http://bmj.com/cgi/content/full/324/7337/584
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 Collections under
which this article appears: Clinical
Research Other
Ethics Changing
physician behavior Quality
improvement (including CQI and TQM) Health
Services Research Adverse
drug reactions Patient
safety / Clinical risk / Medical error |
Tim Wilson
a RCGP Quality Unit, 14 Princes Gate, London SW7 1PU, b Department of Primary Health Care and General Practice, Imperial College of Science, Technology and Medicine, London SW7 2AZ
Correspondence: T Wilson twilson@rcgp.org.uk
Improving the safety record of the NHS is a national priority. This is not surprising, as recent research shows that up to 850 000 adverse events occur in hospitals every year.1 Up to 90 000 iatrogenic deaths may occur each year in hospitals in the United States,2 and the picture is likely to be similar in the United Kingdom. The landmark report To Err is Human has led to substantial investment in the US Agency for Health Research and Quality's safety unit.2 This was closely followed in the United Kingdom by the Department of Health reports An Organisation with a Memory and Building a Safer NHS, heralding the introduction of the National Patient Safety Agency. 3 4 Our understanding of the causes of iatrogenic adverse events in secondary care has increased substantially over the past decade, but the same cannot be claimed of primary care.
In this paper, we consider public safety in primary care. What do we know
about the main causes of harm to patients? To what extent are these
preventable? How can we enhance public safety? We use these
deliberations as a basis from which to propose a strategic response
to the pressing challenge of improving the safety record of primary
care.
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Safety and harm |
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 Top  Safety and
harm  Methods Key findings
Conclusions
References
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Box 1 sets out various notions of safety and harm, but particular considerations apply in primary care. Primary care differs from secondary care in several key respects. It aims to provide longitudinal personalised care that is customised to individual beliefs, needs, values, and preferences across a broad spectrum of concerns relating to health and illness.8-11 This leads to variation in practice and, in some instances, justifiable deviation from recommended practice. 12 13 As the first clinical port of call, general practitioners deal with a very broad range of symptoms and signs, many of which cannot easily be categorised into a clear diagnosis. Given the different population of patients, the different priorities for their care, and the ambiguities of that care in relation to diagnosis and patient choice, delineating "right or wrong" practice is more complex in primary care than in secondary care.
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Methods |
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Top Safety and harm
Methods
Key findings
Conclusions
References
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This paper presents a narrative of findings based on a comprehensive and
systematic search aimed at answering two questions: "What are the key
safety issues?" and "What might be done to improve care?" We searched
Medline, Embase, and CINAHL electronic medical databases and used
Google search engine for a search of the world wide web with the
following search terms: (safety OR harm OR error OR adverse event OR
near miss) AND (general practice OR primary care) for the years
1980 to 2000. We supplemented these searches by hand searching the
journals of the Medical Defence Union and Medical Protection Society.
We also consulted with experts by convening a national roundtable
discussion on 23 April 2001, to which we invited project leads for
research and development initiatives for promoting patient
safety.
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Key findings |
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Top Safety and harm
Methods Key findings
Conclusions
References
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We found 31 relevant articles (see bmj.com).w1-w31 We failed to identify any systematic reviews of direct relevance to primary care services. In the absence of a sound evidence based typology for safety in primary care, deliberations have focused on four broad areas of care: diagnosis, prescribing, communication, and the organisational characteristics of primary care (box 2).
Diagnosis
What are the major safety problems with diagnosis?
In one anonymous reporting study, diagnostic problems accounted for
28% of reported errors, of which half were considered to be
potentially very harmful.w1 The overall frequency with which
diagnostic errors occur in primary care is unknown. Conditions that
seem to be particularly problematic (or for which it is easier to
find a misdiagnosis in hindsightw2) include asthma,w3
cancer, dermatological conditions,w4 substance misuse,w5
and depression.w6
A review of referral patterns highlighted the difficulties for primary care clinicians making diagnoses. Although many health policy makers and managers regard high referral rates as inefficient, "failure to refer appropriately" is a major contributory factor in many successful claims against general practitioners.w7
What might be done to improve diagnostic accuracy?
Little research has been carried out on ways of improving diagnosis
in primary care. This is chiefly because diagnosis in primary care is
by its very nature uncertain and uses a hypothetico-deductive
approach.w8 w9 Use of guidelines and protocols is likely to have
some, but limited, success in improving safety.w10
Decision support tools and (electronic) information systems may prove
to be of greater benefit,w11 but this has yet to be proved
empirically. A full evaluation of the decision support tool used by
NHS Direct will help to determine the case for out of hours
care.
Prescribing
What are the major problems with safety of prescribing?
Perhaps because of its nature, the safety of prescribing has been
intensively researched. Prescribing problems in general practice
occur at a rate of 3-5% of all prescriptions, of which about a third
can be classified as major safety concerns.w12-w14 A quarter of
claims against general practitioner members of the Medical Defence
Union in 1996 were related to drug safety; common themes to emerge
included prescription of contraindicated drugs, errors in dispensing,
ignoring known allergies, or simply prescribing the wrong drug.w15
In an Australian study, around 9% of hospital admissions were thought
to be due to potentially avoidable problems with prescribed drugs.w16
An American study found that 24% of people aged over 65 living at
home (21% of those living in nursing homes) were prescribed a
contraindicated drug, and 20% of these received two or more
contraindicated treatments.w17 Although safety considerations are
important with all prescribed treatments, particular safety concerns
exist for certain classes of drugs, including non-steroidal
anti-inflammatory drugs, lithium, warfarin, corticosteroids, and
antidepressants.w15 w18 Dispensing of drugs by pharmacists is another
potential source of error. One study based in the United States
calculated that 4% of drugs were incorrectly dispensed in the course
of a year.2
What might be done to improve prescribing safety?
Hospital based studies have shown that use of a computer system for
prescribing is likely to improve accuracy.w19 This is particularly so
when the computer contains important information on patients, thereby
offering the opportunity to highlight possible drug-drug interactions
and relevant medical history such as known drug hypersensitivities
and relative and absolute contraindications. There are two major
problems, however. Firstly, many computer systems currently use
alerts so often that many doctors simply choose to ignore them
the
"cry wolf" phenomenon (A J Avery, personal communication, 2001).
Systems should certainly take advantage of "user centred design"that
is, including usability testing and making sure that new systems do
not add a new level of complication and hence increase the likelihood
of harm.w20 Secondly, the increasing use of complementary treatments,
including herbal remedies that may interact with prescribed
treatments, means that many important interactions could be missed.w21
It is estimated that 97% of British general practitioners have a
computer on their desk and that 74% were using it for prescribing in
1993 (probably more now).w22 The imminent change to a system of
repeat prescribing led by pharmacists may have the benefit of making
all but a very few prescriptions computerised. If herbal treatments
were limited to pharmacy only sales, pharmacists would be more likely
to detect potential interactions.
Another important finding of the Harvard studies is the role of pharmacists in improving safety. Use of quality improvement techniques to reduce adverse drug events has improved the recording of allergy information and standardised medication administration times and helped with the implementation of chemotherapy protocols, while encouraging the start of reporting mechanisms.w19 w23 Systems need to be in place to reduce the risk associated with classes of drugs that pose above average risk of harm (table).
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Communication
What are the major problems with communication?
Breakdown in communication is a common cause of harm to patients, but
it is probably a symptom of organisational problems rather than a
cause. The most important communication problems seem to come from
hierarchical structures (see section on organisation below) and
informal communications. Defence organisations have several cases
where breakdown of communication has resulted from the informality of
the communication process; a forgotten comment in the surgery
corridor or a post-it note that fell behind a desk are everyday
occurrences with which all clinicians will readily identify (P
Lambden, personal communication, 2001). Transcription of information
(such as when dictating referral letters), and the associated risk of
inaccuracy, represents another important source of communication
failure. The transition between hospital and community services is
particularly fraught; around 40% of patients have been found to have
discrepancies between the drugs prescribed at the point of discharge
and those they receive in the community.w24
What could be done to improve communication?
Electronic communication is likely to reduce problems with
transcription (including those involving prescribing); if the record
is shared it should be possible for different people to check
important details (such as allergies). Furthermore, the "patient held
record" (perhaps held on the internet) would ensure that clinicians
had immediate access to all relevant clinical information. Electronic
communication is not without problems; confidentiality of records,
for example, would represent an important concern, although it should
eventually be possible to overcome such problems by maintaining
records on secure intranets. A pressing consideration for many people
currently using electronic communication channels is the problem of
information overload, with the possibility of missing important
messages. This problem increases as the amount of information about
patients grows exponentially. The ways in which data are displayed
and filtered will therefore have to become smarter. Most important,
though, is the use of agreed methods of communicating important
messages (for example, by using the message book and not expecting
that a comment made in the corridor will always be
remembered).
Organisational characteristics of primary care
What are the major problems with organisational
characteristics?
Many recent pronouncements from the Department of Health, and
especially those concerned with safety, have emphasised the
importance of developing the "right" organisational culture. However,
little research has been carried out to determine the desirable
characteristics for safety in primary careit
is not even known, for example, if culture is something that can be
determined or managed in health care. Important research has been
done in industryespecially
in the aviation industry, where considerable empirical work has been
carried out to evaluate the role of teamwork, communication, and
leadership in reducing incidents.w25 w26
What might be done to improve organisational characteristics?
Industrial leaders have worked with corporate culture at three
levels: visible organisational structures and processes; strategies,
goals, and philosophies; and beliefs, perceptions, and feelings.w27
Teamwork within primary care has always been strong. In the United Kingdom, this is being expanded with increased sharing between practices in the interests of quality improvement (clinical governance) through developing primary care organisations.w28 However, there is little evidence that this includes activities to improve safety. Sharing and analysing of significant events is well established in primary care,w29 with up to 20% of practices involved in significant event analysis (M Pringle, personal communication, 2001). In some practices, informal logs of errors have led to important changes, and local reporting systems might allow the organisational development needed for greater safety.w30
In Building a Safer NHS, much is made of the culture needed for greater safety.4 In the face of a mandatory reporting system, it is unclear whether this will occur early in the life of the National Patient Safety Agency. Whether this body will help to create the desired "no blame" culture is not yet clear. It must, however, be evident that "no blame" does not equate to "no responsibility." Every member of a healthcare organisation will need to trade the right of not being blamed for making a human error with the absolute responsibility of making safety paramount.
Leadership is central to making systems safer. In industrial settings, many
chief executive officers have made safety one of their top
priorities, with very encouraging results. This is also true of
hospitals; the chief executive at Luther-Mideford Medical Centre in
Wisconsin funds and supports a full time senior clinician to develop
safer systems of care and reduce harm. The commitment and drive from
the senior leader both shows the importance of safety and encourages
changes to reduce harm.w30
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Conclusions |
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Top Safety and harm
Methods Key findings
Conclusions
References
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Safety considerations in healthcare systems are important, but little is known about the epidemiology or typology of harm in primary care. Attention has so far focused on four broad areas: diagnosis, prescribing, communication, and the organisational characteristics of effective and efficient primary care services. We recognise that there are many other areas of care associated with the potential for harm (minor surgery and administration of vaccines, for example). Although cases of harm occur with these areas, less is known about the extent to which harm is caused and what might be done to prevent it.
Much can be done now (box 3). It is important for primary
care leaders to promote public safety, as the profession's credibility
and the population's continued trust in general practitioners
depend on it. Preliminary discussions within the Royal College of
General Practitioners suggest that it is both able and willing to
respond to this challenge.22 At the level of
primary care trusts, boards need to show their willingness through
actions to promote safety and support for initiatives to reduce harm.
At the level of the practice, teams and individuals need to take
responsibility for safetyit
is their job to close a fire door that has been propped open. As
teams, they need to develop an understanding of what happens when
something goes wrong and how they can avoid it in the future. Lastly,
we need to work with the public to help them understand the risks
involved in health care and work with them to reduce harm.w31
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Acknowledgments |
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Many of the ideas in this paper were discussed at a meeting to promote safety of patients in primary care that was hosted by the Nuffield Trust, London.
Contributors: TW and AS jointly conceived the paper. TW conducted the searches, extracted data, and drafted the paper. AS contributed to interpreting data and editing the manuscript. TW is the guarantor.
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Footnotes |
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Funding: TW was supported by the Commonwealth Fund, a private independent foundation based in New York. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff. AS is supported by an NHS R&D national primary care award.
Competing interests: None declared.
A
list of references retrieved by the search appears on bmj.com
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References |
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Top Safety and harm
Methods Key findings
Conclusions
References
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| 2. | Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human. Building a safer health system. Washington, DC: National Academy Press, 1999. |
| 3. | Department of Health. An organisation with memory. London: Stationery Office, 2000. |
| 4. | Department of Health. Building a safer NHS. London: Stationery Office, 2001. |
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| 14. | Reason J. Human error. Cambridge: Cambridge University Press, 1990. |
| 15. | Moore W. Why doctors make mistakes. London: Channel 4 Television Publications, 2000. |
| 16. | Allen D. Counting the cost. Nursing Standard 2000;
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| 19. | Pringle M. Preventing ischaemic heart disease in one
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| 20. | Sweeney G, Westcott R, Stead J. The benefits of significant
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| 22. | Olesen F, Dickinson J, Hjortdahl P. General practicetime
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(Accepted 2 January 2002)
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Collections under
which this article appears:Clinical
Research Other
Ethics Changing
physician behavior Quality
improvement (including CQI and TQM) Health
Services Research Adverse
drug reactions Patient
safety / Clinical risk / Medical error |
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