Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review

Abstract

ObjectiveTo estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents.DesignRetrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded.SettingPrimary care.ParticipantsThirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients).Main outcome measuresThe incidence of significant harm considered at least ‘probably avoidable’ and the nature of the safety incidents.ResultsThe rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines.ConclusionThere is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.

Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations

“…Participants' reports of limited and inconsistent quality assurance processes in inhours general practice were in-keeping with other studies 9,17,18 and set in the context of evidence of a substantial burden of preventable patient harm in English primary care. 5 Whilst our study has indicated the potential of CG to support an increasingly multidisciplinary primary care workforce to practise to its full potential, our findings also reflect the need to ensure such interventions do not become another stressor for a workforce dealing with a challenging and rising workload. 19 The impact of audit and feedback on clinician practice and patient outcomes Consultation peer-review interventions such as CG are a form of clinical audit.…”

“…2 Within primary care internationally there is evidence of significant variation in clinician practice 3 and a substantial burden of preventable harm. 4,5 However, determining the extent to which observed variation is unwarranted and potentially harmful to patients is challenging, and requires detailed assessment of the clinician-patient interaction. 6 Systems to identify and minimise unwarranted variation in individual clinician practice are increasingly relevant in the context of trends towards more multidisciplinary clinical workforces.…”

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices

“… 3 While some incidents, such as unexpected complications during the provision of correct care, are not preventable, others, such as failure to recognise serious illness or patient deterioration, can contribute to avoidable harm. 4 …”

Assessing the Impact of Multi-Morbidity and Related Constructs on Patient Reported Safety in Primary Care: Generalized Structural Equation Modelling of Observational Data

“…Around 2% to 3% of all primary care encounters result in a patient safety incident, with 1 in 25 causing a serious harm outcomes [3]. These incidents are frequently related to diagnosis (either delayed or missed) or to treatment (delayed or inappropriate) [4,5]. A number of different factors contribute to these incidents, such as the working environment, information transfer at the primary-secondary interface, doctor-patient relationship or continuing education [6][7][8].…”