Patient safety events reported in general practice: a taxonomy

Patient safety classifications, taxonomies and ontologies, part 2: A systematic review on content coverage

BACKGROUND

Content coverage of patient safety ontology and classification systems should be evaluated to provide a guide for users to select appropriate ones for specific applications. In this review, we identified and compare content coverage of patient safety classifications and ontologies.

METHODS

We searched different databases and ontology/classification repositories to identify these classifications and ontologies. We included patient safety-related taxonomies, ontologies, classifications, and terminologies. We identified and extracted different concepts covered by these systems and mapped these concepts to international classification for patient safety (ICPS) and finally compared the content of these systems.

RESULTS

Finally, 89 papers (77 classifications or ontologies) were analyzed. Thirteen classifications have been developed to cover all medical domains. Among specific domain systems, most systems cover medication (16), surgery (8), medical devices (3), general practice (3), and primary care (3). The most common patient safety-related concepts covered in these systems include incident types (41), contributing factors/hazards (31), patient outcomes (29), degree of harm (25), and action (18). However, stage/phase (6), incident characteristics (5), detection (5), people involved (5), organizational outcomes (4), error type (4), and care setting (3) are some of the less covered concepts in these classifications/ontologies.

CONCLUSION

Among general systems, ICPS, World Health Organization's Adverse Reaction Terminology (WHO-ART), and Ontology of Adverse Events (OAE) cover most patient safety concepts and can be used as a gold standard for all medical domains. As a result, reporting systems could make use of these broad classifications, but the majority of their covered concepts are related to patient outcomes, with the exception of ICPS, which covers other patient safety concepts. However, the ICPS does not cover specialized domain concepts. For specific medical domains, MedDRA, NCC MERP, OPAE, ADRO, PPST, OCCME, TRTE, TSAHI, and PSIC-PC provide the broadest coverage of concepts. Many of the patient safety classifications and ontologies are not formally registered or available as formal classification/ontology in ontology repositories such as BioPortal. This study may be used as a guide for choosing appropriate classifications for various applications or expanding less developed patient safety classifications/ontologies. Furthermore, the same concepts are not represented by the same terms; therefore, the current study could be used to guide a harmonization process for existing or future patient safety classifications/ontologies.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study

BACKGROUND

The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context.

METHODS

We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript.

RESULTS

We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose.

CONCLUSIONS

We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Defining avoidable healthcare-associated harm in prisons: A mixed-method development study

BACKGROUND

Reducing avoidable healthcare-associated harm is a global health priority. Progress in evaluating the burden and aetiology of avoidable harm in prisons is limited compared with other healthcare sectors. To address this gap, this study aimed to develop a definition of avoidable harm to facilitate future epidemiological studies in prisons.

METHODS

Using a sequential mixed methods study design we first characterised and reached consensus on the types and avoidability of patient harm in prison healthcare involving analysis of 151 serious prison incidents reported to the Strategic Executive Information System (StEIS) followed by in-depth nominal group (NG) discussions with four former service users and four prison professionals. Findings of the NG discussions and StEIS analysis were then synthesised and discussed among the research team and study oversight groups to develop an operational definition of avoidable harm in prison healthcare which was subsequently tested and validated using prison patient safety incident report data derived from the National Reporting and Learning System (NRLS).

RESULTS

Analysis of StEIS incident reports and NG discussions identified important factors influencing avoidable harm which reflected the unique prison setting, including health care delivery issues and constraints associated with the secure environment which limited access to care. These findings informed the development of a new working two-tier definition of avoidable harm using appropriate and timely intervention, which included an additional assessment of harm avoidability taking into the account the prison regime and environment. The definition was compatible with the NRLS incident report narratives and illustrated how the prison environment may influence identification of avoidable harm and judgements of avoidability.

CONCLUSIONS

We have developed a working definition of avoidable harm in prison health care that enables consideration of caveats associated with prison environments and systems. Our definition enables future studies of the safety of prison healthcare to standardise outcome measurement.

Patient safety classification, taxonomy and ontology systems: A systematic review on development and evaluation methodologies

INTRODUCTION

Patient safety classifications/ontologies enable patient safety information systems to receive and analyze patient safety data to improve patient safety. Patient safety classifications/ontologies have been developed and evaluated using a variety of methods. The purpose of this review was to discuss and analyze the methodologies for developing and evaluating patient safety classifications/ontologies.

METHODS

Studies that developed or evaluated patient safety classifications, terminologies, taxonomies, or ontologies were searched through Google Scholar, Google search engines, National Center for Biomedical Ontology (NCBO) BioPortal, Open Biological and Biomedical Ontology (OBO) Foundry and World Health Organization (WHO) websites and Scopus, Web of Science, PubMed, and Science Direct. We updated our search on 30 February 2021 and included all studies published until the end of 2020. Studies that developed or evaluated classifications only for patient safety and provided information on how they were developed or evaluated were included. Systems with covered patient safety terms (such as ICD-10) but are not specifically developed for patient safety were excluded. The quality and the risk of bias of studies were not assessed because all methodologies and criteria were intended to be covered. In addition, we analyzed the data through descriptive narrative synthesis and compared and classified the development and evaluation methods and evaluation criteria according to available development and evaluation approaches for biomedical ontologies.

RESULTS

We identified 84 articles that met all of the inclusion criteria, resulting in 70 classifications/ontologies, nine of which were for the general medical domain. The most papers were published in 2010 and 2011, with 8 and 7 papers, respectively. The United States (50) and Australia (23) have the most studies. The most commonly used methods for developing classifications/ontologies included the use of existing systems (for expanding or mapping) (44) and qualitative analysis of event reports (39). The most common evaluation methods were coding or classifying some safety report samples (25), quantitative analysis of incidents based on the developed classification (24), and consensus among physicians (16). The most commonly applied evaluation criteria were reliability (27), content and face validity (9), comprehensiveness (6), usability (5), linguistic clarity (5), and impact (4), respectively.

CONCLUSIONS

Because of the weaknesses and strengths of the development/evaluation methods, it is advised that more than one method for development or evaluation, as well as evaluation criteria, should be used. To organize the processes of developing classification/ontologies, well-established approaches such as Methontology are recommended. The most prevalent evaluation methods applied in this domain are well fitted to the biomedical ontology evaluation methods, but it is also advised to apply some evaluation approaches such as logic, rules, and Natural language processing (NLP) based in combination with other evaluation approaches. This research can assist domain researchers in developing or evaluating domain ontologies using more complete methodologies. There is also a lack of reporting consistency in the literature and same methods or criteria were reported with different terminologies.

Assessing patient experience with patient safety in primary care: development and validation of the ASK-ME-questionnaire

OBJECTIVE

To develop and test the validity and reliability of a tool measuring patient experiences with patient safety in ambulatory care that is suitable for routine use in general practitioner and specialist practices.

DESIGN

Instrument development was based on a literature review, a 3-round Delphi survey with a multidisciplinary expert panel and cognitive interviews with patients. The instrument was piloted in 22 practices using a cross-sectional survey. Exploratory (EFA) and confirmatory factor analysis (CFA) were performed to test construct validity. Internal consistency and the ability of the questionnaire to differentiate between selected subgroups and at the level of individual practices was examined.

SETTING

General practitioner and specialist practices.

PARTICIPANTS

Patients aged >18 years seeking care in ambulatory care practices between February and June 2020.

RESULTS

The final ASK-ME-questionnaire consisted of 22 items covering 5 theoretical dimensions. A total of 3042 patients (71.1%) completed the questionnaire. Median item non-response rate was 4.2% (IQR 3.4%-4.7%). EFA yielded 3 factors comprising 14 items explaining 64.8% of the variance representing contributing factors to patient safety incidents. CFA confirmed the factorial structure suggested by EFA. The model fit the data satisfactorily (comparative fit index=0.92, root mean square error of approximation=0.08, standardised root mean square residual=0.08). Internal consistency values ranged from 0.7 to 0.9. Discriminant validity was supported by significant differences between patients of different age and differences in self-reported health status. The factors distinguished well between practices.

CONCLUSION

The ASK-ME-questionnaire showed good psychometric properties. It is suitable for routine use in patient safety measurement and improvement systems in ambulatory care. Further research is required to adequately assess number and type of experienced events in routine measurements.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: A mixed-mode survey

Objective

Routine measurement of patient safety from the patients’ perspective receives increasing attention as an important component of safety measurement systems. The aim of this study was to examine patients’ experience with patient safety in ambulatory care and the results’ implications for routine patient safety measurement in ambulatory care.

Design

Cross-sectional mixed-mode survey.

Setting

General practitioner and specialist practices.

Participants

Patients aged >18 years seeking care in ambulatory care practices between February and June 2020.

Methods

A 22-item-questionnaire was completed in the practice or at home either on paper or online. Multivariate logistic regression was used to analyse the influence of survey mode and patient characteristics on patient experience with patient safety.

Results

The overall response rate was 71.1%. Most patients completed the questionnaire on site (76.6%) and on paper (96.1%). Between 30.1% to 68.5% of the respondents report the most positive option for patient experience with the main domains of patient safety. A total of 2.9% of patients reported having experienced a patient-safety event (PSE) during the last 12 months. Patients who filled in the questionnaire off site were more likely to report negative experiences for the scales communication & information (OR 1.2, 95% CI 1.0–1.5), rapport & participation (OR 1.4, 95% CI 1.1–1.7) and access (OR 1.3, 95% CI 0.9–1.4) than those who completed it on site. Those who chose a paper questionnaire were more likely to report negative experiences for all five scales compared to web responders.

Conclusion

Routine measurement of patient experience with factors contributing to the occurrence of PSEs can achieve high response rates by offering flexible participation options. Results gained from mixed-mode surveys need to take mode-effects into account when interpreting and using the results. Further research is needed in how to adequately assess number and type of experienced events in routine measurements.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: The QUMwatch study

AIMS

Most research into medication safety has been conducted in hospital settings with less known about primary care. The aim of this study was to characterise the nature and causes of medication incidents (MIs) in the community using a pharmacy incident reporting programme.

METHODS

Thirty community pharmacies participated in an anonymous or confidential MI spontaneous reporting programme in Sydney, Australia. The Advanced Incident Management System was used to record and classify incident characteristics, contributing factors, severity and frequency ratings.

RESULTS

In total, 1013 incidents were reported over 30 months, 831 of which were near misses while 165 reports involved patient harm. The largest proportion of cases pertained to patients aged >65 years (35.7%). Most incidents involved errors during the prescribing stage (61.1%), followed by dispensing (25.7%) and administration (23.5%), while some errors occurred at multiple stages (17.9%). Systemic antibacterials (12.2%), analgesics (11.8%) and renin-angiotensin medicines (11.7%) formed the majority of implicated classes. Participants identified diverse and interrelating contributing factors: those concerning healthcare providers included violations to procedures/guidelines (75.6%), rule-based mistakes (55.6%) and communication (50.6%); those concerning patients included cognitive factors (31.9%), communication (25.5%) and behaviour (6.1%). Organisational safety culture and inadequate risk management processes were rated as suboptimal.

CONCLUSION

An MI reporting programme can capture and characterise medication safety problems in the community and identify the human and system factors that contribute to errors. Since medicine use is ubiquitous in the community, morbidity and mortality from MIs may be reduced by addressing the prioritised risks and contributing factors identified in this study.

Pediatric Trainees' Speaking Up About Unprofessional Behavior and Traditional Patient Safety Threats

OBJECTIVE

Speaking up is increasingly recognized as essential for patient safety. We aimed to determine pediatric trainees' experiences, attitudes, and anticipated behaviors with speaking up about safety threats including unprofessional behavior.

METHODS

Anonymous, cross-sectional survey of 512 pediatric trainees at 2 large US academic children's hospitals that queried experiences, attitudes, barriers and facilitators, and vignette responses for unprofessional behavior and traditional safety threats.

RESULTS

Responding trainees (223 of 512, 44%) more commonly observed unprofessional behavior than traditional safety threats (57%, 127 of 223 vs 34%, 75 of 223; P < .001), but reported speaking up about unprofessional behavior less commonly (48%, 27 of 56 vs 79%, 44 of 56; P < .001). Respondents reported feeling less safe speaking up about unprofessional behavior than patient safety concerns (52%, 117 of 223 vs 78%, 173 of 223; P < .001). Respondents were significantly less likely to speaking up to, and use assertive language with, an attending physician in the unprofessional behavior vignette than the traditional safety vignette (10%, 22 of 223 vs 64%, 143 of 223, P < .001 and 12%, 27 of 223 vs 57%, 128 of 223, P < .001, respectively); these differences persisted even among respondents that perceived high potential for patient harm in both vignettes (20%, 16 of 81 vs 69%, 56 of 81, P < .001 and 20%, 16 of 81 vs 69%, 56 of 81, P < .001, respectively). Fear of conflict was the predominant barrier to speaking up about unprofessional behavior and more commonly endorsed for unprofessional behavior than traditional safety threats (67%, 150 of 223 vs 45%, 100 of 223, P < .001).

CONCLUSIONS

Findings suggest pediatric trainee reluctance to speak up when presented with unprofessional behavior compared to traditional safety threats and highlight a need to improve elements of the clinical learning environment to support speaking up.

Email Consultations Between Patients and Doctors in Primary Care: Content Analysis

Background

Increasingly, consultations in health care settings are conducted remotely using a range of communication technologies. Email allows for 2-way text-based communication, occurring asynchronously. Studies have explored the content and nature of email consultations to understand the use, structure, and function of email consultations. Most previous content analyses of email consultations in primary care settings have been conducted in North America, and these have shown that concerns and assumptions about how email consultations work have not been realized. There has not been a UK-based content analysis of email consultations.

Objective

This study aims to explore and delineate the content of consultations conducted via email in English general practice by conducting a content analysis of email consultations between general practitioners (GPs) and patients.

Methods

We conducted a content analysis of anonymized email consultations between GPs and patients in 2 general practices in the United Kingdom. We examined the descriptive elements of the correspondence to ascertain when the emails were sent, the number of emails in an email consultation, and the nature of the content. We used a normative approach to analyze the content of the email consultations to explore the use and function of email consultation.

Results

We obtained 100 email consultations from 85 patients, which totaled 262 individual emails. Most email users were older than 40 years, and over half of the users were male. The email consultations were mostly short and completed in a few days. Emails were mostly sent and received during the day. The emails were mostly clinical in content rather than administrative and covered a wide range of clinical presentations. There were 3 key themes to the use and function of the email consultations: the role of the GP and email consultation, the transactional nature of an email consultation, and the operationalization of an email consultation.

Conclusions

Most cases where emails are used to have a consultation with a patient in general practice have a shorter consultation, are clinical in nature, and are resolved quickly. GPs approach email consultations using key elements similar to that of the face-to-face consultation; however, using email consultations has the potential to alter the role of the GP, leading them to engage in more administrative tasks than usual. Email consultations were not a replacement for face-to-face consultations.

Diagnostic error in the emergency department: learning from national patient safety incident report analysis

BACKGROUND

Diagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. We sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015 and to identify the priority areas for intervention to reduce their occurrence.

METHODS

A cross-sectional mixed-methods design using an exploratory descriptive analysis and thematic analysis of patient safety incident reports. Primary data were extracted from a national database of patient safety incidents. Reports were filtered for emergency department settings, diagnostic error (as classified by the reporter), from 2013 to 2015. These were analysed for the chain of events, contributory factors and harm outcomes.

RESULTS

There were 2288 cases of confirmed diagnostic error: 1973 (86%) delayed and 315 (14%) wrong diagnoses. One in seven incidents were reported to have severe harm or death. Fractures were the most common condition (44%), with cervical-spine and neck of femur the most frequent types. Other common conditions included myocardial infarctions (7%) and intracranial bleeds (6%). Incidents involving both delayed and wrong diagnoses were associated with insufficient assessment, misinterpretation of diagnostic investigations and failure to order investigations. Contributory factors were predominantly human factors, including staff mistakes, healthcare professionals' inadequate skillset or knowledge and not following protocols.

CONCLUSIONS

Systems modifications are needed that provide clinicians with better support in performing patient assessment and investigation interpretation. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.

Building Usability Knowledge for Health Information Technology: A Usability-Oriented Analysis of Incident Reports

BACKGROUND

The contribution of usability flaws to patient safety issues is acknowledged but not well-investigated. Free-text descriptions of incident reports may provide useful data to identify the connection between health information technology (HIT) usability flaws and patient safety.

OBJECTIVES

This article examines the feasibility of using incident reports about HIT to learn about the usability flaws that affect patient safety. We posed three questions: (1) To what extent can we gain knowledge about usability issues from incident reports? (2) What types of usability flaws, related usage problems, and negative outcomes are reported in incidents reports? (3) What are the reported usability issues that give rise to patient safety issues?

METHODS

A sample of 359 reports from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database was examined. Descriptions of usability flaws, usage problems, and negative outcomes were extracted and categorized. A supplementary analysis was performed on the incidents which contained the full chain going from a usability flaw up to a patient safety issue to identify the usability issues that gave rise to patient safety incidents.

RESULTS

A total of 249 reports were included. We found that incident reports can provide knowledge about usability flaws, usage problems, and negative outcomes. Thirty-six incidents report how usability flaws affected patient safety (ranging from incidents without consequence, to death) involving electronic patient scales, imaging systems, and HIT for medication management. The most significant class of involved usability flaws is related to the reliability, the understandability, and the availability of the clinical information.

CONCLUSION

Incidents reports involving HIT are an exploitable source of information to learn about usability flaws and their effects on patient safety. Results can be used to convince all stakeholders involved in the HIT system lifecycle that usability should be considered seriously to prevent patient safety incidents.

Processing discharge summaries in general practice: a qualitative interview study with GPs and practice managers

Background

Discharge summaries are essential for communicating patient information from secondary care to general practice on hospital discharge. Although there has been extensive research into their design and completion in secondary care, very little is known about primary care processing of these documents.

Aim

To explore what general practice staff think are the factors associated with failure to respond to actions requested in discharge summaries and what practices do to mitigate this.

Design & setting

Semi-structured interviews were undertaken with primary care staff in three geographical regions of England.

Method

Interviews with 10 practice managers and 10 GPs (one of each at each of the 10 practices) were undertaken to explore management of discharge summaries.

Results

Five themes emerged from the interviews. The 'secondary care factors' theme describes participants' perspectives on the design of summaries, which are inconsistent and often require improvement. The 'safety features of processing systems' theme focuses on document handling in primary care. A theme devoted to 'medicines reconciliation' followed. 'Error and harm as a result of faulty processing' is a theme describing 'human error' and other factors that participants believed contributed to failure to respond to requested actions. Finally, the 'strategies for safety improvement' theme describes initiatives to prevent failures of safer transitions of care.

Conclusion

Correct processing of discharge summaries is essential to ensure patients experience a safe transition of care and not just a hospital discharge. Based on the interview findings, strategies to mitigate against faults in the processing of discharge summaries have been suggested to enhance safer transitions of care.

Validation of the Primary Care Patient Measure of Safety (PC PMOS) questionnaire

BACKGROUND

The Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice.

METHOD

490 adult patients in nine primary care practices in Greater Manchester, UK, completed the PC PMOS. Practice staff (n = 81) completed a survey on patient safety culture to assess convergent validity. Confirmatory factor analysis (CFA) assessed the construct validity and internal reliability of the PC PMOS domains and items. A multivariate analysis of variance was conducted to assess discriminant validity, and Spearman correlation was conducted to establish test-retest reliability.

RESULTS

Initial CFA results showed data did not fit the model well (a chi-square to df ratio (CMIN/DF) = 5.68; goodness-of-fit index (GFI) = 0.61, CFI = 0.57, SRMR = 0.13 and root mean square error of approximation (RMSEA) = 0.10). On the basis of large modification indices (>10), standardised residuals >± 2.58 and assessment of item content; 22 items were removed. This revised nine-factor model (28 items) was found to fit the data satisfactorily (CMIN/DF = 2.51; GFI = 0.87, CFI = 0.91, SRMR = 0.04 and RMSEA = 0.05). New factors demonstrated good internal reliability with average inter-item correlations ranging from 0.20 to 0.70. The PC PMOS demonstrated good discriminant validity between primary care practices (F = 2.64, df = 72, p < 0.001) and showed some association with practice staff safety score (convergent validity) but failed to reach statistical significance (r = -0.64, k = 9, p = 0.06).

CONCLUSION

This study led to a reliable and valid 28-item PC PMOS. It could enhance or complement current data collection methods used in primary care to identify and prevent error.

Factors contributing to patient safety incidents in primary care: a descriptive analysis of patient safety incidents in a French study using CADYA (categorization of errors in primary care)

Background

Patient safety incidents (PSIs) frequently occur in primary care and are often considered to be preventable. Better knowledge of factors contributing to PSIs is required to build safer care. The aim of this work was to describe the underlying factors, specifically the human factors, that are associated with PSIs in primary care using CADYA (“CAtégorisation des DYsfonctionnements en Ambulatoire” or “Categorization of Errors in Primary Care”).

Methods

We followed a mixed method with content analysis and coding in CADYA of PSIs reported in the ESPRIT study, a French cross-sectional survey of primary care. For each incident, a main contributing factor (MD) and, if applicable, a secondary contributing factor (SD) were identified. Several descriptive keywords from an incremental glossary have been suggested to describe each identified human factor (attitudes or behaviours). A descriptive statistical analysis was then conducted.

Results

Among the 482 PSIs reported in the ESPRIT study, from 13,438 acts reported by 127 participating general practitioners (GPs), we identified 590 contributing factors (482 MDs and 178 SDs). Overall, 35% were related to the care process, 30% to human factors, 22% to the healthcare environment and 13% to technical factors. The contributing factors, in decreasing order of frequency, were communication errors (13.7%), human factors related to healthcare providers (12.9%) and human factors related to patients (12.9%). The human factors were mainly related to ‘lack of attention’, ‘stress’, ‘anger’ and ‘fatigue’.

Conclusions

Our results tend to prove that human factors are often involved in PSIs in primary care, with GPs and patients being equally responsible. Beyond the identification of communication errors, often found in other international research, we have described the attitudes and behaviours contributing to unsafe care. Further research exploring the links between working conditions and human factors is required.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0803-9) contains supplementary material, which is available to authorized users.

Patient safety and safety culture in primary health care: a systematic review

BACKGROUND

Patient safety in primary care is an emerging field of research with a growing evidence base in western countries but little has been explored in the Gulf Cooperation Council Countries (GCC) including the Sultanate of Oman. This study aimed to review the literature on the safety culture and patient safety measures used globally to inform the development of safety culture among health care workers in primary care with a particular focus on the Middle East.

METHODS

A systematic review of the literature. Searches were undertaken using Medline, EMBASE, CINAHL and Scopus from the year 2000 to 2014. Terms defining safety culture were combined with terms identifying patient safety and primary care.

RESULTS

The database searches identified 3072 papers that were screened for inclusion in the review. After the screening and verification, data were extracted from 28 papers that described safety culture in primary care. The global distribution of the articles is as follows: the Netherlands (7), the United States (5), Germany (4), the United Kingdom (1), Australia, Canada and Brazil (two for each country), and with one each from Turkey, Iran, Saudi Arabia and Kuwait. The characteristics of the included studies were grouped under the following themes: safety culture in primary care, incident reporting, safety climate and adverse events. The most common theme from 2011 onwards was the assessment of safety culture in primary care (13 studies, 46%). The most commonly used safety culture assessment tool is the Hospital survey on patient safety culture (HSOPSC) which has been used in developing countries in the Middle East.

CONCLUSIONS

This systematic review reveals that the most important first step is the assessment of safety culture in primary care which will provide a basic understanding to safety-related perceptions of health care providers. The HSOPSC has been commonly used in Kuwait, Turkey, and Iran.

Processing of discharge summaries in general practice: a retrospective record review

Background

There is a need for greater understanding of the epidemiology of primary care patient safety in order to generate solutions to prevent future harm.

Aim

To estimate the rate of failures in processing actions requested in hospital discharge summaries, and to determine factors associated with these failures.

Design and setting

The authors undertook a retrospective records review. The study population was emergency admissions for patients aged ≥75 years, drawn from 10 practices in three areas of England.

Method

One GP researcher reviewed the records for 300 patients after hospital discharge to determine the rate of compliance with actions requested in the discharge summary, and to estimate the rate of associated harm from non-compliance. In cases where GPs documented decision-making contrary to what was requested, these instances did not constitute failures. Data were also collected on time taken to process discharge communications.

Results

There were failures in processing actions requested in 46% (112/246) of discharge summaries (95% confidence interval [CI] = 39 to 52%). Medications changes were not made in 17% (124/750) of requests (95% CI = 14 to 19%). Tests were not completed for 26% of requests (95% CI = 16 to 35%), and 27% of requested follow-ups were not arranged (95% CI = 20 to 33%). The harm rate associated with these failures was 8%. Increased risk of failure to process test requests was significantly associated with the type of clinical IT system, and male patients.

Conclusion

Failures occurred in the processing of requested actions in almost half of all discharge summaries, and with all types of action requested. Associated harms were uncommon and most were of moderate severity.

Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives

Background

Primary care is changing rapidly to meet the needs of an ageing and chronically ill population. New ways of working are called for yet the introduction of innovative service interventions is complicated by organisational challenges arising from its scale and diversity and the growing complexity of patients and their care. One such intervention is the multi-strand, single platform, Patient Safety Toolkit developed to help practices provide safer care in this dynamic and pressured environment where the likelihood of adverse incidents is increasing. Here we describe the attitudes of staff toward these tools and how their implementation was shaped by a number of contextual factors specific to each practice.

Methods

The Patient Safety Toolkit comprised six tools; a system of rapid note review, an online staff survey, a patient safety questionnaire, prescribing safety indicators, a medicines reconciliation tool, and a safe systems checklist. We implemented these tools at practices across the Midlands, the North West, and the South Coast of England and conducted semi-structured interviews to determine staff perspectives on their effectiveness and applicability.

Results

The Toolkit was used in 46 practices and a total of 39 follow-up interviews were conducted. Three key influences emerged on the implementation of the Toolkit these related to their ease of use and the novelty of the information they provide; whether their implementation required additional staff training or practice resource; and finally factors specific to the practice’s local environment such as overlapping initiatives orchestrated by their CCG.

Conclusions

The concept of a balanced toolkit to address a range of safety issues proved popular. A number of barriers and facilitators emerged in particular those tools that provided relevant information with a minimum impact on practice resource were favoured. Individual practice circumstances also played a role. Practices with IT aware staff were at an advantage and those previously utilising patient safety initiatives were less likely to adopt additional tools with overlapping outputs. By acknowledging these influences we can better interpret reaction to and adoption of individual elements of the toolkit and optimise future implementation.

Developing a contributing factor classification scheme for Rasmussen's AcciMap: Reliability and validity evaluation

One factor potentially limiting the uptake of Rasmussen's (1997) Accimap method by practitioners is the lack of a contributing factor classification scheme to guide accident analyses. This article evaluates the intra- and inter-rater reliability and criterion-referenced validity of a classification scheme developed to support the use of Accimap by led outdoor activity (LOA) practitioners. The classification scheme has two levels: the system level describes the actors, artefacts and activity context in terms of 14 codes; the descriptor level breaks the system level codes down into 107 specific contributing factors. The study involved 11 LOA practitioners using the scheme on two separate occasions to code a pre-determined list of contributing factors identified from four incident reports. Criterion-referenced validity was assessed by comparing the codes selected by LOA practitioners to those selected by the method creators. Mean intra-rater reliability scores at the system (M = 83.6%) and descriptor (M = 74%) levels were acceptable. Mean inter-rater reliability scores were not consistently acceptable for both coding attempts at the system level (M_T1 = 68.8%; M_T2 = 73.9%), and were poor at the descriptor level (M_T1 = 58.5%; M_T2 = 64.1%). Mean criterion referenced validity scores at the system level were acceptable (M_T1 = 73.9%; M_T2 = 75.3%). However, they were not consistently acceptable at the descriptor level (M_T1 = 67.6%; M_T2 = 70.8%). Overall, the results indicate that the classification scheme does not currently satisfy reliability and validity requirements, and that further work is required. The implications for the design and development of contributing factors classification schemes are discussed.

Application of classification principles to improve the reliability of incident classification systems: A test case using HFACS-ADF

Accident classification systems are important tools for safety management. Unfortunately, many of the tools available have demonstrated poor reliability of coding, making their validity and usefulness questionable. This paper demonstrates the application of four strategies to improve the reliability of accident and incident classification systems. The strategies include creating a domain-specific system with limitations on system size and careful selection of codes, specifically the reduction of abstract concepts and bias-causing terminology. Using HFACS-ADF as a test case, the system was adapted using the strategies and validated using comprehension and comprehensiveness testing. The new system was then assessed for reliability. The reliability of the system increased by at least 20% at all levels of the classification system following the changes made. The results provide evidence that the application of theoretically and empirically-derived classification principles are effective for improving the reliability of accident and incident classification systems in high hazard industries.

Patient safety incidents are common in primary care: A national prospective active incident reporting survey

BACKGROUND

The study objectives were to describe the incidence and the nature of patient safety incidents (PSIs) in primary care general practice settings, and to explore the association between these incidents and practice or organizational characteristics.

METHODS

GPs, randomly selected from a national influenza surveillance network (n = 800) across France, prospectively reported any incidents observed each day over a one-week period between May and July 2013. An incident was an event or circumstance that could have resulted, or did result, in harm to a patient, which the GP would not wish to recur. Primary outcome was the incidence of PSIs which was determined by counting reports per total number of patient encounters. Reports were categorized using existing taxonomies. The association with practice and organizational characteristics was calculated using a negative binomial regression model.

RESULTS

127 GPs (participation rate 79%) reported 317 incidents of which 270 were deemed to be a posteriori judged preventable, among 12,348 encounters. 77% had no consequences for the patient. The incidence of reported PSIs was 26 per 1000 patient encounters per week (95% CI [23‰ -28‰]). Incidents were three times more frequently related to the organization of healthcare than to knowledge and skills of health professionals, and especially to the workflow in the GPs' offices and to the communication between providers and with patients. Among GP characteristics, three were related with an increased incidence in the final multivariable model: length of consultation higher than 15 minutes, method of receiving radiological results (by fax compared to paper or email), and being in a multidisciplinary clinic compared with sole practitioners.

CONCLUSIONS

Patient safety incidents (PSIs) occurred in mean once every two days in the sampled GPs and 2% of them were associated with a definite possibility for harm. Studying the association between organizational features of general practices and PSIs remains a major challenge and one of the most important issues for safety in primary care.

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

BACKGROUND

The 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 FINDINGS

We 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.

CONCLUSIONS

This 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.

Measuring Moral Courage for Interns and Residents: Scale Development and Initial Psychometrics

PURPOSE

To develop a practical and psychometrically sound set of survey items that measures moral courage for physicians in the context of patient care.

METHOD

In 2013, the 731 internal medicine and surgical interns and residents from two northeastern U.S. academic medical centers were invited to anonymously complete a survey about moral courage, empathy, and speaking up about patient safety breaches.

RESULTS

Of the eligible participants, 352 (48%) responded. Principal components analysis of the moral courage items demonstrated a single, meaningful, nine-item factor labeled the Moral Courage Scale for Physicians (MCSP). All item-total score correlations were significant (P < .001) and ranged from 0.57 to 0.76. The Cronbach alpha for the MCSP was 0.90. Consistent with expectations based on theory, MCSP scores were negatively associated with being an intern versus resident (B = -4.17, P < .001), suggesting discriminant validity. MCSP scores were positively associated with respondents' Jefferson Scale of Physician Empathy perspective-taking score (B = 0.53, P < .001), a construct conceptually relevant to moral courage, suggesting convergent validity. Finally, MCSP scores were positively correlated with self-reported speaking up about patient safety breaches (r = 0.19, P = .008), an action that involves moral courage, suggesting concurrent validity.

CONCLUSIONS

The authors provided initial evidence for the reliability and validity of a measure of moral courage for physicians. The MCSP may help researchers and educators to tangibly measure physician moral courage as a concept, and track progress on a set of desired behaviors in response to curricular interventions.

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

Background

There is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.

Aims

To characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.

Methods

We undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.

Main findings

We have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.

Conclusions

Although there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient safety improvement programmes for primary care. Review of a Delphi procedure and pilot studies by the LINNEAUS collaboration on patient safety in primary care

Background: To improve patient safety it is necessary to identify the causes of patient safety incidents, devise solutions and measure the (cost-) effectiveness of improvement efforts.

Objective: This paper provides a broad overview with practical guidance on how to improve patient safety.

Methods: We used modified online Delphi procedures to reach consensus on methods to improve patient safety and to identify important features of patient safety management in primary care. Two pilot studies were carried out to assess the value of prospective risk analysis (PRA), as a means of identifying the causes of a patient safety incident.

Results: A range of different methods can be used to improve patient safety but they have to be contextually specific. Practice organization, culture, diagnostic errors and medication safety were found to be important domains for further improvement. Improvement strategies for patient safety could benefit from insights gained from research on implementation of evidence-based practice. Patient involvement and prospective risk analysis are two promising and innovative strategies for improving patient safety in primary care.

Conclusion: A range of methods is available to improve patient safety, but there is no ‘magic bullet.’ Besides better use of the available methods, it is important to use new and potentially more effective strategies, such as prospective risk analysis.

Patients' views of adverse events in primary and ambulatory care: a systematic review to assess methods and the content of what patients consider to be adverse events

BACKGROUND

Patient safety gained widespread public attention in the last 20 years. However, most patient safety research relied upon professionals' exceptions and was realised especially in the hospital sector. Gradually patients' attention has been focused on safety campaigns in inpatient care. We aimed to better assess patients' perceptions in primary and ambulatory care.

METHODS

A systematic review was conducted by use of database searches with additional reference and hand searching. The search strategy implied MeSH-terms relating to adverse events, incident reporting and outpatient care. Relevant articles were selected by applying defined eligibility criteria. Studies exclusively based on hospital data as well as the professionals' point of view were excluded.

RESULTS

We included 19 studies. Patients were able to identify events that were traditionally recognised by the medical community as technical medical aspects (e.g. errors in diagnosis). An important field of patient participation in prevention of adverse events was proposed in the medication process. Most reported events however could be described as service quality incidents. Communication problems were shown to have implications on the occurrence of technical medical aspects and patients' satisfaction of their care. Further, unsatisfied patients were more likely to recognize adverse events.

CONCLUSION

Patients' perception of patient safety in primary and ambulatorycare broadened the previous focus on technical medical aspects. Especially communication factors played an important role in the occurrence and consequence of adverse events and patients' satisfaction. Future research should concentrate on developing possible ways to integrate patients' views and participation in ensuring safety in outpatient care.

A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice

INTRODUCTION

Incident reports contain descriptions of errors and harms that occurred during clinical care delivery. Few observational studies have characterised incidents from general practice, and none of these have been from the England and Wales National Reporting and Learning System. This study aims to describe incidents reported from a general practice care setting.

METHODS AND ANALYSIS

A general practice patient safety incident classification will be developed to characterise patient safety incidents. A weighted-random sample of 12,500 incidents describing no harm, low harm and moderate harm of patients, and all incidents describing severe harm and death of patients will be classified. Insights from exploratory descriptive statistics and thematic analysis will be combined to identify priority areas for future interventions.

ETHICS AND DISSEMINATION

The need for ethical approval was waivered by the Aneurin Bevan University Health Board research risk review committee given the anonymised nature of data (ABHB R&D Ref number: SA/410/13). The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.

Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports

OBJECTIVE

To identify the categories of problems with information technology (IT), which affect patient safety in general practice.

DESIGN

General practitioners (GPs) reported incidents online or by telephone between May 2012 and November 2013. Incidents were reviewed against an existing classification for problems associated with IT and the clinical process impacted.

PARTICIPANTS AND SETTING

87 GPs across Australia.

MAIN OUTCOME MEASURE

Types of problems, consequences and clinical processes.

RESULTS

GPs reported 90 incidents involving IT which had an observable impact on the delivery of care, including actual patient harm as well as near miss events. Practice systems and medications were the most affected clinical processes. Problems with IT disrupted clinical workflow, wasted time and caused frustration. Issues with user interfaces, routine updates to software packages and drug databases, and the migration of records from one package to another generated clinical errors that were unique to IT; some could affect many patients at once. Human factors issues gave rise to some errors that have always existed with paper records but are more likely to occur and cause harm with IT. Such errors were linked to slips in concentration, multitasking, distractions and interruptions. Problems with patient identification and hybrid records generated errors that were in principle no different to paper records.

CONCLUSIONS

Problems associated with IT include perennial risks with paper records, but additional disruptions in workflow and hazards for patients unique to IT, occasionally affecting multiple patients. Surveillance for such hazards may have general utility, but particularly in the context of migrating historical records to new systems and software updates to existing systems.

Development of safety incident coding systems through improving coding reliability

This paper reviews classification theory sources to develop five research questions concerning factors associated with incident coding system development and use and how these factors affect coding reliability. Firstly, a method was developed to enable the comparison of reliability results obtained using different methods. Second, a statistical and qualitative review of reliability studies was conducted to investigate the influence of the identified factors on the reliability of incident coding systems. As a result several factors were found to have a statistically significant effect on reliability. Four recommendations for system development and use are provided to assist researchers in improving the reliability of incident coding systems in high hazard industries.

Tools for primary care patient safety: a narrative review

Background

Patient safety in primary care is a developing field with an embryonic but evolving evidence base. This narrative review aims to identify tools that can be used by family practitioners as part of a patient safety toolkit to improve the safety of the care and services provided by their practices.

Methods

Searches were performed in 6 healthcare databases in 2011 using 3 search stems; location (primary care), patient safety synonyms and outcome measure synonyms. Two reviewers analysed the results using a numerical and thematic analyses. Extensive grey literature exploration was also conducted.

Results

Overall, 114 Tools were identified with 26 accrued from grey literature. Most published literature originated from the USA (41%) and the UK (23%) within the last 10 years. Most of the literature addresses the themes of medication error (55%) followed by safety climate (8%) and adverse event reporting (8%). Minor themes included; informatics (4.5%) patient role (3%) and general measures to correct error (5%). The primary/secondary care interface is well described (5%) but few specific tools for primary care exist. Diagnostic error and results handling appear infrequently (<1% of total literature) despite their relative importance. The remainder of literature (11%) related to referrals, Out-Of-Hours (OOH) care, telephone care, organisational issues, mortality and clerical error.

Conclusions

This review identified tools and indicators that are available for use in family practice to measure patient safety, which is crucial to improve safety and design a patient safety toolkit. However, many of the tools have yet to be used in quality improvement strategies and cycles such as plan–do–study–act (PDSA) so there is a dearth of evidence of their utility in improving as opposed to measuring and highlighting safety issues. The lack of focus on diagnostics, systems safety and results handling provide direction and priorities for future research.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2296-15-166) contains supplementary material, which is available to authorized users.

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety

BACKGROUND

The role of time management in safe and efficient medicine is important but poorly incorporated into the taxonomies of error in primary care. This paper addresses the lack of time management, presenting a framework integrating five time scales termed 'Tempos' requiring parallel processing by GPs: the disease's tempo (unexpected rapid evolutions, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. The art of medicine is to control all of these tempos in parallel and simultaneously.

METHOD

Two qualified physicians reviewed a sample of 1046 malpractice claims from one liability insurer to determine whether a medical injury had occurred and, if so, whether it was due to one or more tempo-related problems. 623 of these reports were analysed in greater detail to identify the prevalence and characteristics of claims and related time management errors.

RESULTS

The percentages of contributing factors were as follows: disease tempo, 37.9%; office tempo, 13.2%; patient tempo, 13.8%; out-of-office coordination tempo, 22.6%; and GP's access to knowledge tempo, 33.2%.

CONCLUSION

Although not conceptualised in most error taxonomies, the disease and patient tempos are cornerstones in risk management in primary care. Traditional taxonomies describe events from an analytical perspective of care at the system level and offer opportunities to improve organisation, process, and evidence-based medicine. The suggested classification describes events in terms of (unsafe) dynamic control of parallel constraints from the carer's perspective, namely the GP, and offers improvement on how to self manage and coordinate different contradictory tempos and day-to-day activities. Further work is needed to test the validity and usefulness of this approach.

[Medical error: analysis of their type, their consequences and impact of the mortality and morbidity meetings in midwifery (APERIF network maternities)]

OBJECTIVES

The medical error begins to be estimated by mortality and morbidity meetings (MMM). They concern all the medical professions among which the midwives. One of the themes of the congress of APERIF networks in 2013 concerned the evaluation of the medical errors of the midwives. We sounded the midwives of the network to know the type of medical errors, their frequencies, their consequences and the proposed corrective measures.

MATERIALS AND METHODS

A workgroup was set up who allowed to establish a questionnaire of evaluation which was diffused to midwives of the maternities of the network. The questionnaire analysed the population and the existing organizations in the departments regarding staff and MMM. The questionnaire also analyzed the type of committed errors, their mode of revelation, the medical and psychological consequences. The last part of the questionnaire concerned the effective corrective measures and those wished by the midwives.

RESULTS

The rate of answer in spite of brakes to the distribution of questionnaires was satisfactory for this type of behavioural research. We noticed that the errors are very frequent and that they have an important impact in the professional life of the midwives. The MMM is little known by midwives and they are badly informed about their existence.

CONCLUSION

The medical error is inevitable, it has important consequences which are underestimated and consequently without real targeted corrective measures.

[Which definition and taxonomy of incident to use for a French reporting system in primary care settings?]

BACKGROUND

There is no widely accepted definition of incident for primary care doctors in France and no taxonomic classification system for epidemiological use. In preparation for a future epidemiological study on primary care incidents in France (the ESPRIT study), this work was designed to identify the definitions and taxonomic classifications used internationally along with the usual methods and results in terms of frequency in the literature. The goal was to determine a French definition and taxonomy.

DESIGN

Systematic review of the literature and consensus methods.

METHOD

An exhaustive search of epidemiological surveys was performed. A structured grid was used. After having identified the definitions used in the literature, a definition was chosen using the focus groups method. Taxonomies identified in the literature were classified by relationship, architecture, code number, and number of studies published. Subsequently, a consensus among experts, who independently tested these taxonomies on six incidents, was reached for choosing the most appropriate for epidemiological data collection (little information on a large number of cases).

RESULTS

Twenty-four papers reporting 17 studies were selected among 139 articles. Five definitions and eight taxonomies were found. The chosen definition of incident was based on the WHO definition "A patient safety incident is an event or circumstance that could have resulted, or did result, in harm to a patient, and whose wish it is not repeated again". The test of incidents resulted in the choice of the TAPS version of the International Taxonomy of Medical Error in Primary Care for a reproducible and internationally recognized codification and the tempos method for its current use in French general practice.

DISCUSSION

The definitions, taxonomies, data collection characteristics and frequency of incidents results in the international literature on incidents in primary care are key components for the preparation of an epidemiological survey on incidents in primary care.

Reliability studies of incident coding systems in high hazard industries: A narrative review of study methodology

This paper reviews the current literature on incident coding system reliability and discusses the methods applied in the conduct and measurement of reliability. The search strategy targeted three electronic databases using a list of search terms and the results were examined for relevance, including any additional relevant articles from the bibliographies. Twenty five papers met the relevance criteria and their methods are discussed. Disagreements in the selection of methods between reliability researchers are highlighted as are the effects of method selection on the outcome of the trials. The review provides evidence that the meaningfulness of and confidence in results is directly affected by the methodologies employed by the researcher during the preparation, conduct and analysis of the reliability study. Furthermore, the review highlights the heterogeneity of methodologies employed by researchers measuring reliability of incident coding techniques, reducing the ability to critically compare and appraise techniques being considered for the adoption of report coding and trend analysis by client organisations. It is recommended that future research focuses on the standardisation of reliability research and measurement within the incident coding domain.

Health innovation for patient safety improvement

Medication error has been identified as a major factor affecting patient safety. Many innovative efforts such as Computerised Physician Order Entry (CPOE), a Pharmacy Information System, automated dispensing machines and Point of Administration Systems have been carried out with the aim of improving medication safety. However, areas remain that require urgent attention. One main area will be the lack of continuity of care due to the breakdown of communication between multiple healthcare providers. Solutions may include consideration of "health smart cards" that carry vital patient medical information in the form of a "credit card" or use of the Malaysian identification card. However, costs and technical aspects associated with the implementation of this health smart card will be a significant barrier. Security and confidentiality, on the other hand, are expected to be of primary concern to patients. Challenges associated with the implementation of a health smart card might include physician buy-in for use in his or her everyday practice. Training and technical support should also be available to ensure the smooth implementation of this system. Despite these challenges, implementation of a health smart card moves us closer to seamless care in our country, thereby increasing the productivity and quality of healthcare.

Towards the creation of a flexible classification scheme for voluntarily reported transfusion and laboratory safety events

BACKGROUND

Transfusion and clinical laboratory services are high-volume activities involving complicated workflows across both ambulatory and inpatient environments. As a result, there are many opportunities for safety lapses, leading to patient harm and increased costs. Organizational techniques such as voluntary safety event reporting are commonly used to identify and prioritize risk areas across care settings. Creation of functional, standardized safety data structures that facilitate effective exploratory examination is therefore essential to drive quality improvement interventions. Unfortunately, voluntarily reported adverse event data can often be unstructured or ambiguously defined.

RESULTS

To address this problem, we sought to create a "best-of-breed" patient safety classification for data contained in the Duke University Health System Safety Reporting System (SRS). Our approach was to implement the internationally recognized World Health Organization International Classification for Patient Safety Framework, supplemented with additional data points relevant to our organization. Data selection and integration into the hierarchical framework is discussed, as well as placement of the classification into the SRS. We evaluated the impact of the new SRS classification on system usage through comparisons of monthly average report rates and completion times before and after implementation. Monthly average inpatient transfusion reports decreased from 102.1 ± 14.3 to 91.6 ± 11.2, with the proportion of transfusion reports in our system remaining consistent before and after implementation. Monthly average transfusion report rates in the outpatient and homecare environments were not significantly different. Significant increases in clinical lab report rates were present across inpatient and outpatient environments, with the proportion of lab reports increasing after implementation. Report completion times increased modestly but not significantly from a practical standpoint.

CONCLUSIONS

A common safety vocabulary can facilitate integration of information from disparate systems and processes to permit meaningful measurement and interpretation of data to improve safety within and across organizations. Formation of a "best-of-breed" classification for voluntary reporting necessitates an internal examination of localized data needs and workflow in order to design a product that enables comprehensive data capture. A team of clinical, safety, and information technology experts is necessary to integrate the data structures into the reporting system. We have found that a "best-of-breed" patient safety classification provides a solid, extensible model for adverse event analysis, healthcare leader communication, and intervention identification.

Information chaos in primary care: implications for physician performance and patient safety

PURPOSE

The purpose of this article is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.

METHODS

We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.

RESULTS

Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, and its consequences, and we discuss possible solutions and suggest a research agenda that may lead to methods to reduce the problem.

CONCLUSIONS

Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying, and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

Tailoring "best-of-breed" safety classification for patient fall voluntary reporting

OBJECTIVE

Voluntary safety event reporting often produces poorly defined data points, which complicate data analyses across health care settings. Such data should be restructured into a standard patient safety language translatable within and outside health care organizations. We designed and implemented a "best-of-breed" patient safety classification for data created by the Duke University Health System Safety Reporting System.

METHODS

We report our approach for patient fall classification. Our strategy was to deploy the International Classification for Patient Safety Framework of the World Health Organization augmented with additional data points of interest, thereby allowing for data translatability while maintaining local practices. System interface redesign using the "best-of-breed" fall classification was mindful of workflows and known reporting barriers. Custom aggregate reports were also developed.

RESULTS

We estimated the impact of the redesigned portal on Safety Reporting System usage before and after classification through comparisons of fall report volume and report completion time. When normalized as falls per day, the rate of falls only changed slightly, indicating that the enhancement had little effect on reporting desire. Report completion time increased modestly but not significantly from a practical standpoint. The presence of structured data eliminated substantial hours dedicated to manual data management and enabled evaluation of quality improvement interventions within and outside our organization.

CONCLUSIONS

Creation and implementation of a "best-of-breed" patient safety classification for voluntary reporting requires multidisciplinary collaboration between clinical experts, frontline clinicians, and functional and technical analysts. Formal usability evaluations of reporting systems are needed to ensure design facilitates effective data collection.

Performance factors of mobile rich media job aids for community health workers

OBJECTIVE

To study and analyze the possible benefits on performance of community health workers using point-of-care clinical guidelines implemented as interactive rich media job aids on small-format mobile platforms.

DESIGN

A crossover study with one intervention (rich media job aids) and one control (traditional job aids), two periods, with 50 community health workers, each subject solving a total 15 standardized cases per period per period (30 cases in total per subject).

MEASUREMENTS

Error rate per case and task, protocol compliance.

RESULTS

A total of 1394 cases were evaluated. Intervention reduces errors by an average of 33.15% (p = 0.001) and increases protocol compliance 30.18% (p < 0.001). Limitations Medical cases were presented on human patient simulators in a laboratory setting, not on real patients.

CONCLUSION

These results indicate encouraging prospects for mHealth technologies in general, and the use of rich media clinical guidelines on cell phones in particular, for the improvement of community health worker performance in developing countries.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence

OBJECTIVES

To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety.

DATA SOURCES

25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance.

STUDY SELECTION

19 high-quality studies that assessed outcomes were included.

DATA EXTRACTION

All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives.

DATA SYNTHESIS

Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance.

CONCLUSIONS

The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives

We have previously reported a preliminary taxonomy of patient error. However, approaches to managing patients' contribution to error have received little attention in the literature. This paper aims to assess how patients and primary care professionals perceive the relative importance of different patient errors as a threat to patient safety. It also attempts to suggest what these groups believe may be done to reduce the errors, and how. It addresses these aims through original research that extends the nominal group analysis used to generate the error taxonomy. Interviews were conducted with 11 purposively selected groups of patients and primary care professionals in Auckland, New Zealand, during late 2007. The total number of participants was 83, including 64 patients. Each group ranked the importance of possible patient errors identified through the nominal group exercise. Approaches to managing the most important errors were then discussed. There was considerable variation among the groups in the importance rankings of the errors. Our general inductive analysis of participants' suggestions revealed the content of four inter-related actions to manage patient error: Grow relationships; Enable patients and professionals to recognise and manage patient error; be Responsive to their shared capacity for change; and Motivate them to act together for patient safety. Cultivation of this GERM of safe care was suggested to benefit from 'individualised community care'. In this approach, primary care professionals individualise, in community spaces, population health messages about patient safety events. This approach may help to reduce patient error and the tension between personal and population health-care.

Evaluation of an error-reduction training program for surgical residents

PURPOSE

To reduce errors in surgery using a resident training program based on a taxonomy that highlights three kinds of errors: judgment, inattention to detail, and problem understanding.

METHOD

The training program module at the University of South Florida incorporated a three-item situational judgment test, video training (which included a lecture and behavior modeling), and role-plays (in which residents participated and received feedback from faculty). Two kinds of outcome data were collected from 33 residents during 2006-2007: (1) behaviors during the training and (2) on-the-job surgical complication records 12 months before and 6 months after training. For the data collected during training, participants were assigned to a condition (19 video condition, 13 control condition); for the data collected on the job, an interrupted time series design was used.

RESULTS

Data from 32 residents were analyzed (one resident's data were excluded). One of the situational judgment items improved significantly over time (d = 0.45); the other two did not (d = 0.36, 0.25). Surgical complications and errors decreased over the course of the study (the correlation between complications and time in months was r = -0.47, for errors and time, r = -0.55). Effects of video behavior modeling on specific errors measured during role-plays were not significant (effect sizes for binary outcomes were phi = -0.05 and phi = 0.01, and for continuous outcomes, d ranged from -0.02 to 0.34).

CONCLUSIONS

The training seemed to reduce errors in surgery, but the training had little effect on the specific kinds of errors targeted during training.