National study reveals new insights into avoidable harm in primary care
A national study of general practices in England has revealed the frequency of incidents of significant avoidable harm in primary care, and also important new details. For example, according to the research, the main causes are diagnostic error (more than 60%), medication incidents (more than 25%), and delayed referrals (nearly 11%).
The study included 13 independent GPs undertaking a retrospective review of the case notes of more than 90,000 patients from 12 randomly selected general practices in three regions across England over a 12 month period.
The research was funded by the National Institute for Health Research (NIHR) Policy Research Program and is published in the BMJ Quality and Safety. It was led by Professor Tony Avery from the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (GM PSTRC) which is a partnership between The University of Manchester Salford Royal NHS Foundation Trust in collaboration with The University of Nottingham. Researchers from Cardiff University and University of Edinburgh were also key members of the academic team.
The research is one of the largest and most comprehensive studies of avoidable harm in primary care. An instance of avoidable harm could be a problem with diagnosis, such as a delay or an incorrect diagnosis. Alternatively it could be around medication, such as a prescribing error or monitoring errors. When the results are applied to the English population as a whole, researchers expect that there are between 20,000 and 32,000 cases of significant harm to patients each year that are probably avoidable. It should be noted, however, that the population of England is more than 55 million and there are more than 300 million general practice consultations each year.
Tony Avery Professor of Primary Health Care at the University of Nottingham said, "Avoidable harm has been identified by the World Health Organisation as a priority and an area of patient safety which we believe needs to be better understood before it can be improved. That's why our research is so important when considering how to reduce significant avoidable harm. We can't hope to tackle it unless we can first understand how many incidents are occurring. The COVID-19 pandemic has changed the way primary care operates making our recommendations even more relevant in a world where face to face consultations are not always possible."
The research revealed that in 80% of cases the significant harm could have been identified sooner, or prevented, if the GP had taken actions aligned with evidence-based guidelines. Researchers identified a number of factors that contributed to the harm, which include organizational, clinician and patient factors. Patient factors were most important and included old age, and complexities arising from having multiple health problems, including frailty. While there is little that primary care can do to control these patient factors, they illustrate the challenges healthcare professionals face when trying to protect patients from harm.
Andrew Carson-Stevens, Academic GP, Cardiff University and the Primary and Emergency Care Research Centre, Wales, worked on the research, and said: "Most of these cases of significant harm in general practice could be avoided by improving administrative systems that ensure healthcare professionals can: reliably make a referral to another service or clinician, review and action test results, monitor and recall patients that do not attend for important investigations, and, communicate clearly with other clinicians involved in the care of their patients."
Additional recommendations from researchers also include:
- Improving the continuity of care for patients in primary care, particularly older people and those with multiple long term health conditions, frailty and complex presentations
- Identifying and promoting ways in which IT can be used to address some of these improvements.
Dr. Michael Devlin, Head of Professional Standards and Liaison at the MDU, said: "I am really pleased that, although there is no room for complacency, the evidence presented in this research clearly shows that GPs are doing a good job and avoidable harm incidents are rare. The conclusions are really helpful for GPs and I do hope that the recommendations will be acted on."
Professor Martin Marshall, Chair of the Royal College of GPs, said: "GPs and their teams deliver care to around one million patients every single day, and patients should be reassured by this research that in the vast majority of cases this care is safe and that errors are rare.
"GPs work exceptionally hard, in very difficult circumstances, to ensure the right clinical decisions are made. But of course they are human so occasionally errors can and do happen. It's vital that when they do, they are identified, and lessons learnt from them—ultimately, this will improve the care patients receive. The College is supportive of any resources or innovation that are designed to help minimize the risks of making avoidable errors.
"It's also important to recognize and address the root cause of why, although rare, mistakes do happen in general practice. For example, GPs are working under intense resource and workforce pressures—this was the case before the COVID-19 pandemic, and it continues to be so. We are now conducting more consultations than we were in March, alongside delivering the largest ever flu vaccination program and preparing for a likely busy winter. It is vital that general practice receives the necessary resources and support to ensure patients continue to receive high-quality, safe care."
Professor Tony Avery concluded, "It is crucial we put this research into context and remember that for 97% of patients who present with significant health problems, there is no evidence that primary care played any part in the cause."