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 Programme 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 organisational, 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 minimise the risks of making avoidable errors.
"It's also important to recognise 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 programme 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."
Notes for editors:
* Incidence nature and causes of avoidable significant harm in primary care in England - retrospective case note review - http://dx.doi.org/10.1136/bmjqs-2020-011405 - live at 00:01 on 11 November 2020
** All participating general practices rated as good or outstanding by CQC.
***1 April 2015 and 31 March 2016
**** Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review
Greater Manchester Patient Safety and Translational Research Centre
Mary Vingoe - Communications Manager
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About the NIHR Greater Manchester Patient Safety Translational Research Centre: The NIHR Greater Manchester Patient Safety Translational Research Centre is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust in collaboration with The University of Nottingham, which aims to make healthcare safer in primary care and transitions of care. It's funded by the National Institute for Health Research (NIHR) for five years from 2017 until 2022 and is one of three PSTRC in England. The Greater Manchester PSTRC conducts research across four themes: Safety Informatics, Medication Safety, Safer Care Systems and Transitions, and Safety in Marginalised Groups.
For more information visit - http://www.patientsafety.manchester.ac.uk/
About the University of Manchester: The University of Manchester, a member of the prestigious Russell Group, is the UK's largest single-site university with 38,600 students. It has 20 academic schools and hundreds of specialist research groups undertaking pioneering, multi-disciplinary teaching and research of worldwide significance. The University is one of the country's major research institutions, rated fifth in the UK in terms of 'research power' (REF 2014), and has had no fewer than 25 Nobel laureates either work or study there. The University had an annual income of £1 billion in 2014/15. Visit http://www.manchester.ac.uk
About The National Institute for Health Research (NIHR): The NIHR is the nation's largest funder of health and care research. The NIHR:
- Funds, supports and delivers high quality research that benefits the NHS, public health and social care
- Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
- Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
- Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
- Partners with other public funders, charities and industry to maximise the value of research to patients and the economy
The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR supports applied health research for the direct and primary benefit of people in low- and middle-income countries, using UK aid from the UK government.
This work uses data provided by patients and collected by the NHS as part of their care and support and would not have been possible without access to this data. The NIHR recognises and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care. http://www.nihr.ac.uk/patientdata
About the University of Nottingham: The University of Nottingham is a research-intensive university with a proud heritage, consistently ranked among the world's top 100. Studying at the University of Nottingham is a life-changing experience and we pride ourselves on unlocking the potential of our students. We have a pioneering spirit, expressed in the vision of our founder Sir Jesse Boot, which has seen us lead the way in establishing campuses in China and Malaysia - part of a globally connected network of education, research and industrial engagement. The University's state-of-the-art facilities and inclusive and disability sport provision is reflected in its status as The Times and Sunday Times Good University Guide 2021 Sports University of the Year. We are ranked eighth for research power in the UK according to REF 2014. We have six beacons of research excellence helping to transform lives and change the world; we are also a major employer and industry partner - locally and globally. Alongside Nottingham Trent University, we lead the Universities for Nottingham initiative, a pioneering collaboration which brings together the combined strength and civic missions of Nottingham's two world-class universities and is working with local communities and partners to aid recovery and renewal following the COVID-19 pandemic.
About Cardiff University: Cardiff University is recognised in independent government assessments as one of Britain's leading teaching and research universities and is a member of the Russell Group of the UK's most research intensive universities. The 2014 Research Excellence Framework ranked the University 5th in the UK for research excellence. Among its academic staff are two Nobel Laureates, including the winner of the 2007 Nobel Prize for Medicine, Professor Sir Martin Evans. Founded by Royal Charter in 1883, today the University combines impressive modern facilities and a dynamic approach to teaching and research. The University's breadth of expertise encompasses: the College of Arts, Humanities and Social Sciences; the College of Biomedical and Life Sciences; and the College of Physical Sciences and Engineering, along with a longstanding commitment to lifelong learning. Cardiff's flagship Research Institutes are offering radical new approaches to pressing global problems. More at http://www.cardiff.ac.uk
BMJ Quality & Safety