InnovAiT, Vol. 4, No. 8, pp.

472477, 2011

doi:10.1093/innovait/inr017 Advance access publication 25 March 2011

Patient safety
irst do no harm is a central premise of medicine believed to originate from Hippocrates and is the opening statement in many articles relating to patient safety. It focuses the great challenge for current and future 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 from across the world, which demonstrates the level of harm that patients experience during their journeys through health care systems. Between 10 and 20% of all health care encounters result in harm to patients. A worldwide movement has emerged in response to these figures, which aims to improve safety and includes all involved in health care across primary and secondary care.
The GP curriculum and patient safety This article includes information relevant to the GP curriculum statement 3.2: Patient safety, reinforcing and adding to the original patient safety article written for InnovAiT by Baker (2008). The Foundation Curriculum 200709 included a specific section (1.3) on patient safety in its syllabus and competencies. In the 2010 Foundation Curriculum, patient safety is integrated throughout the syllabus and competencies. In the GP curriculum, patient safety is included as a specific curriculum statement, which identifies the learning outcomes related to patient safety in general practice. These are wide ranging, from competencies relating to individual practice to tools and techniquesthat are used at organizational level. Patient safety is a complex field with many areas included in the curriculum outcomes. The outcomes take a comprehensive overview of patient safety in general practice. This article gives an overview of the components of the curriculum.
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Structural factors that contribute to unsafe care Processes that contribute to unsafe care

Much of the research into patient safety arises from secondary care. Some of this is applicable to primary care and the evidence discussed in this article is presented in relation to the curriculum outcomes and identifies evidence originating from primary care and how evidence from secondary care might be applicable to general practice. This article will initially examine how patient safety is defined and measured and then it will examine patient safety from three perspectives: the patient, the professional and the system.

Defining patient safety

There are clear definitions used in patient safety and they are summarized in Box 1.

Box 1. Definitions This greater scrutiny of harm to patients has led to the emergence of the specialist field of patient safety. Much information has come from high-risk industries such as aviation and oil and expertize has now developed within health care. There is a great variety of research into the different aspects of patient safety. A 2008 publication from the World Alliance for Patient Safety outlined the variety of research already completed and areas for future development. It identified three main categories: O Outcomes of unsafe medical care Patient safetyfreedom from accidental harm to individuals receiving health care Patient safety incident (PSI)an episode when something goes wrong in health care resulting in potential or actual harm to patients Patient safety solutionany system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care Organizational resiliencethe positive side of safety, defined as the systems intrinsic resistance to its organizational risks

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Measuring patient safety

When considering patient safety, it is helpful to identify what should be measured and how it can be measured. The main focus is on how many patients have been harmed and in what way, but there are other measures that can be used which give valuable information. There are two ways that are generally used to identify rates of harm to patients. These are through incident reporting and by case note review.

developed under academic review but the evidence for the validation of the tool has not yet been published.

Safety culture
There is a general consensus that the culture of anorganization will influence its approach to patient safety and its response to PSIs. Assessment tools have been developed to test the patient safety culture within an organization and can help practice development. The Manchester framework includes leadership, teamwork, accountability, understanding, communication, awareness of workload pressures and safety systems.

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Incident reporting
Incident reporting is a system where when an error is identified, it is reported either centrally across organizations or within an individual organization. The National Patient Safety Agency (NPSA) set up the National Reporting and Learning Service (NRLS). Rates of harm can then be calculated and types of PSI identified and categorized. If a specific problem is identified via this system, alerts can be issued which may be of relevance to primary care. These alerts include Rapid Response Reports, Patient Safety Alerts, and Safer Practice Notices. In the past, identification of incidents could be variable between practitioners and different organizations and traditionally incident reporting resulted in lower rates of incidents being reported. This was due to a number of factors, including poor recognition of incidents, fear of consequences and the nature of the process itself. From April 2010, the reporting of 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 Safety study (TAPS) developed and tested a three level taxonomy to describe patient safety events in primary care. This describes in increasing detail the types of event starting with distinguishing between processes and practitioners knowledge and skills.

Other measures related to safety

There are other measures of safety, which can be used in primary care. These can include testing practitioners knowledge, measuring patient outcomes and looking at other indicators of safety. Individual practitioners knowledge is important and patient safety is now included in Tomorrows Doctors 2009 and in postgraduate curricula. These result in patient safety forming part of summative assessments. In this way, knowledge about patient safety can be measured. For professionals in practice, patient safety can be measured within an individuals practice or within an overall practice setting. This can be done by assessing specific patient outcomes related to patient safety via audit and by implementing improvement cycles to address safety issues identified. This is consistent with the Quality Outcomes and Quality Improvement frameworks. The Frameworks use Plan Do Study Act (PDSA) cycles to improve patient outcomes. Patient satisfaction surveys, multisource feedback, analysis of surgeries and consultation skills can help to identify areas where patients may be at risk. Information from significant event analysis or audit (SEA) can be used for individual, team and organizational learning; in the same way, root cause analysis can enable organizations to learn from PSIs. Process mapping can also identify patient safety aspects within care pathways.

Patient safety: evidence from patients

In 2006, Sir Liam Donaldson wrote in the foreword to Safety first: Let us not forget that the most important lens for viewing the cost of our lack of progress is the impact on patients and their families. They are the ones who are harmed and sometimes die as a result of unsafe care. They are the stark reality of patient safety and the human face behind 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 from recurring. We also need to understand how to respond to error when it occurs. Patient stories, which are narratives from patients who have experienced harm, have been shown to be very powerful in helping organizations and individual practitioners understand that their response can have a huge impact on the individual and the system.

Case note review

The evidence discussed above about rates of harm ranging from 10 to 20% has arisen using a different type of methodology, that of case note review. In this approach, triggers associated with harm are identified and then samples of notes are reviewed and rates of harm are then calculated. This approach generally results in higher rates being identified than via reporting systems and is a more consistent way of identifying harm. A tool called the Global Trigger Tool has been developed in the acute sector, which uses a series of triggers in patients notes to identify if they have experienced iatrogenic harm. The National Institute for Innovation and Improvement in England has developed a Primary Care Trigger Tool, which has identified a series of primary care triggers. The tool was

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A third area that is being researched is that of patient error. Much focus is on practitioner and systems error but patients are at the centre of all that we do and understanding this dynamic is essential in primary care. Buetow et al. (2010) has suggested a process of reducing patient error from qualitative data, which is shown in Box 2.

is clinical governance. Clinical governance is described by Scally and Donaldson (1998) as A framework through which National Health Service (NHS) organizations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.

Box 2. Process of reducing patient error, Buetow et al. (2010) G row relationships E nable patients and professionals to recognize and manage patient error be Responsive to their shared capacity for change M otivate them to act together for patient safety The National Patient Safety Agency (NPSA) runs the please ask campaign which encourages patients to actively participate in making the care they receive safer. The role of communication in PSIs is highlighted repeatedly. Medical malpractice insurers outside the UK often request training in communication skills before being insuring practitioners. In the UK, these insurers support training in communication skills. The Mayo Clinic has developed a conceptual framework of how patients and health care workers interact to reduce risk. Communication and feedback are central to moderating the risks related to health care worker or patient-related factors.

Error
Error is central to patient safety. The field of error has emerged from different disciplines from both inside and outside of health care. Psychologists from behavioural sciences and high-risk industries have been involved in shaping current understanding. Reason (2000) has described the Swiss cheese model of error in systems. In this section, errors in individual practice are explored. A framework outlining the complexity of behaviour within individual practice has been described by Reason. It describes skill-based, rule-based and cognitive behaviours. Errors can occur in each of these behaviours. One of 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 occur from these processes. He identifies two ways of thinking: using intuitive rules of thumb also called heuristics and metacognition, which is an analytical process different to heuristics. The process of metacognition, incorporating analytical thinking, is described as reducing the risk of cognitive errors. Over 30 cognitive errors are described which can occur in decision making. Understanding these and how cognitive forcing strategies can reduce the risk of error are vital for practitioners who make rapid decisions in settings, such as general practice.
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Patient safety: evidence about professionals

There is a large body of evidence emerging about professional behaviour, error and risk. This section of the paper will focus on evidence in this area relevant to the curriculum. The subheadings follow a cycle in terms of understanding risk and error, how being open can affect patients after errors have occurred, followed by learning from incidents via SEA. This section represents the reflective cycle of patient safety shown in the curriculum and in the seven steps to patient safety (NPSA, 2009b).

Being open approach

Being open about safety incidents and adverse events has been shown to be beneficial both for patients and their carers and for professionals. Patients are more likely to forgive doctors who are open about errors and the patients themselves are likely to feel less trauma if health professionals 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.

Understanding clinical risk

Clinical risk is an avoidable increase in the probability of harm occurring to a patient. The rates of adverse events described above are predominately linked to error. Error will be discussed later but errors tend to occur when usual defence mechanisms, designed to prevent adverse events, fail. If the risks are understood, then these defence mechanisms can be made more robust to withstand different types of situation, which could result in an adverse event. Doctors are not alone in trying to reduce clinical risk. Risk management is the role of 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

Significant event audit

Finally, 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 both primary and secondary care.

Patient safety: evidence about systems

Much research has focused on systems. Frequently errors and adverse events occur as a result of system failures rather than due to individuals. Reason (2008) originally described the Swiss cheese model and subsequently explored it further

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to illustrate the potential harm that can occur from a series of failures within a system. Therefore, reporting and learning from PSIs allows both individuals and systems to learn and prevent further occurrences of error. All the tools that measure harm and identify how harm occurs such as SEA can allow practices to learn about patient safety within the practice system. The interface between primary and secondary care is an important aspect of systems, which is important to understand in general practice. Harm can often occur to patients within systems or at points of transfer between systems. Therefore, any activity that helps team members to understand the system they work and look after patients in, alongside the potential risks in these systems, can promote patient safety. guideline 47 for feverish illness in children has a risk matrix within it which works in the same way. In primary care, there are a range of risk matrices, which are used to asses risk for patients but also at organizational level and individual level. At individual level, risk assessments can be completed via keeping a log of a surgery and identifying possible PSIs and how these could be avoided in future.

What can you do?

The National Patient Safety Agencys National Reporting and Learning Services seven steps to patient safety in general practice encompass the curriculum outcomes within each of the steps. The seven steps to patient safety are shown in Box 3. Box 3. Seven steps to patient safety in general practice (NPSA, NRLS, 2009) Seven steps to patient safety in general practice 1. Build a safety culture 2. 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 safety lessons 7. Implement solutions to prevent harm

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Other research relevant to curriculum outcomes

There are several areas of research that are relevant to the curriculum outcomes. These include transitions of care, teamwork and error and evidence about risk matrices.

Transitions of care
One example of the role of communication at transitions of care is that of medicines reconciliation. This refers to the process of ensuring that on admission into or discharge from hospital, patients medications are accurate and validated at the primary/secondary care interface. The intention is to reduce medication error at the points of transfer across the patient journey. Delate et al. (2008) has shown that this process can result in a significant reduction in mortality. This shows the role of the multidisciplinary team in patient safety across a health care system. Handover is a key aspect of transitions of care. This is widely accepted across all health care disciplines. There is a variety of reported work in this area, which reflects practitioners and patients views on communication and handover and describes the processes involved. The negative impact of poor communication during handover is frequently identified in PSIs.

Build a safety culture

This step involves SEA, assessing safety culture and identifying success in patient safety while being open about errors. A safety culture applies the same rigour to all areas, including health and safety, complaints, incident reporting and quality assurance.

Lead and support your practice team

Leadership can take place in any role in general practice. It involves talking about the importance of patient safety and participating in patient safety activities. Incorporating patient safety into team meetings and making it a regular agenda item are important in leading for patient safety. Practices who wish to demonstrate their commitment to patient safety can include an annual patient safety summary in their practice report. Including patient safety training and improvement techniques in training both in-house and outside of the practice will facilitate patient safety development both within the practice and locally.

Teamwork and error

There are studies from secondary care, which demonstrate the potential role of teamwork in patient safety. 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 relationship between improved teamwork following training and reduced error rates.

Integrate your risk management strategy

Using tools like the Global Trigger Tool or completing an alternative case note review on a regular basis will help practices to identify areas of actual or potential harm. Participating in SEA, clinical governance, appraisals and revalidation and making them part of professional practice will promote patient safety. Widening this to other members of the primary health care team will facilitate understanding beyond the practice.

Risk matrices
Risk matrices are used across medicine in both primary and secondary care. In the acute sector, many will have had experience of early warning scores, which are examples of using a risk matrix. These have been shown to improve the recognition of the acutely unwell patient in secondary care and to improve patient outcomes. The NICE (2007) clinical

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Promote reporting
Promoting reporting encourages a change in patient safety culture and can enable learning in your practice and more widely. This could involve cascading the learning from 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 safety.

REFERENCES AND FURTHER INFORMATION

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Involve and communicate with patients and the public

Using all opportunities to involve patients in patient safety is a key element to patient safety. This could be via surveys, website feedback or complaints. Patient involvement in practice meetings where patient safety is discussed demonstrates partnership in patient safety. Patient Advice and Liaison Services (PALS) can provide key support for patients, their families and carers in this.
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Learn and share safety lessons

Through SEA, practices can reflect and learn from their own experiences. Sharing this learning can enable wider understanding of potential risks and solutions to patient safety problems in general practice.

Implement solutions to prevent harm

When patient safety actions are agreed, they should be documented and a target date for implementation agreed alongside identifying a named person to take responsibility for the action. This process can be assessed via audit. The views of patients are essential in this to ensure the decisions agreed are right for all involved. Thinking more widely to consider how technology may facilitate the implementation of patient safety solutions may help reduce future risk.
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Conclusions
The curriculum outcomes set out all the elements required to take a comprehensive approach to patient safety. The outcomes fit the seven steps to patient safety and this is an ideal approach to patient safety in general practice.

Key points
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Patients are at risk in health care Measuring patient safety will help you understand the risks for patients in your practice Communicating with patients and members of the health care team is a vital element in the prevention and management of PSIs Understanding error and risk management are vital Use SEA to learn from PSIs Follow the seven steps to patient safety in general practice

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Dr Lucy Ambrose General Practitioner and Director of Clinical, Communication and Information Management Skills, Keele University E-mail: l.j.ambrose@hfac.keele.ac.uk

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