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Analysis of paediatric long-term ventilation incidents in the community
  1. Rasanat Fatima Nawaz1,2,
  2. Bethan Page1,
  3. Emily Harrop3,
  4. Charles A Vincent1
  1. 1 Department of Experimental Psychology, University of Oxford, Oxford, UK
  2. 2 Patient Safety Collaborative, Oxford Academic Health Science Network, Oxford, UK
  3. 3 Helen and Douglas House, Oxford, UK
  1. Correspondence to Dr Emily Harrop, Helen and Douglas House, Oxford OX4 1RW, UK; eharrop{at}


Aim To describe the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety.

Methods We undertook an analysis of patient safety incident data relating to long-term ventilation in the community using incident reports from England and Wales’ National Reporting and Learning System occurring between January 2013 and December 2017. Manual screening by two authors identified 220 incidents which met the inclusion criteria. The free text for each report was descriptively analysed to identify the problems in the delivery of care, the contributory factors and the patient outcome.

Results Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment.

Conclusions This study identifies a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.

  • comm child health
  • health services research

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors RFN, BP and CAV conceived and designed the study. RFN and BP analysed the data with the support of paediatrician EH. RFN drafted the manuscript with support from BP, EH and CAV. All authors provided critical feedback on the manuscript and analysis. All authors approved the final manuscript.

  • Funding This work was supported by the Economic and Social Research Council [grant number ES/J500112/1]; and the Health Foundation.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Under our data agreement with NHS England and NHS Improvement we are unable to share the data from this study directly with others. You can apply to obtain incident data from the National and Reporting Learning System through NHS England and NHS Improvement’s Patient Safety Team.

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