NIHR Signal How often do patient safety incidents occur in primary care worldwide?

Published on 23 March 2016

A review of research from around the world suggests that patient safety incidents in primary care are relatively frequent but most do not result in significant harm to patients. While patient safety in hospitals has been well researched, less is known in primary care.

The World Health Organization funded this review. It found that diagnostic and prescribing incidents were most commonly associated with harm to patients. Given the breadth of the review, differences in health systems, variety of study types and incomplete information, it is not possible to identify completely accurate rates of incidents and harm. Estimates based on this review are that around 2 or 3 patients in every hundred have a safety incident, of which around 4% experience severe harm. Most evidence came from reviewing patient notes and medication records, but safety incident reports were also reviewed. One limitation of this is that we know that staff do not report every incident. Also, this review excluded incidents due to inaction, such as not receiving necessary treatment. This well conducted review provides the best evidence so far.

In the UK at present, 2015 NICE recommendations on safer prescribing include encouraging health practitioners and patients to report incidents and associated harms, for example using the National Reporting and Learning System. A large NIHR project in progress in England and Wales will cast more light on what can be done to improve patient safety.

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Why was this study needed?

Primary care is generally the first point of contact people have with the health system, such as in general practices. Each day over a million NHS patients are treated by general practitioners in the UK and 90% of doctor-patient interactions take place in primary care. Despite this, very little is known about the possible risk to patients and the impact of those risks on patient health, compared with efforts to understand the number of occurrences, causes and consequences of patient safety in hospitals. The authors suggest that this may be in part because primary care medical records may not be easily accessible.

In order to look at preventing patient safety errors in primary care, it is important to know how often patient safety incidents occur, what type of incidents these are and what impact they have on patients in terms of severity.

What did this study do?

This systematic review included nine reviews and 100 observational studies on patient safety in primary care, which were assessed for quality. Included studies contained data about numbers or types of safety incidents or the severity or harm associated with safety incidents. Most of the studies measured safety incidents by reviewing records or prescriptions, with some using incident reporting systems, surveys or interviews.

Variation between the studies was too high to pool the results in meta-analyses, and most studies were scored moderate for quality. Seven studies were high quality with a low risk of bias. Thirty-six per cent of studies were from the USA or Canada, and only 20% from the UK, so study findings came from different health systems and might not apply to the UK.

What did it find?

  • Fifty-nine studies estimated the occurrence of patient safety incidents:
    • Twelve studies looking at ‘any type of patient safety incident’ reported between less than one and 24 incidents per 100 patient consultations.
    • These studies looked at patient records or prescribing data and found a median of around two to three incidents per 100 consultations/patient records reviewed.
  • The three most common types of safety incidents were administrative and communication incidents, diagnostic incidents and prescribing and medication management incidents. Ranges in estimates varied widely across the studies, due to different definitions, measurement approaches and quality of the studies, so it is not possible to estimate the precise frequency of these types of safety incidents.
  • Estimates of harm from safety incidents also varied widely across the studies. Seven studies that reviewed records estimated a median of 4% of incidents as being associated with severe harm (range less than 1% to 44% [see Definitions]).
  • Diagnostic and medication-related (prescribing) incidents were most commonly associated with harm to patients, with between 8% and 11% of medication incidents reported to result in harm of any severity.

What does current guidance say on this issue?

NICE provides recommendations about the safe and effective use of medicines in its 2015 guidance on medicines optimisation (NG5). This includes ensuring use of local and national reporting systems such as the National Reporting and Learning System, reporting all incidents consistently and in a timely manner, using tools such as patient safety alerts and considering assessing the training and education provided to health practitioners to identify and report medicines related patient safety incidents. The guidance also recommends considering a screening tool (e.g. the STOPP/START tool in older people) to identify potential medicines-related patient safety in particularly at risk groups.

What are the implications?

The global breadth of this WHO-funded review and the research challenges involved may mean that its main value is in raising awareness of patient safety in primary care, rather than providing accurate incident figures or making specific recommendations for UK practice. An ongoing NIHR study due for publication is looking at patient safety reported by healthcare staff in primary care across England and Wales to identify priority areas to minimise risk for future patients. The NIHR also funds the Greater Manchester Primary Care Patient Safety Translational Research Centre that promotes and generates patient safety evidence in primary care.

This review found that diagnostic and prescribing incidents were most commonly associated with harm to patients, which suggests that attention should focus on preventing these types of incidents. 2015 NICE guidance on medicines optimisation lists recommendations relating to prescribing, including encouraging health practitioners and patients to report all safety incidents (for example, in the National Reporting and Learning System).

Citation and Funding

Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2015. [Epub ahead of print].

This study was funded by the World Health Organization.

Why was this study needed?

Primary care is generally the first point of contact people have with the health system, such as in general practices. Each day over a million NHS patients are treated by general practitioners in the UK and 90% of doctor-patient interactions take place in primary care. Despite this, very little is known about the possible risk to patients and the impact of those risks on patient health, compared with efforts to understand the number of occurrences, causes and consequences of patient safety in hospitals. The authors suggest that this may be in part because primary care medical records may not be easily accessible.

In order to look at preventing patient safety errors in primary care, it is important to know how often patient safety incidents occur, what type of incidents these are and what impact they have on patients in terms of severity.

What did this study do?

This systematic review included nine reviews and 100 observational studies on patient safety in primary care, which were assessed for quality. Included studies contained data about numbers or types of safety incidents or the severity or harm associated with safety incidents. Most of the studies measured safety incidents by reviewing records or prescriptions, with some using incident reporting systems, surveys or interviews.

Variation between the studies was too high to pool the results in meta-analyses, and most studies were scored moderate for quality. Seven studies were high quality with a low risk of bias. Thirty-six per cent of studies were from the USA or Canada, and only 20% from the UK, so study findings came from different health systems and might not apply to the UK.

What did it find?

  • Fifty-nine studies estimated the occurrence of patient safety incidents:
    • Twelve studies looking at ‘any type of patient safety incident’ reported between less than one and 24 incidents per 100 patient consultations.
    • These studies looked at patient records or prescribing data and found a median of around two to three incidents per 100 consultations/patient records reviewed.
  • The three most common types of safety incidents were administrative and communication incidents, diagnostic incidents and prescribing and medication management incidents. Ranges in estimates varied widely across the studies, due to different definitions, measurement approaches and quality of the studies, so it is not possible to estimate the precise frequency of these types of safety incidents.
  • Estimates of harm from safety incidents also varied widely across the studies. Seven studies that reviewed records estimated a median of 4% of incidents as being associated with severe harm (range less than 1% to 44% [see Definitions]).
  • Diagnostic and medication-related (prescribing) incidents were most commonly associated with harm to patients, with between 8% and 11% of medication incidents reported to result in harm of any severity.

What does current guidance say on this issue?

NICE provides recommendations about the safe and effective use of medicines in its 2015 guidance on medicines optimisation (NG5). This includes ensuring use of local and national reporting systems such as the National Reporting and Learning System, reporting all incidents consistently and in a timely manner, using tools such as patient safety alerts and considering assessing the training and education provided to health practitioners to identify and report medicines related patient safety incidents. The guidance also recommends considering a screening tool (e.g. the STOPP/START tool in older people) to identify potential medicines-related patient safety in particularly at risk groups.

What are the implications?

The global breadth of this WHO-funded review and the research challenges involved may mean that its main value is in raising awareness of patient safety in primary care, rather than providing accurate incident figures or making specific recommendations for UK practice. An ongoing NIHR study due for publication is looking at patient safety reported by healthcare staff in primary care across England and Wales to identify priority areas to minimise risk for future patients. The NIHR also funds the Greater Manchester Primary Care Patient Safety Translational Research Centre that promotes and generates patient safety evidence in primary care.

This review found that diagnostic and prescribing incidents were most commonly associated with harm to patients, which suggests that attention should focus on preventing these types of incidents. 2015 NICE guidance on medicines optimisation lists recommendations relating to prescribing, including encouraging health practitioners and patients to report all safety incidents (for example, in the National Reporting and Learning System).

Citation and Funding

Panesar SS, deSilva D, Carson-Stevens A, et al. How safe is primary care? A systematic review. BMJ Qual Saf. 2015. [Epub ahead of print].

This study was funded by the World Health Organization.

How safe is primary care? A systematic review

Published on 31 December 2015

Panesar, S. S.,deSilva, D.,Carson-Stevens, A.,Cresswell, K. M.,Salvilla, S. A.,Slight, S. P.,Javad, S.,Netuveli, G.,Larizgoitia, I.,Donaldson, L. J.,Bates, D. W.,Sheikh, A.

BMJ Qual Saf , 2015

IMPORTANCE: Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care. OBJECTIVE: We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm. EVIDENCE REVIEW: We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised. FINDINGS: Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2-3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm. CONCLUSIONS AND RELEVANCE: Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm. SYSTEMATIC REVIEW REGISTRATION: This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

In this review, primary care was defined as ‘first port of call’ generalist care, delivered outside hospital inpatient settings including the specialities of family practice, general practice, general internal medicine, general paediatrics, obstetricians and gynaecologists.

Harm was defined as impairing the structure or function of the body or mind including pain, nausea, psychological distress, disability or death.

No harm was defined as any patient safety incident that had the potential to cause harm but was prevented, resulting in no harm or that ran to completion but no harm occurred.

Low harm was defined as requiring extra observation or minor treatment and caused minimal harm.

Moderate harm was defined as resulting in a moderate increase in treatment and caused significant but not permanent harm (e.g. hospitalisation).

Severe harm was defined as resulting in permanent harm such as disability, death, or long-lasting physical or mental consequences.

Expert commentary

This is an important study that updates literature reviews carried out over 10 years ago. Primary care is considered the poor relative in terms of patient safety research probably because the incidents occur in a low-tech environment and most incidents do not cause harm. However because the use of primary care underpins many health systems, even a low percentage of incidents may be relevant. In the context of 340 million GP consultations per annum in the UK, a 2% incident rate translates into over 6 million consultations where something should not have happened and over 250,000 consultations where some harm actually took place. What is reassuring from a research perspective is that these estimates of incidents and harm are now fairly robust so the challenge for researchers and policymakers is to develop interventions which can address this problem.

Aneez Esmail, Professor of General Practice, Centre for Primary Care, Institute of Population Health, The University of Manchester