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

• Published in: Health services and delivery research 2016-09, Vol.4 (27), p.1-76
• Main Authors: Carson-Stevens, Andrew, Hibbert, Peter, Williams, Huw, Evans, Huw Prosser, Cooper, Alison, Rees, Philippa, Deakin, Anita, Shiels, Emma, Gibson, Russell, Butlin, Amy, Carter, Ben, Luff, Donna, Parry, Gareth, Makeham, Meredith, McEnhill, Paul, Ward, Hope Olivia, Samuriwo, Raymond, Avery, Anthony, Chuter, Antony, Donaldson, Liam, Mayor, Sharon, Panesar, Sukhmeet, Sheikh, Aziz, Wood, Fiona, Edwards, Adrian
• Format: Article
• Language: English
• Subjects: clinical governance; general practice; mixed-methods study; patient safety; primary care; quality improvement
• ISSN: 2050-4349; 2050-4357
• DOI: 10.3310/hsdr04270

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 mismanage