scholarly journals Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative

2004 ◽  
Vol 2 (4) ◽  
pp. 327-332 ◽  
Author(s):  
D. H. Fernald
2020 ◽  
Author(s):  
Ian J Litchfield ◽  
Rachel Spencer ◽  
Brian Bell ◽  
Anthony Avery ◽  
Katherine Perryman ◽  
...  

Abstract Background In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion. Methods An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews.Results In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful. Conclusions As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.


BMJ Open ◽  
2018 ◽  
Vol 8 (2) ◽  
pp. e020870 ◽  
Author(s):  
Rebecca Lauren Morris ◽  
Susan Jill Stocks ◽  
Rahul Alam ◽  
Sian Taylor ◽  
Carly Rolfe ◽  
...  

ObjectivesTo identify the top 10 unanswered research questions for primary care patient safety research.DesignA modified nominal group technique.SettingUK.ParticipantsAnyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions.Main outcomesA top 10, and top 30, future research questions for primary care patient safety.Results443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality.ConclusionsThis study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety.


Author(s):  
Montserrat Gens-Barberà ◽  
Cristina Rey-Reñones ◽  
Núria Hernández-Vidal ◽  
Elisa Vidal-Esteve ◽  
Yolanda Mengíbar-García ◽  
...  

Background: Reducing incidents related to health care interventions to improve patient safety is a health policy priority. To strengthen a culture of safety, reporting incidents is essential. This study aims to define a patient safety risk map using the description and analysis of incidents within a primary care region with a prior patient safety improvement strategy organisationally developed and promoted. Methods: The study will be conducted in two phases: (1) a cross-sectional descriptive observational study to describe reported incidents; and (2) a quasi-experimental study to compare reported incidents. The study will take place in the Camp de Tarragona Primary Care Management (Catalan Institute of Health). In Phase 1, all reactive notifications collected within one year (2018) will be analysed; during Phase 2, all proactive notifications of the second and third weeks of June 2019 will be analysed. Adverse events will also be assessed. Phases 1 and 2 will use a digital platform and the proactive tool proSP to notify and analyse incidents related to patient safety. Expected Results: To obtain an up-to-date, primary care patient safety risk map to prioritise strategies that result in safer practices.


PRiMER ◽  
2021 ◽  
Vol 5 ◽  
Author(s):  
Joanne E. Wilkinson ◽  
Garrett Bowen ◽  
Jeanette Gonzalez-Wright

Background and Objectives: During the COVID-19 pandemic, medical students were unable to participate in clinical learning for several weeks. Many primary care patients no-showed to appointments and did not receive care. We implemented a telephone outreach program using medical students to call primary care patients who no-showed to appointments and did not receive care. Methods: A brief plan-do-study-act cycle was used to establish protocols and supervision for the phone calls. Results: In the first 5 weeks, of 3,274 scheduled patients there were 426 no-shows; 309 received outreach from students. We developed protocols for supervision, routing, and triage. Conclusion: It is feasible and educationally valuable to collaborate with students to reach patients who are at home due to the pandemic. Other practices could adapt this tool in similar situations.


2019 ◽  
pp. 18-27
Author(s):  
Matthew Grissinger ◽  
Michael Gaunt ◽  
Alexander Shilman

Medication allergies can and do cause patient harm. Managing a patient’s allergies is a challenge for institutionsbecause failures can happen throughout the medication-use process. A total of 854 Medication Error events associated with patient allergies that occurred between July 2016 and June 2018 were reported through a large event reporting database. Analysts categorized these events into the following five stages: obtaining information from the patient, documenting allergies in the record, ordering medications, verifying orders, and administering medications. More than half (56.3%; n = 481) of the events reached the patient. Most likely to reach patients were events involving breakdowns when obtaining information from the patient (74.7%, n = 68 of 91) and administering medications (97.6%, n = 281 of 288). In reports that indicated allergies were properly documented, the majority (87.3%, n = 289 of 331) of the events that reached patients passed through two or more stages. Organizations may use this information to inform proactive efforts to implement system-based strategies to improve the medication-use process. Keywords: drug allergy, drug reaction, medication errors, medication safety, patient safety


2020 ◽  
Author(s):  
Shawn Kepner ◽  
Rebecca Jones ◽  
Caitlyn Allen ◽  
Daniel Glunk ◽  
Eric Weitz ◽  
...  

Pennsylvania is the only state that requires healthcare facilities to report all events of harm or potential for harm. Serious Events and Incidents are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS)*, which is the largest repository of patient safety data in the United States, and one of the largest in the world, with over 3.6 million acute care records. The overwhelming majority (97.1%) of all acute care event reports are Incidents. For 2019, there were 284,847 Incidents and 8,553 Serious Events for a total of 293,400 reported events. The counts of all events and the percentage that are Serious Events reported over the last eight years are provided in Figure 1. The total number of event reports has increased during the last four years. The number of reported Serious Events has increased over the past three years with the largest annual increase occurring in 2019 (+5.7%). This article will show details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used for improving patient safety.


2020 ◽  
Author(s):  
Ian J Litchfield ◽  
Rachel Spencer ◽  
Brian Bell ◽  
Anthony Avery ◽  
Katherine Perryman ◽  
...  

Abstract Background In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion. Methods An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews.Results In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful. Conclusions As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.


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