{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T16:59:32Z","timestamp":1793293172568,"version":"4.5.0"},"reference-count":30,"publisher":"SAGE Publications","issue":"7","license":[{"start":{"date-parts":[[2023,5,17]],"date-time":"2023-05-17T00:00:00Z","timestamp":1684281600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"publisher","award":["Award ID: PR-R20-0318-21001"],"award-info":[{"award-number":["Award ID: PR-R20-0318-21001"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J R Soc Med"],"published-print":{"date-parts":[[2023,7]]},"abstract":"<jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities. Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures<\/jats:title>\n                    <jats:p>Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 4112 reports, the most frequently observed incidents were medication-related (n\u2009=\u20091167, 33%), specifically whilst administering medications (n\u2009=\u2009626, 54%). Next, were access-related (n\u2009=\u2009559,15%), inclusive of delays in patients accessing healthcare professionals (n\u2009=\u2009236, 42%) and managing medical appointments (n\u2009=\u2009 171, 31%). The workshops contextualised incidents involving contributing factors (n\u2009=\u20091529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/01410768231166138","type":"journal-article","created":{"date-parts":[[2023,5,17]],"date-time":"2023-05-17T19:05:30Z","timestamp":1684350330000},"page":"236-245","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":20,"title":["Patient safety in prisons: a multi-method analysis of reported incidents in England"],"prefix":"10.1177","volume":"116","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9766-2681","authenticated-orcid":false,"given":"Isobel J","family":"McFadzean","sequence":"first","affiliation":[{"name":"Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kate","family":"Davies","sequence":"additional","affiliation":[{"name":"Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4504-2111","authenticated-orcid":false,"given":"Thomas","family":"Purchase","sequence":"additional","affiliation":[{"name":"Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrian","family":"Edwards","sequence":"additional","affiliation":[{"name":"PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stuart","family":"Hellard","sequence":"additional","affiliation":[{"name":"Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Darren M","family":"Ashcroft","sequence":"additional","affiliation":[{"name":"Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK"},{"name":"NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony J","family":"Avery","sequence":"additional","affiliation":[{"name":"NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK"},{"name":"Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sandra","family":"Flynn","sequence":"additional","affiliation":[{"name":"Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Hewson","sequence":"additional","affiliation":[{"name":"Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melanie","family":"Jordan","sequence":"additional","affiliation":[{"name":"School of Sociology & Social Policy, University of Nottingham, Nottingham, NG7 2RD, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Keers","sequence":"additional","affiliation":[{"name":"Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK"},{"name":"NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK"},{"name":"Greater Manchester Mental Health NHS Foundation Trust (GMMH), Manchester, M25 3BL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maria","family":"Panagioti","sequence":"additional","affiliation":[{"name":"NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, Manchester, M13 9PL, UK"},{"name":"Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, M13 9NT, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Verity","family":"Wainwright","sequence":"additional","affiliation":[{"name":"Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florian","family":"Walter","sequence":"additional","affiliation":[{"name":"Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenny","family":"Shaw","sequence":"additional","affiliation":[{"name":"Faculty of Biology, Medicine and Health, Centre for Mental Health and Safety, University of Manchester, Manchester, M13 9PL, UK"},{"name":"Greater Manchester Mental Health NHS Foundation Trust (GMMH), Manchester, M25 3BL, UK"},{"name":"Independent Advisory Panel on Deaths in Custody, London, SW1H 9AJ, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew","family":"Carson-Stevens","sequence":"additional","affiliation":[{"name":"PRIME Centre Wales, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, CF14 4YU, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2023,5,17]]},"reference":[{"key":"bibr1-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1080\/09581596.2016.1156649"},{"key":"bibr2-01410768231166138","unstructured":"Ministry of Justice and HM Prison and Probation Service. Prison population figures: 2021. Gov.UK; 2021. See www.gov.uk\/government\/statistics\/prison-population-figures-2021 (last checked 3 October 2022)."},{"key":"bibr3-01410768231166138","unstructured":"Penal Reform International. Global Prison Trends. May 2022. See www.penalreform.org\/global-prison-trends-2022\/ (last checked 3 October 2022)"},{"key":"bibr4-01410768231166138","unstructured":"World Health Organization. Prisons and Health. Regional Office for Europe; 2014. See https:\/\/apps.who.int\/iris\/handle\/10665\/128603 (last checked 3 October 2022)."},{"key":"bibr5-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1186\/s40352-018-0082-5"},{"key":"bibr6-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2018.07.009"},{"key":"bibr7-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1136\/jech.55.5.364"},{"key":"bibr8-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(22)00141-4"},{"key":"bibr9-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.e5921"},{"key":"bibr10-01410768231166138","author":"Committee of Ministers","year":"2022","journal-title":"Council of Europe"},{"key":"bibr11-01410768231166138","unstructured":"Royal College of General Practitioners. Equivalence of care in Secure Environments in the UK \u2013 Position statement. Secure Environments Group; 2018. See www.rcgp.org.uk\/policy\/rcgp-policy-areas\/equivalence-of-care-in-secure-environments (last checked 3 October 2022)."},{"key":"bibr12-01410768231166138","unstructured":"Davies M, Rolewicz L, Schlepper L, Fagunwa F. Locked out? Prisoners' use of hospital care. Research report, Nuffield Trust. 2022. See www.nuffieldtrust.org.uk\/research\/locked-out-prisoners-use-of-hospital-care (last checked 3 October 2022)."},{"key":"bibr13-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(20)30008-6"},{"key":"bibr14-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1016\/j.puhe.2009.04.005"},{"key":"bibr15-01410768231166138","unstructured":"National Reporting and Learning System. Welcome to NRLS Reporting. See https:\/\/report.nrls.nhs.uk\/nrlsreporting\/ (last checked 3 October 2022)."},{"key":"bibr16-01410768231166138","unstructured":"NHS England. Report a patient safety incident. See www.england.nhs.uk\/patient-safety\/report-patient-safety-incident\/ (last checked 3 October 2022)."},{"key":"bibr17-01410768231166138","unstructured":"Ministry of Justice Statistics bulletin. Guide to Safety in Custody Statistics. Ministry of Justice; 2012. See https:\/\/assets.publishing.service.gov.uk\/government\/uploads\/system\/uploads\/attachment_data\/file\/774881\/guide-to-safety-in-custody-statistics-2018-Q3.pdf (last checked 3 October 2022)."},{"key":"bibr18-01410768231166138","unstructured":"NHS England and NHS Improvement. Service specification. Primary care service \u2013 medical and nursing for prisons in England. NHS England; 2020. See www.england.nhs.uk\/wp-content\/uploads\/2020\/03\/primary-care-service-spec-medical-nursing-for-prisons-2020.pdf (last checked 3 October 2022)."},{"key":"bibr19-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-009079"},{"key":"bibr20-01410768231166138","volume-title":"A Recursive Model of Incident Analysis","author":"Hibbert P","year":"2007"},{"key":"bibr21-01410768231166138","unstructured":"World Health Organization & WHO Patient Safety. Conceptual Framework for the International Classification for Patient Safety Version 1.1: final technical report. World Health Organization; January 2009. See www.who.int\/publications\/i\/item\/WHO-IER-PSP-2010.2 (last checked 3 October 2022)."},{"key":"bibr22-01410768231166138","volume-title":"Exploratory Data Analysis","author":"Tukey JW.","year":"1970"},{"key":"bibr23-01410768231166138","unstructured":"National Institute for Health and Care Research. Understanding the scale and nature of avoidable harm in prison healthcare. NIHR; 2019. See www.fundingawards.nihr.ac.uk\/award\/PR-R20-0318-21001 (last checked 3 October 2022)."},{"key":"bibr24-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1016\/S2468-2667(21)00050-5"},{"key":"bibr25-01410768231166138","volume-title":"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","author":"Carson-Stevens A","year":"2016"},{"key":"bibr26-01410768231166138","unstructured":"Inquest \u2013 Truth, Justice & Accountability. Deaths in Prison: A National scandal. Inques; 2020. See www.inquest.org.uk\/deaths-in-prison-a-national-scandal (last checked 3 October 2022)."},{"key":"bibr27-01410768231166138","unstructured":"Royal College of General Practitioners. Safer Prescribing in Prisons: guidance for clinicians. Second edition. RCGP; 2019. See https:\/\/bulger.co.uk\/prison\/RCGPsaferprescribinginprisons2019.pdf (last checked 3 October 2022)."},{"key":"bibr28-01410768231166138","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.15107"},{"key":"bibr29-01410768231166138","unstructured":"UK Parliament \u2013 Committees. Government is failing its duty of care towards prisoners. 2018. See https:\/\/committees.parliament.uk\/committee\/81\/health-and-social-care-committee\/news\/104617\/government-is-failing-its-duty-of-care-towards-prisoners\/ (last checked 3 October 2022)."},{"key":"bibr30-01410768231166138","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp21X714653"}],"container-title":["Journal of the Royal Society of Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/01410768231166138","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/01410768231166138","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/01410768231166138","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:49:04Z","timestamp":1777528144000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/01410768231166138"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,5,17]]},"references-count":30,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2023,7]]}},"alternative-id":["10.1177\/01410768231166138"],"URL":"https:\/\/doi.org\/10.1177\/01410768231166138","relation":{},"ISSN":["0141-0768","1758-1095"],"issn-type":[{"value":"0141-0768","type":"print"},{"value":"1758-1095","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,5,17]]}}}