Objectives: (1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed. Design: Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service. Setting: 24 Catalan Institute of Health PC health centres of the Tarragona region (Spain). Participants: Professionals from the PC health centres and a Patient Safety Functional Unit. Measurements: Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions. Results: A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%). Conclusions: PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.

Objetivo Analizar y comparar la epidemiologia de los incidentes de seguridad del paciente notificados en centros de atención primaria, antes y después del inicio de la pandemia COVID-19. Diseño y emplazamiento Estudio descriptivo analítico comparando los incidentes notificados del 01-marzo-2019 al 28-febrero-2020, y del 01-marzo-2020 al 28-febrero-2021, realizados a través de la plataforma TPSC Cloud™ accesible desde la Intranet corporativa en 25 centros de atención primaria del distrito de Tarragona, Cataluña, España. Mediciones Registros obtenidos a partir de notificaciones voluntarias mediante formulario electrónico, estandarizado y anonimizado. Variables: centro sanitario, profesional, tipo de incidente, matriz de riesgo, factores causales, contribuyentes y evitabilidad. Análisis estadístico: Se realizó análisis descriptivo del total de notificaciones y otro específico de los eventos adversos, comparando ambos períodos. Resultados Se notificaron un total de 2.231 incidentes. Comparando ambos períodos, en el de pandemia se observó una reducción del número de incidentes notificados (solo representaron un 20% del total), pero en proporción se incrementó el porcentaje de notificaciones por parte de profesionales sanitarios y el de eventos adversos que requirieron observación. También aumentaron los factores causales relacionados con los cuidados y el diagnóstico, y disminuyeron los de medicación. Además, se observó un incremento de los factores contribuyentes relacionados con el profesional. La evitabilidad fue elevada (>95%) en ambos períodos. Conclusiones Durante la pandemia, se han notificado un menor número de incidentes de seguridad del paciente, pero en proporción, más eventos adversos, siendo en su mayoría evitables. El propio profesional se convierte en el principal factor contribuyente.

Background: Reducing incidents related to health care interventions to improve patient safety is a health policy priority. To strengthen a culture of safety, reporting incidents is essential. This study aims to define a patient safety risk map using the description and analysis of incidents within a primary care region with a prior patient safety improvement strategy organisationally developed and promoted. Methods: The study will be conducted in two phases: (1) a cross-sectional descriptive observational study to describe reported incidents; and (2) a quasi-experimental study to compare reported incidents. The study will take place in the Camp de Tarragona Primary Care Management (Catalan Institute of Health). In Phase 1, all reactive notifications collected within one year (2018) will be analysed; during Phase 2, all proactive notifications of the second and third weeks of June 2019 will be analysed. Adverse events will also be assessed. Phases 1 and 2 will use a digital platform and the proactive tool proSP to notify and analyse incidents related to patient safety. Expected Results: To obtain an up-to-date, primary care patient safety risk map to prioritise strategies that result in safer practices.