Safety Incidents in the Primary Care Office Setting

Rees, Philippa; Edwards, Adrian; Panesar, Sukhmeet S.; Powell, Colin; Carter, Ben; Williams, Huw; Hibbert, Peter; Luff, Donna; Parry, Gareth; Mayor, Sharon; Avery, Anthony J; Sheikh, Aziz; Donaldson, Sir Liam; Carson‐Stevens, Andrew

doi:10.1542/peds.2014-3259

Cited by 33 publications

(32 citation statements)

References 40 publications

(46 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…This involved systematically coding data using multiple coding frameworks to describe the incident, quantitatively exploring coded data to identify important patterns, and thematically analyzing a purposive sample of reports containing new theoretical insights. This methodology has been accepted by the international literature [23,25,28]. …”

Section: Methodsmentioning

confidence: 99%

Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

et al. 2017

View full text Add to dashboard Cite

BackgroundThe UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.Methods and FindingsWe undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales’ National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions.Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.ConclusionsThis study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.

show abstract

Section: Methodsmentioning

confidence: 99%

Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis

et al. 2017

View full text Add to dashboard Cite

show abstract

“…[21][22][23][24] In 2003, a major investment was made in the NRLS to better understand incidents occurring in England and Wales. Each hospital and health-care facility has a reporting system that collects paper or electronically submitted incident forms.…”

Section: Patient Safety Incident Reporting In England and Walesmentioning

confidence: 99%

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

Carson‐Stevens

Hibbert

Williams

et al. 2016

Health Serv Deliv Res

119

View full text Add to dashboard Cite

show abstract

“…The volume of these data supports the identification of themes for priority setting and intervention, and the generation of hypotheses about the underlying causes of safety incidents. The work has already resulted in publications on childhood vaccination, 14 with suggestions for safety improvement during hospital discharge included in this issue. "It is only by understanding how and why patient safety incidents are caused in primary care, along with their contributory factors, that learning can be derived and systems set up to prevent such incidents reoccurring."…”

Section: Creating Urgency For Changementioning

confidence: 99%