primary care: Mixed methods analysis of incident reports – published in British Journal of General Practice https://doi.org/10.3399/bjgp15X687877
- Diagnostic error in the emergency department: learning from national patient safety incident report analysis – published in BMC Emergency Medicine https://doi.org/10.1186/s12873-019-0289-3.
- Learning from patient safety incident involving acute sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement – published in Journal of the Royal Society of Medicine. https://doi.org/10.1177/01410768211032589
- Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis – published in BMC Emergency Medicine https://doi.org/10.1186/s12873-021-00537-w
Dentistry
- Patient safety incidents in primary care dentistry in England and Wales: A mixed-methods study – published in the Journal of Patient Safety http://dx.doi.org/10.1097/PTS.0000000000000530
Vulnerable societal groups across the care continuum
- Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports – published in Archives of Disease in Childhood. http://dx.doi.org/10.1136/archdischild-2019-318406
- A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales – published in Addiction https://doi.org/10.1111/add.15039
- Patient safety incidents in advance care plans for serious illness: a mixed methods analysis – published in BMJ Supportive and Palliative Care http://dx.doi.org/10.1136/bmjspcare-2019-001824
- Sources of unsafe primary care for older adults: A mixed-methods analysis of patient safety incident reports – published in Age and Ageing https://dx.doi.org/10.1093%2Fageing%2Fafx044
- Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database – published in Palliative Medicine https://doi.org/10.1177%2F0269216318817692
- Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents – published in Palliative Medicine https://doi.org/10.1177/0269216318776846
Building capacity and capability to enable a transition from 'learning to action'
Worldwide, attempts to identify and learn from the most important sources of harm to patients have been restricted by the lack of a universal standard system for classifying harm severity and the general neglect of psychological harm in this context. My research group has empirically developed a series of classification systems, for example the PISA Harm Severity Classification System published in the Bulletin of the World Health Organization, to be applied internationally to improve the detection and prevention of incidents that cause the most severe harm to patients.
- Development of an international classification system for patient safety in primary care – published in the Bulletin of the World Health Organization http://dx.doi.org/10.2471/BLT.17.199802
Harrowing, unsafe care experiences of patients and their families are too often depicted in patient safety incident reports. Such reports represent a unique perspective for learning. However, the volume of data in many patient safety incident reporting systems is so great that many have never been analysed or used to support improvement in patient safety. We have developed machine learning approaches (i.e. text classification methods) to overcome this challenge which will automate the capture of essential information to understand patient safety incidents including extracting details about what happened (incident type), why it happened (contributory factors) and the severity of the outcome (harm severity).
- Automated classification of primary care patient safety incident report content and severity using supervised machine learning (ML) approaches – published in Health Informatics https://doi.org/10.1177/1460458219833102
Organisations have also been hindered by lack of investment for building capacity and capability of staff to analyse such data. Supported by a Health Foundation Advancing Analytics Award, we are currently exploring methods for 'harnessing data analytics to maximise NHS learning from patient safety incident reports' and working to realise synergy between data analysts, managers and clinicians for identifying and acting on learning from patient safety data.
Teaching
Overview of educational scholarship
Internationally, I have shared with other researchers the innovative mixed method approaches developed by my research group to investigate and understand the epidemiology of patient safety incidents (guest lecturer at the Harvard Chan School of Public Health in 2017). I have trained researchers to learn from patient safety incidents using the PISA Method nationally and worldwide (Australia, Brazil, Canada, France, Kuwait, Mexico, Spain, Turkey, USA) leading to many international research collaborations and impactful outputs. The PISA Group welcomes expressions of interests from those seeking to advance their patient safety research proficiencies (postgraduate students, clinical academics, post-doctoral fellows, senior academics) through visiting appointments at Cardiff University.
Lessons learnt from my research studies have influenced World Health Organization strategy for patient safety. Learning is shared back to frontline providers through established educational systems like the Royal College of General Practitioners; one example includes a programme designed to support the primary care workforce to recognise, report and learn from patient safety incidents through e-learning courses, national seminars, and a practical ‘how to’ guide. I have also contributed internationally to Boston Children's Hospital / Harvard Medical School's OPEN Pediatrics programme, aimed predominantly at learners from low- and middle-income settings, on disclosure and apology to patients and families following unsafe healthcare.
From 2012-16, I was the Institute for Healthcare Improvement UK and Ireland Faculty Lead for the online and community-based educational programme, the IHI Open School (2012-16) – now the largest provider of quality improvement and patient safety education worldwide. In 2008, I was an intern to Professor Donald Berwick at the Institute for Healthcare Improvement in Cambridge, USA. I was a co-founding leader of the IHI Open School. Utilising social organising methods and the IHI Open School's growing network of quality improvement enthusiasts, I was co-founder of a global patient safety campaign for junior healthcare professionals called "Check a Box. Save a Life." supporting the spread and dissemination of the WHO Surgical Safety Checklist. In later years, as a faculty member, I developed methods for students to learn about the experience of patients and families in healthcare to inform quality improvement through Ask One Question – encouraging students to adopt simple strategies like asking every patient they meet, "What can I do to improve your care today?". These educational innovations have since been implemented into multiple medical curricula, for example, at Cardiff University and the University of British Columbia (Canada).
Educational leadership at Cardiff University
Module leadership and contributions
Year from/ to |
School |
Module/ course title |
Level of study |
Role |
2019 – 2021 |
Medicine |
Quality and Safety (20 credits) module developed for use in the: Critical Care MSc, Clinical Leadership and Change Management in Cardiology MSc, Palliative Medicine for Health Care Professionals MSc. |
MSc |
Module leader |
2019 – 2021 |
Business |
Strategic Planning and Innovation |
PG Diploma in Healthcare Planning |
Faculty |
2014 – ongoing |
Medicine |
Year 5 Medicine: Changing Practice, MB BCh |
Year 5 Medical Students (n=300+) |
Module leader |
2017 – ongoing |
Medicine |
Improving the quality of clinical care |
Population Medicine Intercalated BSc (n=10+) |
Module leader |
2018 – ongoing |
Medicine |
Year 2 SSC Research Taster Week |
Year 2 Medical Students (n=20) |
SSC Tutor |
2018/2019 |
Medicine |
Practical Research Experience Student Selected Component |
Year 1 Medical Students (n=10) |
Tutor |
Academic leadership, management and teaching/research-related administration roles
- Director of Research, Division of Population Medicine, April 2021 – ongoing
- Division of Population Medicine Academic Meeting Schedule Co-ordinator, November 2018 – ongoing.
- Member of School of Medicine Research Ethics Committee, July 2020 – April 2021
- Medical students interviewer, December 2019 – ongoing
- Wellcome INSPIRE taster day, December 2019 – ongoing
- PhD Exam Board Chair, September 2019
- Member of faculty securing Welsh Government funding for the Cardiff University Diploma in Healthcare Planning, 2018
- Member of Cardiff University Phoenix project, 2018 – 2020
- C21 Lead and Member, Education Management Group, Division of Population Medicine, School of Medicine, October 2018 – March 2021
- Patient safety theme leader, Division of Population Medicine, School of Medicine, August 2018 – ongoing
- Member of Senior Leadership Team, Division of Population Medicine, School of Medicine, August 2018 – ongoing
- Member of Research Management Group, Division of Population Medicine, August 2018 – March 2021
- Primary and Emergency Care Centre: work package lead for patient safety, May 2015 – ongoing
- Exam board for Intercalated BSc Clinical Epidemiology, June 2017 – ongiong
- Academic mentor / personal tutor, November 2015 – ongoing
Quality assurance / examiner roles
- Expert advisor, BMJ Learning Collection on Quality Improvement, 2023 – ongoing
- PhD Examiner, Swansea University, University of Glasgow, University College London, University of Sydney
- PhD Examination Chair, Cardiff University
- External Examiner, Quality Improvement in MB BS curriculum, King's College London, 2016 – 2021.
- External Evaluator for the European Commission to the 'Improvement Science Training for European Healthcare Workers' Study, a multi-country educational research and development project, 2013 – 2016.
External teaching contributions
- Invited workshop, 'Generating actionable learning from healthcare-associated harm', 9th Annual Patient Safety Trainees and Students Day, Royal Society of Medicine, London, UK, November 2019
- Expert advisor, Cancer Research UK's project to develop a series of educational screencasts on 'Quality Improvement to Aid Early Diagnosis of Cancers in General Practice', Royal College of General Practitioners, London, UK, March – October 2019
- Expert advisor, as above for CRUK, for RCGP 'Improvement of End of Life Care' screencasts, Royal college of General Practitioners, July 2019 –
- Developed two online e-learning modules on 'Improving patient safety in general practice', RCGP eLearning modules, Royal College of General Practitioners, London, UK, April 2018
- Delivered national workshops on 'Learning from patient safety incidents in general practice', Royal College of General Practitioners (Cardiff, Liverpool, London), Spring 2017
- Invited speaker at RCGP Faculty events (RCGP Midlands, RCGP West of Scotland, Winter 2017 / Spring 2018) and RCGP Annual Conference (Liverpool), October 2017
- Faculty, 'Building Essential QI Skills', co-taught (with Dr Kedar Mate) one-day course for Institute for Healthcare Improvement at the University of British Columbia, Vancouver, Canada, June 2017
- Invited faculty, 'Epidemiologic methods for patient safety', co-taught (with Prof Malcolm Maclure) one-week course at the Harvard Chan School of Public Health, Boston, USA, January 2017
- Online lecturer, 'Disclosure and apology to patients and families following unsafe healthcare', Boston Children's Hospital / Harvard Medical School's OPEN Pediatrics programme, Boston, USA, December 2015 (delivered for CPD on a recurring annual basis)
- Faculty, IHI Open School Student Organizing Leadership Academy, Institute for Healthcare Improvement, Cambridge, USA; and, delivered workshop on 'Utilising social media for social mobilizing to improve patient and population health', August 2015
- Online lecture, 'What is quality Improvement?' for the Master of Public Health Programme at King's College London, 2015
- Co-organiser, Quality Improvement Masterclass for Healthcare and Policy Leaders, Faculty of Medical Leadership and Management, March 2013
Textbook
- Co-editor, Patient Safety and Healthcare Improvement at a Glance, Wiley Blackwell
Biography
Education and qualifications
- 2024: Fellow of the Royal College of General Practitioners
- 2019: Value Measurement for Health Care, Harvard Business School Executive Education, Boston USA
- 2018: Member of the Royal College of General Practitioners
- 2017: Doctor of Philosophy, Generating learning from patient safety incident reports from general practice, Cardiff University, UK
- 2014: Improvement Advisor Professional Development Program, Institute for Healthcare Improvement, Cambridge, USA
- 2011: Leading Innovation in Health Care & Education, Harvard Macy Institute, Harvard University, Boston, USA
- 2010: Master of Philosophy (Medical Education), Cardiff University, Cardiff, UK
- 2010: MB BCh, University of Wales College of Medicine, Cardiff, UK
- 2007: BSc (1st Class Hons, Public Health), University of Wales, Cardiff, UK
Honours and awards
Awards
- Health and Social Care Research Partnership Award with Industry (co-recipient) awarded by MediWales, 2020
- Awarded 'ISQua expert' status by the The International Society for Quality in Healthcare (ISQua), 2018
- Public Involvement Achievement Award – Runner-up, Health and Care Research Wales, 2018
- Honorary Membership of The Faculty of Public Health, 2017
- Best Research Team Award (Primary and Emergency Care Research Centre), School of Medicine, Cardiff University, 2017
- Royal College of General Practitioners 'Spotlight Award', 2016
- International Visiting Peter Wall Scholar, Institute of Advanced Studies, University of British Columbia, 2016/17
- Health Service Journal Rising Star Award, 2015
- Churchill Fellow, Winston Churchill Memorial Trust, 2013–2015
- Innovation and Engagement Award, School of Medicine Cardiff University, 2013
- NHS Wales Award (co-recipient) for Promoting Clinical Research and Application to Practice, 2012
- Permanente Journal Health Services Award, 2012
- Gold Award Winner, Worshipful Livery Company of Wales, 2010
Peer esteem
International
- Member of the WHO Expert Consultation on Monitoring and Reporting on Global Patient Safety Action Plan 2021-2030, November 2021.
- Member of the Expert Advisory Group on measurement, WHO Global Patient Safety Action Plan (2020-2030), July – August 2020.
- Member of the Taskforce for drafting and reviewing the WHO Global Patient Safety Action Plan (2020-2030), June 2020.
- Invited speaker and co-chair of working group for 'Measurement, reporting, learning and surveillance', Global Consultation – A Decade of Patient Safety 2020-2030: Formulating the Global Patient Safety Action Plan, World Health Organization, Geneva, Switzerland, February 2020
- International project grant reviewer, Health Research Council, New Zealand, January 2020
- Member of International Research Advisory Panel, Centre for Research Excellence for Indigenous Health Care Equity funded by the Australian Government's National Health and Medical Research Council (NHMRC) Centre for Research Excellence, January 2020
- Member of international expert advisory group, WHO Patient Safety Meeting on Global Knowledge Sharing, Florence, Italy, December 2019
- Grant reviewer, Health Research Board, Ireland, October 2019.
- Member (Welsh Government's representative) of International Working Party, OECD Patient Reported Indicator Surveys (PaRiS) programme. Organisation for Economic Co-operation and Development (OECD), Paris, France, May 2019 –
- Member of International Working Group, OECD Patient-reported Experiences of Safety project. OECD, Paris, France, February 2019 –
- Keynote speaker, Queen's University Health Quality Research Forum, Kingston, ON, Canada, May 2019
- Invited member of international implementation group, WHO Medication Safety Challenge, World Health Organization, Geneva, Switzerland, November 2018
- Invited speaker, WHO Ministerial Summit on Patient Safety, Tokyo, Japan, April 2018
- ISQua expert, The International Society for Quality in Healthcare, March 2018
- Invited speaker, WHO Patient Safety Expert Meeting on Global Knowledge Sharing, Florence, Italy, November 2017
- Member of international research advisory board, Harnessing systems science to build an effective and efficient health system programme grant, NHMRC, Australia, July 2017 –
- Guest lecturer, Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA, January 2017
- Member, World Health Organization Patient Safety Incident Reporting System Guideline Review Group, Geneva, Switzerland, November 2016
- Invited member, WHO Global Consultation `Setting Priorities for Global Patient Safety', Florence, Italy, September 2016
- External assessor, European Commission-appointed assessor, "Improvement Science Training for European Healthcare Workers (ISTEW)" programme (Funder: The European Lifelong Learning Erasmus programme for multilateral project), 2014-2015
- UK and Ireland Faculty Lead, IHI Open School, Institute for Healthcare Improvement, Boston, USA, 2012-2016
National
- Invited speaker, 30th Conference of the European Wound Management Association, London UK, May 2020
- Invited plenary, 'Learning from patient safety incidents in primary care: the pros, the challenges and opportunities ahead', Inquests, Indemnity and Incidents in Primary Care, Royal Society of Medicine, London, UK, April 2020
- Keynote speaker, 999 EMS Research Forum, Brighton, UK, March 2020
- Invited speaker, Marie Curie Out of Hours Palliative and End of Life Care Workshop, London UK, January 2020
- Invited expert advisor to NIHR panel, National Institute for Health Research Policy Programme, December 2019
- Invited workshop and 'Dragon's Den Judge', 9th Annual Patient Safety Trainees and Students Day, Royal Society of Medicine, London, UK, November 2019
- Grant reviewer for Medical Research Council, Clinical Research Fellowship, London, UK, November 2019
- Appointed member of the Advanced Disease and End of Life Care Workstream, Living With and Beyond Cancer Group, National Cancer Research Institute (NCRI), London, UK, November 2019 –
- Scientific advisory committee (evaluation), Advancing Quality Alliance (AQuA), Manchester, UK, September 2019
- Programme grant reviewer, NIHR Programme Grants for Applied Research, UK, September 2019
- Grant reviewer, NIHR Health Services and Delivery Research, February 2019
- Peer reviewer, NHS Innovation Accelerator Fellowships, November 2018
- Scientific advisor to NHS Education for Scotland, Patient Safety and Quality Improvement Research and Educational Development, Scotland, UK, April 2018 –
- Invited participant, International Symposium on Safety Investigation in Healthcare, organised by the Healthcare Safety Investigation Branch (England), March 2018
- Invited member, Reducing Medicines Related Harm in NHS Wales Working Group, Welsh Government, Wales, UK, November 2017 –
- Keynote speaker, National Association of Educators in Practice, UK, March 2015
Professional memberships
- Fellow, Royal College of General Practitioners (2023–)
- Member, Royal College of General Practitioners (2018–2024)
- Fellow, Royal Society of Arts (2018–)
- Member, Q initiative, Health Foundation (2017–)
- Member, European Public Health Association (2017–)
- Honorary Member, UK Faculty of Public Health (2017–)
- Associate Member, Royal College of General Practitioners (2012–2018)
- Registered medical practitioner, General Medical Council (2010–)
Academic positions
- 2019 – present: Adjunct Professor, Queen's University, Kingston, ON, Canada
- 2016 – present: Honorary Professor, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
- 2015 – 2018: Visiting Chair (Professor) of Healthcare Improvement and Leadership, Department of Family Practice, University of British Columbia
- 2015 – present: Patient Safety Research Lead, Primary and Emergency Care Research Centre, Wales
- 2012 – 2018: Wales Clinical Academic Training Lectureship (Clinical Lecturer), Cardiff University
- 2010 – 2012: Clinical Fellow, Cochrane Institute of Public Health, Cardiff University
Committees and reviewing
National
- Member, Strategic Advisory Group, Health and Care Research Wales Evidence Centre, 2022 – ongoing.
- Member, Marie Curie Research Funding Committee, January 2022 – ongoing.
- Member, Clinical Research Delivery in Wales Review, Welsh Government, September – December 2023.
- Member, Data for Research Programme for Wales Working Group, June 2022 – ongoing.
- Observer (representing Health and Care Research Wales), NIHR Primary Care Programme Board, August 2021 – ongoing.
- Member, Long COVID in Children Expert Group, NIHR, August 2021
- Member, Health Service Research Wales Expert Reference Group, Health and Care Research Wales, August 2021.
- Member, Long COVID (non-hospitalised patients) research funding panel, NIHR, June 2021
- Member, COVID-19 Understanding and Eliminating COVID-19 Trials Implementation Panel (CUE-TIP), April 2021 - March 2022
- Member, Primary Care Reference Group, Our Future Health (December 2020 – ongoing)
- Member, Wales COVID-19 Vaccine Research Delivery Group (now Wales Vaccines Research Delivery Group), July 2020 – ongoing
- Member, Urgent Public Health Group (COVID-19), NIHR / DHSC / CMOs, March 2020 – 2021
- Prioritisation Oversight Committee, NIHR / Health and Care Research Wales – RfPPB (2020–) and Health Research Awards (2020–)
- Grant / final report reviewer for: National Institute for Health Research – HS&DR (2015-); NIHR Policy Research Programme (2019–), Health Foundation (2017–), NIHR Programme grants for Applied Research (2018-); NHS Innovation Accelerator Awards (2018–); Medical Research Council (2019-); NIHR Advanced Fellowships (2020–); Wellcome (2022 –).
- Invited expert, Funding Committee of the National Institute for Health Research Policy Research Programme (2019)
- Member, Advanced Disease and End of Life Care workstream, Living With and Beyond Cancer Group, National Cancer Research Institute (NCRI), London, UK (2019-2022)
- Member, Salford Integrated Care Organisation Evaluation Panel, Advancing Quality Alliance (AQuA) (2019-2020)
- Scientific advisor, Patient Safety and Quality Improvement Research and Educational Development, NHS Education for Scotland (2018- ongoing)
- Member, College of Assessors for Innovating for Improvement and Scaling Up Improvement grants, Health Foundation (2017)
- Member, Primary Care Safety Expert Group, 1000 Lives Improvement Service, Public Health Wales (2017)
- Member, Reducing Medicines Related Harm in NHS Wales Working Group, Welsh Government (2017)
- Executive Management Committee, PRIME Centre Wales (2015-ongoing) and co-Chair of PRIME Annual Meeting (2021)
International
- Guest Academic Editor, PLOS Medicine (2020)
- Grant reviewer, Health Research Board, Ireland (2019), Health Research Board, New Zealand (2020), Swiss National Science Foundation (2020).
- International Research Advisory Panel, Centre for Research Excellence for Indigenous Health Care Equity funded by the Australian Government's National Health and Medical Research Council (NHMRC) Centre for Research Excellence, Sydney. CI: Prof Ross Bailie. (2020-)
- Member, Working Party for the OECD Patient Reported Indicator Surveys (PaRIS) programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-2022)
- Member, Working Group for the OECD Patient Reported Safety Outcomes programme. Organisation for Economic Co-operation and Development. Paris, France. (2019-)
- Expert advisory group, WHO Global Knowledge Sharing Platform for Patient Safety (1st meeting 2017, 2nd meeting 2019)
- International scientific advisory board, "Care Track Aged: appropriate care delivered to Australians living in residential aged care." Project No. 1143223 awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2018-)
- International scientific advisory board, “Harnessing systems science to build an effective and efficient health system” programme grant ($10.75 million) awarded by the National Health and Medical Research Council to Macquarie University, Sydney. CI: Prof Jeffrey Braithwaite. (2017-)
- Editorial advisory board, BMJ Open Quality (2017-)
- Institute for Healthcare Improvement Scientific Symposium Advisory Board Member (2013)
- Coordinating member, World Health Organization Safer Primary Care Expert Group, (2012-)
Supervisions
Current PhD / supervision of researchers / postgraduate research students:
PhD students
- Dr Imogen John, Safety of end of life care. Wales Clinical Academic Training Fellow.
- Dr Thomas Purchase, IncorporAting parental health aDVOcaCy when mAnaging unwell Children in primarY care (ADVOCACY): a multi-methods systems approach to co-develop a complex intervention. NIHR Doctoral Fellowship.
- Dr Joy McFadzean, Methods to learn from patient safety incidents. PhD by portfolio.
- Setareh Majidian, The influence of artificial intelligence (AI) capabilities and innovative performance on new service development.
- Nichole Pereira, Evaluating the implementation of electronic health record implemention in paediactric care.
- Shalini Ganasan, Resilience-driven learning to improve and sustain safer healthcare systems. ESRC PhD Fellowship.
- Laura Pozzobon, Measurement of medication-related harm.
- Samantha Laws, Safety of ambulance non-conveyance.
In-Practice / Post-doctoral mentorship
- Dr Sarah Yardley, Use of 'close-to-practice' methodologies to explain and change impact of interpersonal relationships in quality improvement. THIS Institute Post-doctoral Fellowship, University College London (2019–).
- Dr Ben Bowers, Using injectable end-of-life symptom control medications at home: understanding human and system factors through inclusive design. Wellcome Early Career Fellowship Award, University of Cambridge (2023–).
- Dr Rebecca Barnes, Optimising patient risk management in urgent primary care services. NIHR Advanced Fellowship, University of Oxford (2023–).
- Dr Peter Edwards, NIHR In-Practice Fellowship, University of Bristol (2022–).
Current supervision
Shalini Ganasan-Ryan
Graduate Tutor
Sam Laws
Research student
Past projects
- Elinor MacFarlane, Evaluation of patient safety in the delivery of care to patients with eye-related problems. KESS. PhD. Co-Supervisor. Awarded 2024.
- Thomas Hewson, Exploring Mental Healthcare Patient Safety Incidents in English Prisons: a multi-methods study. MRes. Co-supervisor. Awarded 2023.
- Jaafer Qasem, Exploring the Acceptability of an International Patient Safety Learning System: An Exploratory Sequential Mixed Methods Approach, PhD. Supervisor. Awarded 2023.
- Samuel Evans, The quality of evidence collected at the child protection medical: The development and pilot testing of infrared, ultraviolet, cross polarisation and high frequency ultrasound to improve standardised
collection of bruises, PhD. Co-supervisor. Awarded 2022. - Khalid Muhammad, Primary Care Medication Safety Incidents Reported to the National Reporting and Learning System (NRLS), PhD. Co-supervisor. Awarded 2021.
- Alison Cooper, Exploring opportunities for patient safety when GPs work in or alongside emergency departments: realist synthesis and evaluation, PhD. Co-supervisor. Awarded 2020.
- Flore Laforest, MPH, and Jawaher Alkhaldi, MPH,Cardiff University. Supervisor. Awarded 2019.
- Doctoral students at Macquarie University, Sydney: Melissa Riddoch DPT, Avanthi Rajaratnam DPT, Natalie Fowler DPT, Kelsy Weavil DPT, Michelle Khan DPT, Maxine Delaney DPT. Co-supervisor. Awarded 2019.
- Haroon Chughtai, MSc Clinical Bioinformatics, University of Liverpool. Co-supervisor. Awarded 2019.
- Doctoral students at Macquarie University, Sydney: Harriet Amey DPT, Luke Davies DPT, Sarah Trifogli DPT, Kathryn Walker DPT. Co-supervisor. Awarded 2018.
- Eduardo Ensaldo-Carrasco, Describing and understanding patient safety incidents in primary care dentistry and building consensus on Never Events, PhD, University of Edinburgh. Co-supervisor. Awarded 2018.
- Huw Evans, MSc Health Informatics, Swansea University. Co-supervisor. Awarded 2016.
- Philippa Claire Rees, Paediatric safety in primary care: A cross-sectional mixed methods study of national incident report data, MPhil, Cardiff University (intercalating medical student). Supervisor. Awarded 2015.
Engagement
Examples of engagement activities
Activity |
Partner |
Effect |
A study to improve the quality of out of hours palliative care services for end of life patients (Marie Curie / RCGP Research Fellowship, 2016–2018) |
Aneurin Bevan University Health Board (ABUHB) |
|
Harnessing data analytics to maximise NHS learning from patient safety incident reports; funded by Health Foundation (Advancing Analytics Award, September 2019-2020) |
Cardiff and Vale University Health Board |
|
KESS-2 funded PhD to explore patient safety in eye health |
|
|
Sustained research-based contributions to knowledge translation within the general practice profession (external to HEI sector) |
|
Research themes
Specialisms
- Patient safety