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| Patient Safety
This section describes my work in the area of
threats to patient safety in primary care
Background and rationale for work
in this area
The majority of people who have contact with health
care providers will receive high quality care but unfortunately for some
people this care will actually harm them or be potentially harmful to
them. The identification and reduction of harm has become a major priority
for the NHS and although the main impetus has come from highly publicised
adverse events in the secondary sector there is now an increased focus
on primary care. Recent interest in the field of patient safety has tended
to focus on care delivered in hospitals. However, the potential for safety
problems in primary care is significant, not least because of the volume
of patient contacts that take place, the complexity of the interactions
and the level of uncertainty associated with providing care in the community
setting. A recent review of patient safety in general practice which I
carried out estimated that medical error occurs between five and 80 times
per 100 000 consultations. Prescription errors were most common, occurring
in about 11% of prescribing incidents, but communication and diagnostic
errors were also important, as were interactions which took place across
the primary/secondary care interface.
Despite the high prevalence and importance of patient safety in primary
care, there has been little empirical research in the field. What has
taken place has mostly been limited to the epidemiology and frequency
of medical errors from the point of view of the physician.
The Department of Health has reviewed the extent and nature of adverse
events in the NHS, with particular reference to how it may learn
from such events to improve the quality of care that it provides. Most
experience has been gained from secondary care where it can be expected
that adverse events are more likely to occur in a complex organisational
and technical environment. However, little is known about the situation
in primary care where the majority of contacts with health care providers
will occur. Learning from adverse events is a component of clinical governance
and Primary Care Trusts are responding to this challenge. In
response to a report by the expert group on learning from adverse events
in the NHS, the Department of Health has started to implement a process
to improve patient safety, a major component of which is a system to identify
both the extent and nature of adverse events in both primary and secondary
care. The National Patient Safety Agency has already developed
the National Learning and Reporting System which is being rolled
out for use in secondary care. The work that I
am involved in on patient safety (work that is completed, currently being
undertaken and which is planned) contributes directly to this agenda.
The work that I do on patient safety is based within the National
Primary Care Research and Development Centre. Within the programme
of work identified within the NPCRDC, our work on patient safety sits
firmly within the work on quality. It is our view that emphasising the
importance of patient safety can act as an important trigger in improving
the quality of healthcare both at the patient doctor interface and in
the organisation of primary care. The way that this could be done in the
primary care setting has not been explored and our research agenda will
contribute directly to this by linking the outputs of the research on
patient safety with the current work that we are doing on quality improvement.
Because research on improving patient safety is relatively underdeveloped
within primary care, our strategy has concentrated on identifying researchers
who have an interest in improving patient safety from a variety of backgrounds
and building alliances with them. Our emphasis has been on building multidisciplinary
alliances with practitioners from the wider health related disciplines
(nursing, pharmacy and clinical medicine) and with researchers from psychology,
engineering, management sciences and law and ethics. This is particularly
important in the field of patient safety research because of the complex
interaction between human factors, organisations and technology in the
genesis of critical incidents in health care Understanding and implementing
solutions related to patient safety requires significant input from all
these disciplines. We are working collaboratively in obtaining the limited
funding which is currently available to carry out research related to
patient safety research. The partnership involving researchers in Manchester
has obtained significant funding from the DoH (£200,000
for analysis of the medico-legal databases, £140,000 for an ethnographic
study into understanding errors in operating theatres, and £250,000
for exploring the role of community pharmacists in reducing medication
error). We obtained funding from the MRC (£60,000)
for developing a patient safety network. Completed work also includes an
NPCRDC funded project working with colleagues from psychology and nursing
which developed a framework for assessing the patient safety
culture in primary care.
We have also developed important international collaborations. We are
an important part of an international collaboration with the American
Academy of Family Physicians and the LINNEAUS Collaboration.
The LINNEAUS Collaboration has just received major funding from the European Union to develop a patient safety network in the EU.
Plans for Further Research
We have identified an ambitious programme of research,
which we think needs to be carried out in primary care. We believe that
identifying the potential for further research together with a strategy
for deepening our current research collaborations provide the best means
for taking forward all or some of this work.
We have identified short term and long term priorities for work in the
area of patient safety. What we have outlined below is a roadmap of our
research plans which builds on our existing expertise and on our collaborative
partnerships. There is much overlap between the categories and future
research may combine several categories. Incident reporting, analysis
of error and rectification of error are inter- related but for ease of
presentation are separated. This research will require a trans disciplinary
approach, which combines a variety of research methods from a variety
of disciplines. Such an approach recognises the complexity of the nature
of threats to patient safety in primary care.
Short term priority:
• Continuing with
developing and completing the existing projects
• Developing and evaluating a model
for making Significant Event Audit more systematic in a pilot selection
of Primary Care Organisations
• Development and evaluation
of a model for incident reporting based on Significant Event Audit. There
is potential for enhancing the use of Significant Event Audit in identifying
and rectifying medical error, especially by making the process more systematic
by introducing root cause analysis. This model is likely to be perceived
as less threatening than a model introduced from outside since many practices
are already using this form of audit and have ownership of the process.
It would require input from organisational psychologists, management sciences,
nursing and clinical medicine.
• Identification of threats
to patient safety associated with the use of medication.
There is concern that a significant number of errors are associated with
the use of medication both in the hospital setting and in primary care.
The enhanced role of community pharmacists creates an opportunity to develop
a programme of work, which will be highly relevant. Funding has already
been obtained for this work in collaboration with researchers from the
University of Nottingham and Edinburgh.
Long term priority:
• Developing a
taxonomy of error in primary care.
• Clear definition of what constitutes
an error. This is essential for both incident reporting and more systematic
identification. Categorisation is essential for identifying trends and
causation patterns. Research in secondary care has adopted two approaches:
an iterative development of categories and use of fixed, previously designed
categories. Our current work in the LINNEAUS Collaboration together with
the work on analysis of the medical-legal databases will provide an important
starting point for the development of categories of error suitable for
use in the primary care setting.
• Work on diagnostic error in Primary Care
• Developing an incident reporting
system for primary care
Our work with the LINNEAUS collaboration has already piloted a workable
system and some of the lessons learnt have been incorporated into the
NRLS which has been developed by the NPSA. Consideration needs to be given
to widening the reporting system, for example patient feedback and role
of other health care professionals e.g. pharmacists and practice nurses.
Strategies to develop and change clinical practice using both empirical
research methods and existing knowledge about change management need to
be developed so that the full potential of the NRLS is realised.
• Assessing the feasibility
of case note review for identification of error in primary care.
This work could build on our experience in Primary Care. We would
seek to identify the frequency and nature of error by a systematic process
of case note review or standardised patients. Exemplar studies of medical
error have adopted a case note review process but this is expensive in
time, cost and trained resources. The development of a systematic process
for a limited number of index areas, such as referral for cancer needs
to be explored and the collaborative work that we are undertaking with
the Federal School of Management will give us an insight into the feasibility
of doing this for index conditions.
Investigation of identified events
Previous research in industry and other medical fields
have used root cause analysis models to identify root causes. There are
numerous models with differing degrees of rigour and resource implications.
Our work on analysis of the medico-legal databases will lead to the development
of a template of root cause analysis for use in the primary care setting.
Modification of use of existing audit and quality improvement
data to identify and analyse error
The investigation of shortfalls in care, are usually
not performed in a systematic process, resulting in lack of identification
and rectification of underlying causes. However, adaptation of root cause
analysis is a possibility to enhance error identification, analysis and
rectification. It has the potential to be an integral part of our work
on quality improvement also building on work that we have completed as
part of the QUASAR study.
Feedback and mechanisms for producing change
The ultimate aim of any system that considers error
is to reduce such errors occurring in the future. There are a variety
of models that have been used in an attempt to change professional practice,
mainly related to feedback of audit and quality data. Little research
has considered feedback on threats to patient safety
We are aiming to use our experience gained from the LINNEUS collaboration
to develop a model for feedback to primary care teams. The potential for
working together with colleagues in North America is significant.
Development of mechanisms in Primary Care Organisations
to learn from threats to patient safety. Organisational learning, with
resultant change in culture, is essential if a patient safety culture
is to be established. NPCRDC is currently funding a pilot project, which
seeks to develop a framework by which primary care organisations can asses
their safety culture. When the project is completed we hope to develop
a programme of work which will seek to identify the barriers to organisational
change and develop strategies on how they can be overcome.
If you would like further information or wish to collaborate
or study in this area, contact me.
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