This section describes my work in the area of threats to Patient Safety in Primary Care.
Background and rationale for work in this area
The majority of people who have contact with health care providers will receive high quality care but unfortunately for some people this care will actually harm them or be potentially harmful to them. The identification and reduction of harm has become a major priority for the NHS and although the main impetus has come from highly publicised adverse events in the secondary sector there is now an increased focus on primary care. Recent interest in the field of patient safety has tended to focus on care delivered in hospitals. However, the potential for safety problems in primary care is significant, not least because of the volume of patient contacts that take place, the complexity of the interactions and the level of uncertainty associated with providing care in the community setting. A recent review of patient safety in general practice which I carried out estimated that medical error occurs between five and 80 times per 100 000 consultations. Prescription errors were most common, occurring in about 11% of prescribing incidents, but communication and diagnostic errors were also important, as were interactions which took place across the primary/secondary care interface.
Despite the high prevalence and importance of patient safety in primary care, there has been little empirical research in the field. What has taken place has mostly been limited to the epidemiology and frequency of medical errors from the point of view of the physician.
The Department of Health has reviewed the extent and nature of adverse events in the NHS, with particular reference to how it may learn from such events to improve the quality of care that it provides. Most experience has been gained from secondary care where it can be expected that adverse events are more likely to occur in a complex organisational and technical environment. However, little is known about the situation in primary care where the majority of contacts with health care providers will occur. Learning from adverse events is a component of clinical governance and Primary Care Trusts are responding to this challenge. In response to a report by the expert group on learning from adverse events in the NHS, the Department of Health has started to implement a process to improve patient safety, a major component of which is a system to identify both the extent and nature of adverse events in both primary and secondary care. The National Patient Safety Agency has already developed the National Learning and Reporting System which is being rolled out for use in secondary care. The work that I am involved in on patient safety (work that is completed, currently being undertaken and which is planned) contributes directly to this agenda.
The work that I do on patient safety is based within the National Primary Care Research and Development Centre. Within the programme of work identified within the NPCRDC, our work on patient safety sits firmly within the work on quality. It is our view that emphasising the importance of patient safety can act as an important trigger in improving the quality of healthcare both at the patient doctor interface and in the organisation of primary care. The way that this could be done in the primary care setting has not been explored and our research agenda will contribute directly to this by linking the outputs of the research on patient safety with the current work that we are doing on quality improvement.
Because research on improving patient safety is relatively underdeveloped within primary care, our strategy has concentrated on identifying researchers who have an interest in improving patient safety from a variety of backgrounds and building alliances with them. Our emphasis has been on building multidisciplinary alliances with practitioners from the wider health related disciplines (nursing, pharmacy and clinical medicine) and with researchers from psychology, engineering, management sciences and law and ethics. This is particularly important in the field of patient safety research because of the complex interaction between human factors, organisations and technology in the genesis of critical incidents in health care Understanding and implementing solutions related to patient safety requires significant input from all these disciplines. We are working collaboratively in obtaining the limited funding which is currently available to carry out research related to patient safety research. The partnership involving researchers in Manchester has obtained significant funding from the DoH (£200,000 for analysis of the medico-legal databases, £140,000 for an ethnographic study into understanding errors in operating theatres, and £250,000 for exploring the role of community pharmacists in reducing medication error). We obtained funding from the MRC (£60,000) for developing a patient safety network. Completed work also includes an NPCRDC funded project working with colleagues from psychology and nursing which developed a framework for assessing the patient safety culture in primary care.
We have also developed important international collaborations. We are an important part of an international collaboration with the American Academy of Family Physicians and the LINNEAUS Collaboration. The LINNEAUS Collaboration has just received major funding from the European Union to develop a patient safety network in the EU.
Plans for Further Research
We have identified an ambitious programme of research, which we think needs to be carried out in primary care. We believe that identifying the potential for further research together with a strategy for deepening our current research collaborations provide the best means for taking forward all or some of this work.
We have identified short term and long term priorities for work in the area of patient safety. What we have outlined below is a roadmap of our research plans which builds on our existing expertise and on our collaborative partnerships. There is much overlap between the categories and future research may combine several categories. Incident reporting, analysis of error and rectification of error are inter- related but for ease of presentation are separated. This research will require a trans disciplinary approach, which combines a variety of research methods from a variety of disciplines. Such an approach recognises the complexity of the nature of threats to patient safety in primary care.
Short term priority:
- Continuing with developing and completing the existing projects
- Developing and evaluating a model for making Significant Event Audit more systematic in a pilot selection of Primary Care Organisations
- Development and evaluation of a model for incident reporting based on Significant Event Audit. There is potential for enhancing the use of Significant Event Audit in identifying and rectifying medical error, especially by making the process more systematic by introducing root cause analysis. This model is likely to be perceived as less threatening than a model introduced from outside since many practices are already using this form of audit and have ownership of the process. It would require input from organisational psychologists, management sciences, nursing and clinical medicine.
- Identification of threats
to patient safety associated with the use of medication.
There is concern that a significant number of errors are associated with the use of medication both in the hospital setting and in primary care. The enhanced role of community pharmacists creates an opportunity to develop a programme of work, which will be highly relevant. Funding has already been obtained for this work in collaboration with researchers from the University of Nottingham and Edinburgh.
Long term priority:
Developing a taxonomy of error in primary care.
- Clear definition of what constitutes an error. This is essential for both incident reporting and more systematic identification. Categorisation is essential for identifying trends and causation patterns. Research in secondary care has adopted two approaches: an iterative development of categories and use of fixed, previously designed categories. Our current work in the LINNEAUS Collaboration together with the work on analysis of the medical-legal databases will provide an important starting point for the development of categories of error suitable for use in the primary care setting.
- Work on diagnostic error in Primary Care.
- Developing an incident reporting system for primary care.
Our work with the LINNEAUS collaboration has already piloted a workable system and some of the lessons learnt have been incorporated into the NRLS which has been developed by the NPSA. Consideration needs to be given to widening the reporting system, for example patient feedback and role of other health care professionals e.g. pharmacists and practice nurses. Strategies to develop and change clinical practice using both empirical research methods and existing knowledge about change management need to be developed so that the full potential of the NRLS is realised.
- Assessing the feasibility of case note review for identification of error in primary care. This work could build on our experience in Primary Care. We would seek to identify the frequency and nature of error by a systematic process of case note review or standardised patients. Exemplar studies of medical error have adopted a case note review process but this is expensive in time, cost and trained resources. The development of a systematic process for a limited number of index areas, such as referral for cancer needs to be explored and the collaborative work that we are undertaking with the Federal School of Management will give us an insight into the feasibility of doing this for index conditions.
Investigation of identified events
Previous research in industry and other medical fields have used root cause analysis models to identify root causes. There are numerous models with differing degrees of rigour and resource implications. Our work on analysis of the medico-legal databases will lead to the development of a template of root cause analysis for use in the primary care setting.
Modification of use of existing audit and quality improvement data to identify and analyse error.
The investigation of shortfalls in care, are usually not performed in a systematic process, resulting in lack of identification and rectification of underlying causes. However, adaptation of root cause analysis is a possibility to enhance error identification, analysis and rectification. It has the potential to be an integral part of our work on quality improvement also building on work that we have completed as part of the QUASAR study.
Feedback and mechanisms for producing change
The ultimate aim of any system that considers error
is to reduce such errors occurring in the future. There are a variety
of models that have been used in an attempt to change professional practice,
mainly related to feedback of audit and quality data. Little research
has considered feedback on threats to patient safety
We are aiming to use our experience gained from the LINNEUS collaboration to develop a model for feedback to primary care teams. The potential for working together with colleagues in North America is significant.
Development of mechanisms in Primary Care Organisations to learn from threats to patient safety. Organisational learning, with resultant change in culture, is essential if a patient safety culture is to be established. NPCRDC is currently funding a pilot project, which seeks to develop a framework by which primary care organisations can asses their safety culture. When the project is completed we hope to develop a programme of work which will seek to identify the barriers to organisational change and develop strategies on how they can be overcome.
If you would like further information or wish to collaborate or study in this area, contact me.