Senior Lecturer in Community Based Education, Medical Education Unit, The University of Leeds, Leeds, UK
Received date: 5 March 2007; Accepted date: 13 March 2007
Patient safety remains a major priority for primary care despite massive financial investment and a plethora of policies and approaches. Recent developments include increased understanding of the frequency and nature of threats to patient safety,interventions to improve prescribing and diagnosis,the implementation of reporting and investigation systems, the active role of patients and an appreciation of the importance of a safety culture. At the same time, future priorities for research and educationhave been proposed.
education, patient safety, research
There are few high-profile cases of harm to patients in primary care, but this is no reason to be complacent. Patient safety remains a major priority for primary care despite massive financial investment and a plethora of policies and approaches. There have been some recent developments, but a significant challenge for the future remains.
This article is based on my selective review of the news items that have been featured on the safer healthcare and the National Patient Safety Agency (NPSA) websites over the last two years.1,2 I have also been a member of the patient safety research network that was hosted by Manchester’s Institute of Health Sciences and I have contributed to several recent articles and books. The main developments are increased understanding of the frequency and nature of threats to patient safety in primary care, andmethods that are being developed to reduce these threats, including future research and education priorities.
Estimates of threats to patient safety in primary care may appear to be low, with a range of between five and 80 per 100 000 consultations, but every day one million people visit their general practitioner (GP) and 1.5 million prescriptions are dispensed.3 The main dangers are delayed diagnosis, inappropriate treatment and the use of medication. Between 60% and 83% of these threats to patient safety are preventable. It is difficult to obtain precise estimates since different methods are used to identify and classify these threats, especially when many are due to a combination of factors.
Delayed diagnosis is the commonest cause (54%) of malpractice claims.4 An essential aspect of general practice is dealing with uncertainty, and many serious illnesses can present with non-specific symptoms, especially cancer, meningococcal disease and cardiovascular disease. Guidelines for urgent referral have the possibility to improve care but they are not easily followed.5 Recently the National Institute for Health and Clinical Excellence (NICE) has issued revised, and more practical, guidelines for the urgent referral of suspected breast, lower gastrointestinal and lung cancer. Computerised algorithms that interpret various combinations of symptoms and signs hold promise but need to be developed further.6
Use of medication
Over 600 million items are prescribed by English GPs each year. There is a high potential for patients to be harmed. Between 13% and 51% of all reported adverse incidents that occur in primary care are related to medication.3 In two recent UK-based studies of admissions to hospital, about 6% were regarded as being due to an adverse drug reaction.7,8 The adverse reaction resulted in death in 2% of cases. The largest UKbased study on adverse drug reactions as a cause of hospital admission considered that 72% of adverse drug reactions were definitely avoidable, and were considered to be inconsistent with present-day best medical practice.8 The commonest causes of admission were gastrointestinal haemorrhage related to aspirin and non-steroidal anti-inflammatory drugs, and adverse events caused by diuretics and angiotensinconverting enzyme (ACE) inhibitors.
There is potential to reduce these threats. Computers have become commonplace for initiating prescriptions in primary care and this can reduce errors, but reliance on drug interaction alerts can lead to clinically important adverse events.9 Medication reviews and monitoring are important especially in the elderly. The new Quality and Outcomes Framework (QOF) has standards for medicines management, but nearly half of all nursing and care homes fail to meet national minimum standards for how they manage their residents’ medicines.10 The role of the community pharmacist has become increasingly important and the new pharmacy contract includes a medicines use review (MUR), but this is restricted to enhanced services.11 Pharmacists can also provide a valuable source of information (for example on drug interactions and side-effects) and they can act as an additional filter to identify medication errors that can have the potential to harm patients. However, community pharmacists do not have full access to the patient’s health and medication record.
The role of the patient
The NPSA has launched the Please Ask campaign to highlight the active role of patients in making the care they receive safer.12 There is encouragement to offer information, such as previous side-effects, to question treatment decisions and to report safety concerns. Poor communication with patients is a frequent contributory factor to adverse events, and recently in the US and Australia, medical malpractice insurers are sufficiently confident in the improved outcomes of specific communication skills training that they are a condition of being insured.13
Research from high-reliability organisations, such as nuclear power or petrochemical industries, has identified the importance of developing a positive safety culture in which all actions are governed by a mind set that constantly ‘keeps an eye on the situation’.14 Whenever an action is performed, there is an automatic awareness of the potential errors that can occur, and steps are instituted to mitigate these influences. The recent advice by the NPSA on practice-based commissioning is a useful example of how this approach can be used.2 It is suggested that whenever a new or different service or patient pathway is being proposed, risk assessments should carefully examine the systems to identify factors that could potentially cause or contribute to patient harm.
Future challenges and priorities
It is becoming increasingly appreciated that the causes of threats to patient safety are complex, and most adverse events are due to multiple factors that are often interrelated. There is no single solution.
The NPSA has recently launched their Seven Steps to Patient Safety For Primary Care campaign, and one of the major recommendations is learning from adverse incidents. There is encouragement to locally perform significant event analysis (SEA) and to report centrally through the National Reporting and Learning System (NRLS). However, identification of incidents is low, with only 1185 reports (0.4% of total reported) between November 2003 and September 2005. Increased reporting, and subsequent learning, will only occur if there is a safety culture, but this will require strong leadership and an ethos that is fair and open. Everyone will need to feel safe from disciplinary action or litigation. These aspects are recognised in the report but how they can be achieved within the wider social and political context is uncertain.
Themes for future research have been identified.15 There is now greater understanding of when and why events happen, but the challenge will be to develop methods of preventing adverse events and ensuring that change is sustained in both individuals and organisations. Thiswill require adequate Funding to support multidisciplinary researchers.
An important aspect of improving patient safety in primary care is education, especially specialty training for general practice registrars and continuing medical education for GPs. The Royal College of General Practitioners has recently issued a detailed curriculum statement to guide general practice training that includes patient safety.16
Wilson and Sheikh identified the main challenges to improving patient safety in 2002: diagnosis, prescribing, communication and organisational change.17 These factors have seen little change except for tinkering around the edges. Five years is a short time to produce significant organisational change, but it is essential that over the next five years there is intensive action on patient safety.
John Sandars is on the editorial board of saferhealthcare and is amember of the reference group for the NRLS for Primary Care. He is programme director for a postgraduate certificate in patient safety and clinical risk management at the University of Leeds, which is run in partnership with MPS (Medical Protection Society) Risk Consulting. John Sandars has written modules on medical errors and medication errors for BMJ Learning.