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

Carson-Stevens, Andrew; Hibbert, Peter; Williams, Huw; Prosser Evans, Huw; Cooper, Alison; Rees, Philippa; Deakin, Anita; Shiels, Emma; Gibson, Russell; Butlin, Amy; Carter, Ben; Luff, Donna; Parry, Gareth P.; Makeham, Meredith; McEnhill, Paul; Ward, Hope Olivia; Samuriwo, Raymond; Avery, Anthony; Chuter, Anthony; Donaldson, Liam; Mayor, Sharon; Singh Panesar, Sukhmeet; Sheikh, Aziz; Wood, Fiona; Edwards, Adrian

Abstract

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.

Citation

Carson-Stevens, A., Hibbert, P., Williams, H., Prosser Evans, H., Cooper, A., Rees, P., Deakin, A., Shiels, E., Gibson, R., Butlin, A., Carter, B., Luff, D., Parry, G. P., Makeham, M., McEnhill, P., Ward, H. O., Samuriwo, R., Avery, A., Chuter, A., Donaldson, L., …Edwards, A. (2016). 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. Health Services and Delivery Research, 4(27), 1-76. https://doi.org/10.3310/hsdr04270

• Journal Article Type: Article
• Acceptance Date: Mar 1, 2016
• Publication Date: Sep 1, 2016
• Deposit Date: Sep 26, 2016
• Publicly Available Date: Sep 26, 2016
• Journal: Health Services and Delivery Research
• Print ISSN: 2050-4349
• Electronic ISSN: 2050-4357
• Publisher: NIHR Journals Library
• Peer Reviewed: Peer Reviewed
• Volume: 4
• Issue: 27
• Pages: 1-76
• DOI: https://doi.org/10.3310/hsdr04270
• Keywords: Primary Care; Patient safety incident reports; England and Wales National Reporting and Learning System
• Public URL: https://nottingham-repository.worktribe.com/output/802696
• Publisher URL: http://www.journalslibrary.nihr.ac.uk/hsdr/volume-4/issue-27#
• Related Public URLs: https://creativecommons.org/licenses/by/4.0/
• Additional Information: Contractual start date: 12-2013; Editorial review begun: 06-2015; Accepted for publication: 03-2016
• Contract Date: Sep 26, 2016