http://bmj.com/cgi/content/full/324/7337/584
BMJ 2002;324:584-587 ( 9 March )
Primary care
Enhancing public safety in primary care
Tim Wilson, director a, Aziz Sheikh,
NHS R&D national primary care training fellow b.
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.
| Summary points
-
Safety is of increasing concern to the public and profession alike, but
until now attention has been focused on secondary care -
Valuable research on safety has been conducted in primary care, and
many other sources of information indicate where the major causes of harm
might occur -
Safety is a major concern in four main areas diagnosis,
prescribing, communication, and organisational change -
Prescribing is the area about which most is known3-5%
of all prescriptions in primary care might cause problems, and one third
of these can be classified as serious -
Of all adverse incidents reported in primary care, 28% are related to
problems with diagnosis -
This paper proposes seven steps towards improving safety
|
 |
Safety and harm |
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.
Box 1: Notions of
safety and harm
|
|
| |
Methods |
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.
| |
Key findings |
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).
Box 2: Key safety
issues for primary care
| DiagnosisIn
general, under-referral is condemned by the public but encouraged by
budgets. Primary care deals primarily with uncertainty of diagnosis
PrescribingPrescribing
is the most easily analysed area. It is increasingly fraught as more
complex drugs are prescribed in primary care and as polypharmacy
increases (for example, through implementation of national service
frameworks)
CommunicationPoor
communication is symptomatic of problems with systems. Electronic
communication may help but can lead to information overload
Organisational changeMuch
has been made of the organisational culture needed for safety.
Primary care has the advantage of a strong history of teamwork and
small size |
|
|
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 themthe
"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).
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
| |
Conclusions |
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
Box 3: Stepwise
approach to enhancing patient safety
| Step one: understand systems
The key to improving safety is understanding how systems work and
how people within those systems will regularly fail.14
Many safety problems can be overcome by design, assuming that people
make mistakes for many reasons (insertion of checks or forcing steps
can make a substantial difference). Relying on memory and
observance, especially in stressful situations, is bound to failthe
use in these circumstance of reminders (message alerts on screen to
visit a patient), clear signage (bottle shaped holes for bottles),
or forcing mechanisms (for example, the wrong tubing cannot be
attached because it is a different size) can be helpful. Clinicians
are already under considerable pressure, so simply asking them to
try harder will only exacerbate the problem 15
16
Step two: leadership and culture
People lead systems and are responsible for the design. Until
chairs and chief executives of primary care trusts come to regard
safety as their concern, there is little hope for progress. Leaders
within the system should reward and encourage people to report
problems, exempt such people from disciplinary action, and then take
immediate action to prevent the problem occurring again
Step three: research
Research in primary care is urgently needed on:
- Accurate and reliable estimates of the scale and health costs
of iatrogenic harm to patients
- Detailed description of a typology of harm to patients in
primary care
- Appreciation of the barriers to promoting patient safety and
ways of overcoming these obstacles
Step four: analysis
We should learn from near misses and errors by using tools such
as significant event analysis and that developed by the Clinical
Risk Unit.17 Analysing events in this
fashion has been found to be very helpful in primary care and has
altered cultural perspectives in many cases18-20
Step five: establish best practice
Some procedures are known to be safer than othersfor
example, handling incoming mail by using a proper stamp that does
not allow the letter to be filed until any necessary action has been
taken.21 Many such procedures do not
need large resourcesall
that is needed is the will. Professional bodies and organisations
such as the National Patient Safety Agency should develop a list of
established processes that can improve care
Step six: use improvement techniques and technology
Systems can be adapted to make them safer by the use of
plan-do-study-act cycles and other quality improvement techniques.
Use of sensible technologymeaningful
warnings, communication, and knowledge couplingcould
substantially improve safety
Step seven: monitor safety
Once improvement has been made it is crucial to maintain the
gains and continue to improve the system by using reporting systems
(of incidents and near misses). "Triggers" are a sensitive method of
detecting when harm has occurred, although none has been tested in a
primary care setting (C Haraden, personal communication, 2001) |
|
|
| |
Acknowledgments |
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.
| |
Footnotes |
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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(Accepted 2 January 2002)
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Top
Safety and
harm 
Methods
blocker
to a patient with no contraindications after a myocardial
infarction 