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The Author 2011. Published by Oxord University Press on behal o the RCGP. All rights reserved.

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InnovAiT, Vol. 4, No. 8, pp. 472477, 2011 doi:10.1093/innovait/inr017

Advance access publication 25 March 2011

Patient saety

First do no harm is a central premise o medicine believed to originate rom

Hippocrates and is the opening statement in many articles relating to

patient saety. It ocuses the great challenge or current and uture

practitioners to minimize risk to our patients. Over the last two decades, it has been

demonstrated that we do harm to our patients on a regular basis. Evidence has

emerged rom across the world, which demonstrates the level o harm that patients

experience during their journeys through health care systems. Between 10 and 20%

o all health care encounters result in harm to patients. A worldwide movement has

emerged in response to these fgures, which aims to improve saety and includes all

involved in health care across primary and secondary care.

This greater scrutiny o harm to patients has led to the

emergence o the specialist eld o patient saety. Much

inormation has come rom high-risk industries such as

aviation and oil and expertize has now developed within

health care.

There is a great variety o research into the dierent aspects

o patient saety. A 2008 publication rom the World Alliance

or Patient Saety outlined the variety o research already

completed and areas or uture development. It identied

three main categories:

O Outcomes o unsae medical care

The GP curriculum and patient saety

This article includes inormation relevant to the GP

curriculum statement 3.2: Patient safety, reinorcing

and adding to the original patient saety article written

or InnovAiTby Baker (2008).

The Foundation Curriculum 200709 included a specic

section (1.3) on patient saety in its syllabus and

competencies. In the 2010 Foundation Curriculum,

patient saety is integrated throughout the syllabus and

competencies.

In the GP curriculum, patient saety is included as a

specic curriculum statement, which identies the

learning outcomes related to patient saety in general

practice. These are wide ranging, rom competencies

relating to individual practice to tools and techniquesthat

are used at organizational level. Patient saety is a

complex eld with many areas included in the curriculum

outcomes. The outcomes take a comprehensive overview

o patient saety in general practice. This article gives an

overview o the components o the curriculum.

O Structural actors that contribute to unsae care

O Processes that contribute to unsae care

Much o the research into patient saety arises rom

secondary care. Some o this is applicable to primary care

and the evidence discussed in this article is presented in

relation to the curriculum outcomes and identies evidence

originating rom primary care and how evidence rom

secondary care might be applicable to general practice.

This article will initially examine how patient saety is dened

and measured and then it will examine patient saety romthree perspectives: the patient, the proessional and the

system.

Defning patient saety

There are clear denitions used in patient saety and they

are summarized in Box 1.

Box 1. Defnitions

Patient saetyreedom rom accidental harm to

individuals receiving health carePatient saety incident (PSI)an episode when

something goes wrong in health care resulting in

potential or actual harm to patients

Patient saety solutionany system design or

intervention that has demonstrated the ability to prevent

or mitigate patient harm stemming rom the processes o

health care

Organizational resiliencethe positive side o saety,

dened as the systems intrinsic resistance to its

organizational risks


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Measuring patient saety

When considering patient saety, it is helpul to identiy

what should be measured and how it can be measured. The

main ocus is on how many patients have been harmed and

in what way, but there are other measures that can be used

which give valuable inormation. There are two ways that

are generally used to identiy rates o harm to patients.

These are through incident reporting and by case note

review.

Incident reportingIncident reporting is a system where when an error is

identied, it is reported either centrally across organizations

or within an individual organization. The National Patient

Saety Agency (NPSA) set up the National Reporting and

Learning Service (NRLS). Rates o harm can then be

calculated and types o PSI identied and categorized.

I a specic problem is identied via this system, alerts can

be issued which may be o relevance to primary care. These

alerts include Rapid Response Reports, Patient Saety Alerts,and Saer Practice Notices.

In the past, identication o incidents could be variable

between practitioners and dierent organizations and

traditionally incident reporting resulted in lower rates o

incidents being reported. This was due to a number o actors,

including poor recognition o incidents, ear o consequences

and the nature o the process itsel.

From April 2010, the reporting o all serious PSIs became

mandatory. This currently is via the NRLS reporting to the

Care Quality Commission. This will change when the NPSA is

abolished but it likely that the processes will be preserved

but taken over by other organizations.

The Threats to Australian Patient Saety study (TAPS)

developed and tested a three level taxonomy to describe

patient saety events in primary care. This describes in

increasing detail the types o event starting with

distinguishing between processes and practitioners

knowledge and skills.

Case note reviewThe evidence discussed above about rates o harm ranging

rom 10 to 20% has arisen using a dierent type o

methodology, that o case note review. In this approach,

triggers associated with harm are identied and then

samples o notes are reviewed and rates o harm are thencalculated. This approach generally results in higher rates

being identied than via reporting systems and is a more

consistent way o identiying harm.

A tool called the Global Trigger Tool has been developed in

the acute sector, which uses a series o triggers in patients

notes to identiy i they have experienced iatrogenic harm.

The National Institute or Innovation and Improvement in

England has developed a Primary Care Trigger Tool, which

has identied a series o primary care triggers. The tool was

developed under academic review but the evidence or the

validation o the tool has not yet been published.

Saety cultureThere is a general consensus that the culture o

anorganization will infuence its approach to patient saety

and its response to PSIs. Assessment tools have been

developed to test the patient saety culture within an

organization and can help practice development. TheManchester ramework includes leadership, teamwork,

accountability, understanding, communication, awareness

o workload pressures and saety systems.

Other measures related to saetyThere are other measures o saety, which can be used in

primary care. These can include testing practitioners

knowledge, measuring patient outcomes and looking at

other indicators o saety. Individual practitioners knowledge

is important and patient saety is now included in Tomorrows

Doctors 2009 and in postgraduate curricula. These result in

patient saety orming part o summative assessments. In

this way, knowledge about patient saety can be measured.

For proessionals in practice, patient saety can be measured

within an individuals practice or within an overall practice

setting. This can be done by assessing specic patient

outcomes related to patient saety via audit and by

implementing improvement cycles to address saety issues

identied. This is consistent with the Quality Outcomes and

Quality Improvement rameworks. The Frameworks use Plan

Do Study Act (PDSA) cycles to improve patient outcomes.

Patient satisaction surveys, multisource eedback, analysis

o surgeries and consultation skills can help to identiy areas

where patients may be at risk. Inormation rom signicant

event analysis or audit (SEA) can be used or individual,

team and organizational learning; in the same way, rootcause analysis can enable organizations to learn rom PSIs.

Process mapping can also identiy patient saety aspects

within care pathways.

Patient saety: evidencerom patients

In 2006, Sir Liam Donaldson wrote in the oreword to Saety

rst: Let us not orget that the most important lens or

viewing the cost o our lack o progress is the impact on

patients and their amilies. They are the ones who are

harmed and sometimes die as a result o unsae care. They

are the stark reality o patient saety and the human acebehind the statistics.

We now have methods to measure harm to patients so that

in turn we can implement changes in order to try and prevent

the harm rom recurring. We also need to understand how to

respond to error when it occurs. Patient stories, which are

narratives rom patients who have experienced harm, have

been shown to be very powerul in helping organizations

and individual practitioners understand that their response

can have a huge impact on the individual and the system.
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A third area that is being researched is that o patient error.

Much ocus is on practitioner and systems error but patients

are at the centre o all that we do and understanding this

dynamic is essential in primary care. Buetow et al. (2010)

has suggested a process o reducing patient error rom

qualitative data, which is shown in Box 2.

Box 2. Process o reducing patient error, Buetowet al. (2010)

G row relationships

E nable patients and proessionals to recognize and

manage patient error

be Responsive to their shared capacity or change

M otivate them to act together or patient saety

The National Patient Saety Agency (NPSA) runs the please

ask campaign which encourages patients to actively

participate in making the care they receive saer. The role o

communication in PSIs is highlighted repeatedly. Medical

malpractice insurers outside the UK oten request training in

communication skills beore being insuring practitioners. In

the UK, these insurers support training in communication

skills. The Mayo Clinic has developed a conceptual ramework

o how patients and health care workers interact to reduce

risk. Communication and eedback are central to moderating

the risks related to health care worker or patient-related

actors.

Patient saety: evidenceabout proessionals

There is a large body o evidence emerging about

proessional behaviour, error and risk. This section o thepaper will ocus on evidence in this area relevant to the

curriculum. The subheadings ollow a cycle in terms o

understanding risk and error, how being open can aect

patients ater errors have occurred, ollowed by learning

rom incidents via SEA. This section represents the refective

cycle o patient saety shown in the curriculum and in the

seven steps to patient saety (NPSA, 2009b).

Understanding clinical riskClinical risk is an avoidable increase in the probability o

harm occurring to a patient.

The rates o adverse events described above are

predominately linked to error. Error will be discussed laterbut errors tend to occur when usual deence mechanisms,

designed to prevent adverse events, ail. I the risks are

understood, then these deence mechanisms can be made

more robust to withstand dierent types o situation, which

could result in an adverse event.

Doctors are not alone in trying to reduce clinical risk. Risk

management is the role o the whole health care team and

organizations now have risk managers who work with health

care teams to reduce risk. The counterbalance to clinical risk

is clinical governance. Clinical governance is described by

Scally and Donaldson (1998) as A ramework through which

National Health Service (NHS) organizations are accountable

or continually improving the quality o their services and

saeguarding high standards o care by creating an

environment in which excellence in clinical care will fourish.

ErrorError is central to patient saety. The eld o error has emergedrom dierent disciplines rom both inside and outside o health

care. Psychologists rom behavioural sciences and high-risk

industries have been involved in shaping current understanding.

Reason (2000) has described the Swiss cheese model o error in

systems. In this section, errors in individual practice are explored.

A ramework outlining the complexity o behaviour within

individual practice has been described by Reason. It describes

skill-based, rule-based and cognitive behaviours. Errors can

occur in each o these behaviours. One o the main authors who

have explored cognitive errors in clinical practice is Croskerry

(2003) who has written extensively on the subject. He has

written about how we reach diagnoses and make decisions

about management in clinical practice and how errors can occurrom these processes. He identies two ways o thinking: using

intuitive rules o thumb also called heuristics and

metacognition, which is an analytical process dierent to

heuristics. The process o metacognition, incorporating

analytical thinking, is described as reducing the risk o cognitive

errors. Over 30 cognitive errors are described which can occur in

decision making. Understanding these and how cognitive

orcing strategies can reduce the risk o error are vital or

practitioners who make rapid decisions in settings, such as

general practice.

Being open approach

Being open about saety incidents and adverse events hasbeen shown to be benecial both or patients and their

carers and or proessionals. Patients are more likely to

orgive doctors who are open about errors and the patients

themselves are likely to eel less trauma i health proessionals

are open with them about what has happened.

The NPSA published an alert in 2009 about Being open in

order to promote open discussion with patients and their carers

about PSIs.

Signicant event auditFinally, SEA allows practitioners to learn as an individual and

within their team and organization about PSIs. This learning

can also be shared across health care organizations in bothprimary and secondary care.

Patient saety: evidenceabout systems

Much research has ocused on systems. Frequently errors

and adverse events occur as a result o system ailures rather

than due to individuals. Reason (2008) originally described

the Swiss cheese model and subsequently explored it urther
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to illustrate the potential harm that can occur rom a series

o ailures within a system. Thereore, reporting and learning

rom PSIs allows both individuals and systems to learn and

prevent urther occurrences o error.

All the tools that measure harm and identiy how harm

occurs such as SEA can allow practices to learn about patient

saety within the practice system. The interace between

primary and secondary care is an important aspect osystems, which is important to understand in general

practice. Harm can oten occur to patients within systems or

at points o transer between systems. Thereore, any activity

that helps team members to understand the system they

work and look ater patients in, alongside the potential risks

in these systems, can promote patient saety.

Other research relevant tocurriculum outcomes

There are several areas o research that are relevant to the

curriculum outcomes. These include transitions o care,

teamwork and error and evidence about risk matrices.

Transitions o careOne example o the role o communication at transitions o

care is that o medicines reconciliation. This reers to the

process o ensuring that on admission into or discharge rom

hospital, patients medications are accurate and validated at

the primary/secondary care interace. The intention is to

reduce medication error at the points o transer across the

patient journey. Delate et al. (2008) has shown that this

process can result in a signicant reduction in mortality. This

shows the role o the multidisciplinary team in patient saety

across a health care system.

Handover is a key aspect o transitions o care. This is widely

accepted across all health care disciplines. There is a variety

o reported work in this area, which refects practitioners

and patients views on communication and handover and

describes the processes involved. The negative impact o

poor communication during handover is requently identied

in PSIs.

Teamwork and errorThere are studies rom secondary care, which demonstrate

the potential role o teamwork in patient saety. They have

shown that team training can result in a reduction in errors.

The studies were based in an emergency department and an

operating department but there appears to be a relationshipbetween improved teamwork ollowing training and reduced

error rates.

Risk matricesRisk matrices are used across medicine in both primary and

secondary care. In the acute sector, many will have had

experience o early warning scores, which are examples o

using a risk matrix. These have been shown to improve the

recognition o the acutely unwell patient in secondary care

and to improve patient outcomes. The NICE (2007) clinical

guideline 47 or everish illness in children has a risk matrix

within it which works in the same way.

In primary care, there are a range o risk matrices, which are

used to asses risk or patients but also at organizational level

and individual level. At individual level, risk assessments can

be completed via keeping a log o a surgery and identiying

possible PSIs and how these could be avoided in uture.

What can you do?

The National Patient Saety Agencys National Reporting

and Learning Services seven steps to patient saety in

general practice encompass the curriculum outcomes within

each o the steps. The seven steps to patient saety are

shown in Box 3.

Box 3. Seven steps to patient saety in general

practice (NPSA, NRLS, 2009)

Seven steps to patient saety in general practice

1. Build a saety culture2. Lead and support your practice team

3. Integrate your risk management strategy

4. Promote reporting

5. Involve and communicate with patients and the

public

6. Learn and share saety lessons

7. Implement solutions to prevent harm

Build a saety cultureThis step involves SEA, assessing saety culture and

identiying success in patient saety while being open about

errors. A saety culture applies the same rigour to all areas,

including health and saety, complaints, incident reportingand quality assurance.

Lead and support your practice teamLeadership can take place in any role in general practice. It

involves talking about the importance o patient saety and

participating in patient saety activities. Incorporating

patient saety into team meetings and making it a regular

agenda item are important in leading or patient saety.

Practices who wish to demonstrate their commitment to

patient saety can include an annual patient saety summary

in their practice report. Including patient saety training and

improvement techniques in training both in-house and

outside o the practice will acilitate patient saety

development both within the practice and locally.

Integrate your risk management strategyUsing tools like the Global Trigger Tool or completing an

alternative case note review on a regular basis will help

practices to identiy areas o actual or potential harm.

Participating in SEA, clinical governance, appraisals and

revalidation and making them part o proessional practice

will promote patient saety. Widening this to other members

o the primary health care team will acilitate understanding

beyond the practice.
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Promote reportingPromoting reporting encourages a change in patient saety

culture and can enable learning in your practice and more

widely. This could involve cascading the learning rom SEA to

your local primary care organizations and reporting to the

National Reporting and Learning Service (NRLS). Recording

events and learning and including them in a practice report

show a commitment to reporting and learning about patient

saety.

Involve and communicate with patients andthe publicUsing all opportunities to involve patients in patient saety

is a key element to patient saety. This could be via surveys,

website eedback or complaints. Patient involvement in

practice meetings where patient saety is discussed

demonstrates partnership in patient saety. Patient Advice

and Liaison Services (PALS) can provide key support or

patients, their amilies and carers in this.

Learn and share saety lessons

Through SEA, practices can refect and learn rom their ownexperiences. Sharing this learning can enable wider

understanding o potential risks and solutions to patient

saety problems in general practice.

Implement solutions to prevent harmWhen patient saety actions are agreed, they should be

documented and a target date or implementation agreed

alongside identiying a named person to take responsibility

or the action. This process can be assessed via audit. The

views o patients are essential in this to ensure the decisions

agreed are right or all involved. Thinking more widely to

consider how technology may acilitate the implementation

o patient saety solutions may help reduce uture risk.

Conclusions

The curriculum outcomes set out all the elements required

to take a comprehensive approach to patient saety. The

outcomes t the seven steps to patient saety and this is an

ideal approach to patient saety in general practice.

Key pointsO Patients are at risk in health careO Measuring patient saety will help you understand

the risks or patients in your practice

O Communicating with patients and members o the

health care team is a vital element in the prevention

and management o PSIs

O Understanding error and risk management are vital

O Use SEA to learn rom PSIs

O Follow the seven steps to patient saety in general

practice

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E-mail: [email protected]
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