Promoting patient safety in primary care

Editorials

Promoting patient safety in primary care

Research, action, and leadership are required

Medicine has always put patients at risk. Modern medicine raises the stakes as its power to do good is accompanied by increasingpotential for harm. Only now is the medical world waking up tothe importance of ensuring patient safety. ¹ ² The shift inthe debate from individual mistakes to understanding the systemicfactors that predispose to harm is welcome and offers the prospectfor making important and sustained improvements in patient safety. ³ ⁴ However, there is a dearth of understanding of patient safetyin primary carewhere the vast majority of patient-clinician encounterstake placeposing a particular challenge to the nascent NationalPatient Safety Agency.⁵

Patient care in the community is becoming increasingly complex. Early discharge from hospital, the prescribing and monitoringof potentially dangerous drugs such as methotrexate for rheumatoidarthritis, the pressure of short consultations, and the increasinglyfragmented nature of primary care services all increase the riskof unintentional patientharm.

There are, however, two advantages enjoyed by primary care. Firstly, practices are small organisations with fewer layers ofbureaucracy than most hospitals. Implementing systemic changesis thus likely to prove easier than in hospitals. Secondly, thestrong tradition of multidisciplinary teamwork in many practicesis an important component in creating the right cultural environmentfor safercare.

What then are the priorities for developing a patient safety agenda for primary care? Research, action, andleadership.

Research is urgently needed to identify the commonest forms of patient harm in primary care and their underlying causes. Thiswill require both epidemiological studies, from which it shouldbe possible to create a typology of harm for primary care, andqualitative research designed to understand the contributory systemsfailures that predispose to such problems.⁶ Building a saferNHS guarantees that money to fund such research should beavailable.

The need for "more research" can serve as a convenient smoke screen for inaction, but this must not be allowed to happen.We already have some information on how patients are being harmed.Defence organisations hold databases of the commonest errors thatcome to litigation, patient complaints can offer insights, andall of us will have experienced something going wrong with a patient'scare that we never acted on. Using analytical tools such as significantevent audit⁷ or those developed by Vincent and colleagues⁸will offer an understanding of how general practice systems canfail patients. Informal estimates put the number of practicesusing significant event audit in the UK at around 20%. The beneficialcultural effects of analysis using a safe and supportive frameworkshould not beunderestimated.

Nevertheless, we should also try to find areas for immediate action. Given the overwhelming feeling of being swamped thatpervades primary care at present, these should be simple and preferablynot include a large amount of work. For instance, three actionsthat could be done tomorrow in every surgery are: ensuring thatmessages are taken in a safe manner through the use of messagebooks; placing sharps boxes on a shelf, out of the reach of children;and identifying patients who do not attend for their warfarinchecks so that they can be offered safer alternatives such asaspirin. As a result, and within months, lives may be saved. Animportant first step would have been made.

Send us reports of your errors

We encourage readers to send us accounts of errors that they have made. These accounts should be of not more than 400 words and will be published as fillers. We must know the names and addresses of authors, but we will be willing to publish some anonymously. Authors should, however, sign the pieces whenever possible. Patient consent will be needed.

The BMJ has a long history of publishing on medical error, and we think of our Lessons of the Week as "cock ups of the week." The original idea behind lessons of the week was that we learn so much from our own errors that it would be good if we could learn just a little from the errors of others. But we also want to publish accounts of errors in order to help encourage a culture where we can all admit to error, give some idea of the range of errors, and sometimesas today (p 615)provide ideas on how such errors might be avoided.

Lastly, we need strong leadership. Leaders of professional bodies must put safety high on their agendas. Chief executivesand chairs of primary care trusts and groups should be lying awakeworrying about patient harm and should ensure that improving patientsafety is one of their priorities. Promoting a long term shiftin culture also requires a major rethink of the way in which medicaleducation is delivered. One small but very visible step wouldbe for educational leaders to introduce the subject of error preventionand patient safety into undergraduate and postgraduate medicalcurriculums andexaminations.

Leaders need to emphasise that it is not individuals who make mistakes but systems that fail. Certainly, when misconduct hasoccurred individuals should be admonished or punished. But whensomeone reports that they have made an error or reports a riskthey should be supported. In the airline industry a pilot whoreports an error is immune from disciplinary action.⁹ Mostimportantly, the person who reports the problem should see thesystem leap into action. Leaders in primary care need to ensurea mandatory reacting system, not just mandatory reportingsystem.

Tim Wilson, director, quality unit.

(twilson@rcgp.org.uk)

Mike Pringle, chair.

Royal Collage of General Practitioners, London SW7 1PU

Aziz Sheikh, NHS R&D national primary care training fellow.

Department of General Practice and Primary Health Care, Imperial College School of Medicine, London W6 8RP

Footnotes

TW was supported by the Commonwealth Fund, a private independentfoundation.

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© BMJ 2001

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Editorials

Promoting patient safety in primary care

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