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Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review

Avery, Anthony J; Sheehan, Christina L; Bell, Brian G; Armstrong, Sarah J; Ashcroft, Darren M; Boyd, Matthew J; Chuter, Antony; Cooper, Alison; Donnelly, Ailsa; Edwards, Adrian; Prosser Evans, Huw; Hellard, Stuart; Lymn, Joanne; Mehta, Rajnikant; Rodgers, Sarah; Sheikh, Aziz; Smith, Pam; Williams, Huw; Campbell, Stephen; Carson-Stevens, Andrew

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review Thumbnail


Christina L Sheehan

Sarah J Armstrong

Darren M Ashcroft

Antony Chuter

Alison Cooper

Ailsa Donnelly

Adrian Edwards

Huw Prosser Evans

Stuart Hellard

Professor of Healthcare Education

Rajnikant Mehta

Sarah Rodgers

Aziz Sheikh

Pam Smith

Stephen Campbell

Andrew Carson-Stevens


Objective To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. Design Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded. Setting Primary care. Participants Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients). Main outcome measures The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents. Results The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines. Conclusion There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.


Avery, A. J., Sheehan, C. L., Bell, B. G., Armstrong, S. J., Ashcroft, D. M., Boyd, M. J., …Carson-Stevens, A. (2021). Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Quality and Safety, 30(12), 961-976.

Journal Article Type Article
Acceptance Date Sep 12, 2020
Online Publication Date Nov 10, 2020
Publication Date 2021-12
Deposit Date Sep 16, 2020
Publicly Available Date Nov 10, 2020
Journal BMJ Quality & Safety
Print ISSN 2044-5415
Electronic ISSN 2044-5423
Publisher BMJ Publishing Group
Peer Reviewed Peer Reviewed
Volume 30
Issue 12
Pages 961-976
Public URL
Publisher URL


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