The Patient Safety Collaborative

Making a difference - Prevention Systems for Patient Safety

Patient Safety in Primary Care

The Department of Health Report “Organisation with a Memory”, states that the great majority of available information and evidence on adverse events in the health care sector relates to hospital based care. The lack of evidence about errors in primary care is made more evident in the structured literature review carried out by N C Elder of the University of Cincinnati, USA, on all original research performed primarily in an outpatient setting or with primary care physicians as the providers of care. (Poster - A Taxonomy of Medical Errors in Primary Care: A Structured Literature Review - NAPCRG 2001).This focus of research and data collection on hospital-based care has hitherto been founded on the perception that such care leads to the most serious incidents. This perception ignores the fact that the vast majority of patient contacts take place every year in the primary care setting and there is still the potential for patients to be seriously harmed by failures in primary care. Further, this potential is increasing, as patient care in the community becomes increasingly complex. As Wilson et al state (BMJ 2001;323:583-584) “Early discharge from hospital, the prescribing and monitoring of potentially dangerous drugs such as methotrexate for rheumatoid arthritis, the pressure of short consultations and the fragmented nature of primary care services all increase the risk of unintentional patient harm.”

Whilst evidence as to harm in primary care is scarce, two small studies have been conducted in the USA and Australia. In a small pilot study in the USA during 2000/2001, Dovey et al reported that, in a sample of over 300 errors reported by 42 American Family Physicians over a 20-month period, some 45% of the errors had adverse consequences. In an Australian study, Bhasale stated that some 27% of the errors reported had the potential for severe harm and that over 75% were considered preventable.

In addition, risk management and reporting systems are generally far less developed in primary care than secondary care, mainly due to the lack of organisational structures to support such systems. Retrospective analysis of data from such systems is therefore not a valid possibility.

All health care systems, including primary care systems, should be designed to minimise the possibility of errors occurring. The first step in designing such systems, or to effect changes in existing systems, is to identify the errors and near misses that already occur and to study their pattern of occurrence. As detailed above, in the case of primary care, this dataset simply does not exist at present.

The design of healthcare systems should also incorporate the capacity and mechanisms to learn from those mistakes that do occur. There is currently very little evidence about the capacity of primary care organisations, down to the level of individual practices and physicians, to actively learn from failures by changing systems and procedures and filling knowledge gaps. What is therefore required is a systematic dissemination and follow up of lessons learned and this study aims to determine how this capacity can be best achieved.

This lack of empirical data and research means that Primary Care faces the real danger of rules and procedures designed for the hospital setting for reporting and dealing with patient safety issues being imposed on primary care, which will prove to be impractical, unrealistic and overly burdensome.

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Failure to study FPs’ medical errors a mistake ;Patrick Sullivan; CMAJ o October 2, 2001; 165 (7)