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Background and objectives: Approaches to translating medical error information into effective interventions have not been well described. The Applied Strategies for Improving Patient Safety (ASIPS) Collaborative developed a mixed-methods approach to analyze medical errors to (1) develop an initial conceptual framework for depicting specific clinica...
Citations
... Incidents in our study occurred during all stages of the medication use process with the majority originating at the prescribing stage, outside the control of the participant. Prescribing and prescription errors have been identified as the commonest stage of MIs in primary care irrespective of the investigative method used,47,58,[65][66][67][68] and are the most likely to result in patient harm of all error types reported in general practice.15,58,69 The prevalence of prescribing and prescription errors have been identified to occur in up to 11% of all prescriptions,70,71 and up to 77% with handwritten prescriptions.72 ...
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.
... A total of 10 studies were included in the final analysis; a summary of these can be found in table 2. The results from the critical appraisal of included studies are found in online supplemental appendix 2. Seven studies considered prescription errors and error reporting within general practice [27][28][29][30][31][32][33] and three within a community pharmacy setting. [34][35][36] Four studies took place in the USA and six studies in the UK, with a total of 206 general practices and 121 community pharmacies included across all studies. ...
... 28 29 Reporting contemporaneously was found in one study to aid memory recall. 31 Kennedy et al 30 considered error reporting by other general practice staff members including nurses and administrators and concluded that this can increase reporting rates and take some of the pressure from GPs. Participants found the intervention acceptable, with 90.5% agreeing that it would improve patient care and 90.6% stating the reporting process was not a burden to them. However, the authors also found that no one continued to report incidents after the study had ended. ...
rescribing errors can cause avoidable harm to patients. Most prescriptions originate in primary care, where medications tend to be self-administered and errors have the most potential to cause harm. Reporting prescribing errors can identify trends and reduce the risk of the reoccurrence of incidents; however, under-reporting is common. The organisation of care and the movement of prescriptions from general practice to community pharmacy may create difficulties for professionals to effectively report errors.
This review aims specifically to identify primary research studies that examine barriers and facilitators to prescription error reporting across primary care. A systematic research of the literature was completed in July 2019. Four databases (PubMed/Medline, Cochrane, CINAHL and Web of Science) were searched for relevant studies. No date or language limits were applied. Eligible studies were critically appraised using the Mixed Methods Appraisal Tool, and data were descriptively and narratively synthesised.
Ten articles were included in the final analysis. Seven studies considered prescription errors and error reporting within general practice and three within a community pharmacy setting. Findings from the included studies are presented across five themes, including definition of an error, prescribing error reporting culture, reporting processes, communication and capacity.
Healthcare professionals appreciate the value of prescription error reporting, but there are key barriers to implementation, including time, fear of reprisal and organisation separation within primary care.
... The analysis of safety incident reports has largely been organised and managed by safety classification systems. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] Several patient safety classifications were reviewed and considered for inclusion, 4 32-35 including those developed for general practice. 34 36-40 These classification systems provided considerable guidance for shaping the scope of the system needed. ...
Background
older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting.
Objectives
to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care.
Design and Setting
a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013.
Subjects
1,591 primary care patient safety incident reports regarding patients aged 65 years and older.
Methods
we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care.
Results
the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm).
Conclusion
priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.
... The analysis of safety incident reports has largely been organised and managed using safety classification systems called taxonomies. [46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Several patient safety classifications were reviewed and considered for inclusion, 20,63-66 including those developed for general practice. 7,65,67-70 These classification systems provided considerable guidance for shaping the scope of the system needed; however, we did not judge that they would support detailed coding of patient safety incidents from 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.
... The analysis of safety incident reports has largely been organised and managed by safety classification systems. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31] Several patient safety classifications were reviewed and considered for inclusion, 4 32-35 including those developed for general practice. 34 36-40 These classification systems provided considerable guidance for shaping the scope of the system needed. ...
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.
... For the direct observation of maintenance activities in the practice, the research team identified and mapped each process identified through the initial key informant interviews. 12 Process flow mapping has long been established as a useful method for making the implicit steps of complex activities both visible and clear. This technique has been used extensively for analyzing recurring decisions and processes involving multiple people and complex situations, and it is recognized as a critical component of event flow and sequencing analysis. ...
Information about the costs and experiences of collecting and reporting quality measure data are vital for practices deciding whether to adopt new quality improvement initiatives or monitor existing initiatives.
Six primary care practices from Colorado's Improving Performance in Practice program participated. We conducted structured key informant interviews with Improving Performance in Practice coaches and practice managers, clinicians, and staff and directly observed practices.
Practices had 3 to 7 clinicians and 75 to 300 patients with diabetes, half had electronic health records, and half were members of an independent practice association. The estimated per-practice cost of implementation for the data collection and reporting for the diabetes quality improvement program was approximately $15,552 per practice (about $6.23 per diabetic patient per month). The first-year maintenance cost for this effort was approximately $9,553 per practice ($3.83 per diabetic patient per month).
The cost of implementing and maintaining a diabetes quality improvement effort that incorporates formal data collection, data management, and reporting is significant and quantifiable. Policymakers must become aware of the financial and cultural impact on primary care practices when considering value-based purchasing initiatives.
... At this same time, we reviewed published recommendations from organizations such as the National Patient Safety Foundation (NPSF) [27], the Agency for Healthcare Quality and Safety (AHRQ) [8], the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) [9] and others [10,28,29]. In addition, to ensure that the recommendations to patients were applicable to important medical problems, we also reviewed the medical literature describing common errors and problems in primary care [26,303132. Combining these sources, we collated an initial list of safety recommendations applicable to ambulatory care. ...
To develop a survey to measure seniors' embracement of ambulatory patient safety self-advocacy behaviors, the Senior Empowerment and Advocacy in Patient Safety (SEAPS) survey.
Content was developed by review of published recommendations combined with interviews and focus groups with community members; items were generated for subscales based on the health belief model (HBM). Psychometric characteristics were assessed by cluster and correlation analyses on a pilot test of 143 community dwelling seniors; the ability of the subscales and demographic variables to predict reported behavior was investigated by multiple regression.
The four subscales of the SEAPS were outcome efficacy (OE), attitudes (ATT), self-efficacy (SE) and behaviors (BEH). Cronbach alphas were 0.74 for ATT, 0.79 for BEH, and 0.91 for OE and SE. Analysis of variance showed that there were no differences in any subscale score by race, education level or frequency of doctor visits, but women were noted to have significantly higher scores (p<.01) on the ATT and SE subscales and for the total of all the scales. Multiple regressions showed that SE significantly predicted self-reported behavior (p<.001). OE was a significant predictor for whites (p<.001) but not for African-Americans (p=.24).
We have developed a short, 21-item self-administered survey to assess seniors' views about their participation in safety tasks.
We believe the SEAPS shows promise to be a tool for evaluating interventions and training programs aimed at improving seniors' self-advocacy skills. Effective interventions may improve the involvement of patients in their own safety in the clinical setting.
Background: The testing process in primary care is complex, and it varies from one office to another. We sought to understand how family medicine offices create safety in this process. Methods: Using observations, interviews, and surveys, we collected data at four family medicine offices. We searched the interview and observation notes for stories of safety, error prevention, and recovery and coded them to a model of resilient engineering properties, work system components, and testing process steps. Results: We found only six examples of practices that were systematically creating safety in the testing process via organizational resilience. The most common resilience properties were top-level commitment and a learning culture applied to work system components of people and their tasks. Offices predominantly depended on individuals to double-check, remember, and work around ongoing problems. Conclusions: While family medicine offices overwhelming depend on individuals to work around testing process problems, important properties of office-wide safety practices included a top-level commitment and a learning culture.
Objective: The Applied Strategies for Improving Patient Safety (ASIPS) collaborative developed an ambulatory primary care patient safety reporting system through an Agency for Healthcare Research and Quality (AHRQ)-funded demonstration grant. Such systems can potentially inform the development of interventions to improve patient safety, but only if the data contained in incident reports can be transformed into usable information. This paper presents our mixed methods approach to analyzing such data. Methods: We describe our approach in terms of its rationale, techniques, prioritization of quantitative and qualitative methods, implementation, and integration of mixed methods. We also describe the nature of the data reported to ASIPS. Results: We illustrate our approach using an analysis of diagnostic testing errors. We describe why this error type is significant, how we selected reports for analysis, the results of both our quantitative and qualitative analyses, and what we learned from them. Based on our experience, we present a protocol for applying a mixed methods approach to the study of patient safety reporting data to inform the development of interventions. Conclusions: Using mixed methods to study patient safety is an effective and efficient approach to data analysis that provides both information and motivation for developing and implementing patient safety improvements.
We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management.
Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes.
We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness-a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption-the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements).
Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.
