How often do patient safety incidents occur in primary care worldwide?

2016 ◽  
Author(s):  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Patient Safety Incidents

scholarly journals Patient safety incidents are common in primary care: A national prospective active incident reporting survey

PLoS ONE ◽  
2017 ◽  
Vol 12 (2) ◽  
pp. e0165455 ◽  
Author(s):  
Philippe Michel ◽  
Jean Brami ◽  
Marc Chanelière ◽  
Marion Kret ◽  
Anne Mosnier ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Incident Reporting ◽  
Patient Safety Incidents

scholarly journals Physician factors associated with increased risk for complaints in primary care emergency services: a case – control study

2020 ◽  
Vol 21 (1) ◽  
Author(s):  
Svein Zander Bratland ◽  
Valborg Baste ◽  
Knut Steen ◽  
Esperanza Diaz ◽  
Svein Gjelstad ◽  
...  
Keyword(s):  
Primary Care ◽  
General Practice ◽  
Patient Safety ◽  
Emergency Services ◽  
Medical Training ◽  
Organizational Factors ◽  
Case Control ◽  
Study Patient ◽  
Increased Risk ◽  
Patient Safety Incidents

Abstract Background Patient safety incidents defined as any unintended or unexpected incident that could have or were judged to have led to patient harm, are reported as relatively common. In this study patient complaints have been used as an indicator to uncover the occurrence of patient safety incidents in primary care emergency units (PCEUs) in Norway. Methods Ten PCEUs in major cities and rural parts of Norway participated. These units cover one third of the Norwegian population. A case-control design was applied. The case was the physician that evoked a complaint. The controls were three randomly chosen physicians from the same PCEU as the physician having evoked the complaint. The following variables regarding the physicians were chosen: gender, citizenship at, and years after authorization as physician, and specialty in general practice. The magnitude of patient contact was defined as the workload at the PCEU. The physicians’ characteristics and workload were extracted from the medical records from the fourteen-day period prior to the consultation that elicited the complaint. The rest of the variables were then obtained from the Norwegian physician position register. Logistic regression was used to estimate odds ratio for complaints both unadjusted and adjusted for the independent variables. The data were analyzed using SPSS (Version25) and STATA. Results A total of 78 cases and 217 controls were included during 18 months (September 1st 2015 till March 1st 2017). The risk of evoking a complaint was significantly higher for physicians without specialty in general practice, and lower for those with medium low and medium high workload compared to physicians with no duty during the fourteen-day period prior to the index consultation. The limited strength of the study did not make it possible to assess any correlation between workload and the other variables (physician’s gender, seniority and citizenship at time of authorization). Conclusions Continuous medical training and achieving the specialty in general practice were decisively associated with a reduced risk for complaints in primary care emergency services. Future research should focus on elements promoting quality of care such as continuing education, duty rosters and other structural and organizational factors.

scholarly journals Patient Safety Incidents in Primary Care Dentistry in England and Wales

2018 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Eduardo Ensaldo-Carrasco ◽  
Asiyah Sheikh ◽  
Kathrin Cresswell ◽  
Raman Bedi ◽  
Andrew Carson-Stevens ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
England And Wales ◽  
Patient Safety Incidents

scholarly journals Tip of the iceberg: patient safety incidents in primary care

2015 ◽  
Vol 25 (7) ◽  
pp. 477-479 ◽  
Author(s):  
Urmimala Sarkar
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Patient Safety Incidents

scholarly journals Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

PLoS Medicine ◽  
2017 ◽  
Vol 14 (1) ◽  
pp. e1002217 ◽  
Author(s):  
Philippa Rees ◽  
Adrian Edwards ◽  
Colin Powell ◽  
Peter Hibbert ◽  
Huw Williams ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
England And Wales ◽  
Sick Children ◽  
Patient Safety Incidents

scholarly journals Contributory factors to patient safety incidents in primary care: protocol for a systematic review

2015 ◽  
Vol 4 (1) ◽  
Author(s):  
Sally Giles ◽  
Maria Panagioti ◽  
Andrea Hernan ◽  
Sudeh Cheraghi-Sohi ◽  
Rebecca Lawton
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Patient Safety ◽  
Contributory Factors ◽  
Care Protocol ◽  
Patient Safety Incidents

scholarly journals A mixed methods analysis of lithium-related patient safety incidents in primary care

2020 ◽  
Vol 11 ◽  
pp. 204209862092274
Author(s):  
Richard Simon Young ◽  
Paul Deslandes ◽  
Jennifer Cooper ◽  
Huw Williams ◽  
Joyce Kenkre ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Safety ◽  
Mixed Methods ◽  
Improve Patient Safety ◽  
Descriptive Analysis ◽  
Learning System ◽  
Contributory Factors ◽  
Safety Incident ◽  
Patient Safety Incidents ◽  
Dispensing Errors

Background: Lithium is a drug with a narrow therapeutic range and has been associated with a number of serious adverse effects. This study aimed to characterise primary care lithium-related patient safety incidents submitted to the National Reporting and Learning System (NRLS) database with respect to incident origin, type, contributory factors and outcome. The intention was to identify ways to minimise risk to future patients by examining incidents with a range of harm outcomes. Methods: A mixed methods analysis of patient safety incident reports related to lithium was conducted. Data from healthcare organisations in England and Wales were extracted from the NRLS database. An exploratory descriptive analysis was undertaken to characterise the most frequent incident types, the associated chain of events and other contributory factors. Results: A total of 174 reports containing the term ‘lithium’ were identified. Of these, 41 were excluded and, from the remaining 133 reports, 138 incidents were identified and coded. Community pharmacies reported 100 incidents (96 dispensing related, two administration, two other), general practitioner (GP) practices filed 22 reports and 16 reports originated from other sources. A total of 99 dispensing-related incidents were recorded, 39 resulted from the wrong medication dispensed, 31 the wrong strength, 8 the wrong quantity and 21 other. A total of 128 contributory factors were identified overall; for dispensing incidents, the most common related to medication storage/packaging ( n = 41), and ‘mistakes’ ( n = 22), whereas no information regarding contributory factors was provided in 41 reports. Conclusion: Despite the established link between medication packaging and the risk of dispensing errors, our study highlighted storage and packaging as the most commonly described contributory factors to dispensing errors. The absence of certain relevant data limited the ability to fully characterise a number of reports. This highlighted the need to include clear and complete information when submitting reports. This, in turn, may help to better inform the further development of interventions designed to reduce the risk of incidents and improve patient safety.

scholarly journals Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis

PLoS ONE ◽  
2015 ◽  
Vol 10 (8) ◽  
pp. e0135947 ◽  
Author(s):  
Maria Panagioti ◽  
Jonathan Stokes ◽  
Aneez Esmail ◽  
Peter Coventry ◽  
Sudeh Cheraghi-Sohi ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Patient Safety ◽  
Meta Analysis ◽  
Patient Safety Incidents

scholarly journals 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

2016 ◽  
Vol 4 (27) ◽  
pp. 1-76 ◽  
Author(s):  
Andrew Carson-Stevens ◽  
Peter Hibbert ◽  
Huw Williams ◽  
Huw Prosser Evans ◽  
Alison Cooper ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
General Practice ◽  
Patient Safety ◽  
Learning System ◽  
England And Wales ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Patient Safety Incidents

BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

scholarly journals Identifying ‘avoidable harm’ in family practice: a RAND/UCLA Appropriateness Method consensus study

2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Andrew Carson-Stevens ◽  
Stephen Campbell ◽  
Brian G. Bell ◽  
Alison Cooper ◽  
Sarah Armstrong ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Patient Safety ◽  
Family Practice ◽  
World Health ◽  
Evidence Based ◽  
Safety Incident ◽  
Significant Harm ◽  
Definition Of ◽  
Patient Safety Incidents

Abstract Background Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

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