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Garzón González G, Alonso Safont T, Conejos Míquel D, Castelo Jurado M, Aguado Arroyo O, Jurado Balbuena JJ, Villanueva Sanz C, Zamarrón Fraile E, Luaces Gayán A, Cañada Dorado A, Martínez Patiño D, Magán Tapia P, Barberá Martín A, Toribio Vicente MJ, Drake Canela M, Mediavilla Herrera I. Validation of a Reduced Set of High-Performance Triggers for Identifying Patient Safety Incidents with Harm in Primary Care: TriggerPrim Project. J Patient Saf 2023; 19:508-516. [PMID: 37707868 PMCID: PMC10662617 DOI: 10.1097/pts.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVE The aim of the study was to construct and validate a reduced set of high-performance triggers for identifying adverse events (AEs) via electronic medical records (EMRs) review in primary care (PC). METHODS This was a cross-sectional descriptive study for validating a diagnostic test. The study included all 262 PC centers of Madrid region (Spain). Patients were older than 18 years who attended their PC center over the last quarter of 2018. The randomized sample was n = 1797. Main measurements were as follows: ( a ) presence of each of 19 specific computer-identified triggers in the EMR and ( b ) occurrence of an AE. To collect data, EMR review was conducted by 3 doctor-nurse teams. Triggers with statistically significant odds ratios for identifying AEs were selected for the final set after adjusting for age and sex using logistic regression. RESULTS The sensitivity (SS) and specificity (SP) for the selected triggers were: ≥3 appointments in a week at the PC center (SS = 32.3% [95% confidence interval {CI}, 22.8%-41.8%]; SP = 92.8% [95% CI, 91.6%-94.0%]); hospital admission (SS = 19.4% [95% CI, 11.4%-27.4%]; SP = 97.2% [95% CI, 96.4%-98.0%]); hospital emergency department visit (SS = 31.2% [95% CI, 21.8%-40.6%]; SP = 90.8% [95% CI, 89.4%-92.2%]); major opioids prescription (SS = 2.2% [95% CI, 0.0%-5.2%]; SP = 99.8% [95% CI, 99.6%-100%]); and chronic benzodiazepine treatment in patients 75 years or older (SS = 14.0% [95% CI, 6.9%-21.1%]; SP = 95.5% [95% CI, 94.5%-96.5%]).The following values were obtained in the validation of this trigger set (the occurrence of at least one of these triggers in the EMR): SS = 60.2% (95% CI, 50.2%-70.1%), SP = 80.8% (95% CI, 78.8%-82.6%), positive predictive value = 14.6% (95% CI, 11.0%-18.1%), negative predictive value = 97.4% (95% CI, 96.5%-98.2%), positive likelihood ratio = 3.13 (95% CI, 2.3-4.2), and negative likelihood ratio = 0.49 (95% CI, 0.3-0.7). CONCLUSIONS The set containing the 5 selected triggers almost triples the efficiency of EMR review in detecting AEs. This suggests that this set is easily implementable and of great utility in risk-management practice.
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Affiliation(s)
- Gerardo Garzón González
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Tamara Alonso Safont
- Information Systems Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Dolores Conejos Míquel
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Marta Castelo Jurado
- “Federica Montseny” Primary Healthcare Centre (Centro de Salud Federica Montseny), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Oscar Aguado Arroyo
- “Francia” Primary Healthcare Centre (Centro de Salud Francia), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Juan José Jurado Balbuena
- “Alicante” Primary Healthcare Centre (Centro de Salud Alicante), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Cristina Villanueva Sanz
- “Vicente Muzas” Primary Healthcare Centre (Centro de Salud Vicente Muzas), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Ester Zamarrón Fraile
- “Baviera” Primary Healthcare Centre (Centro de Salud Baviera), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Arancha Luaces Gayán
- “Torrelodones” Primary Healthcare Centre (Centro de Salud Torrelodones), Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Asunción Cañada Dorado
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Dolores Martínez Patiño
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Purificación Magán Tapia
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - Aurora Barberá Martín
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
| | - María José Toribio Vicente
- “Gregorio Marañon” University General Hospital (Hospital General Universitario Gregorio Marañón), Madrid Health Service (SERMAS)
| | - Mercedes Drake Canela
- “Infanta Leonor” University Hospital (Hospital Universitario Infanta Leonor), Madrid Health Service (SERMAS), Madrid (Spain)
| | - Inmaculada Mediavilla Herrera
- From the Quality and Safety Unit, Primary Care Management (Gerencia Asistencial de Atención Primaria), Madrid Health Service (SERMAS)
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Madden C, Lydon S, Murphy AW, O'Connor P. Patients' perception of safety climate in Irish general practice: a cross-sectional study. BMC FAMILY PRACTICE 2021; 22:257. [PMID: 34961484 PMCID: PMC8710927 DOI: 10.1186/s12875-021-01603-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/22/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Although patients have the potential to provide important information on patient safety, considerably fewer patient-report measures of safety climate (SC) have been applied in the primary care setting as compared to secondary care. Our aim was to examine the application of a patient-report measure of safety climate in an Irish population to understand patient perceptions of safety in general practice and identify potential areas for improvement. Specifically, our research questions were: 1. What are patients' perceptions of SC in Irish general practice? 2. Do patient risk factors impact perceptions of SC? 3. Do patient responses to an open-ended question about safety enhance our understanding of patient safety beyond that obtained from a quantitative measure of SC? METHODS The Patient Perspective of Safety in General Practice (PPS-GP) survey was distributed to primary care patients in Ireland. The survey consisted of both Likert-response items, and free-text entry questions in relation to the safety of care. A series of five separate hierarchical regressions were used to examine the relationship between a range of patient-related variables and each of the survey subscales. A deductive content analysis approach was used to code the free-text responses. RESULTS A total of 584 completed online and paper surveys were received. Respondents generally had positive perceptions of safety across all five SC subscales of the PPS-GP. Regarding patient risk factors, younger age and being of non-Irish nationality were consistently associated with more negative SC perceptions. Analysis of the free-text responses revealed considerably poorer patient perceptions (n = 85, 65.4%) of the safety experience in primary care. CONCLUSION Our findings indicate that despite being under-utilised, patients' perceptions are a valuable source of information for measuring SC, with promising implications for safety improvement in general practice. Further consideration should be given to how best to utilise this data in order to improve safety in primary care.
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Affiliation(s)
- Caoimhe Madden
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Lower Newcastle, Galway, Ireland.
- Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland.
| | - Sinéad Lydon
- Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Andrew W Murphy
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Lower Newcastle, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Paul O'Connor
- Department of General Practice, School of Medicine, National University of Ireland Galway, 1 Distillery Road, Lower Newcastle, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland
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Madden C, Lydon S, Murphy AW, O'Connor P. Development and validation of a patient-report measure of safety climate for general practice. Fam Pract 2021; 38:837-844. [PMID: 33738502 DOI: 10.1093/fampra/cmab011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients remain an under-utilized source of information on patient safety, as reflected by the dearth of patient-report measures of safety climate, particularly for use in general practice settings. Extant measures are marked by poor coverage of safety climate domains, inadequate psychometric properties and/or lack of consideration of usability. OBJECTIVE To develop a novel patient-report measure of safety climate specifically for completion by general practice patients, and to establish the validity, reliability and usability of this measure. METHODS An iterative process was used to develop the safety climate measure, with patient and general practitioner input. A cross-sectional design was employed to examine the validity (content, construct and convergent), reliability (internal consistency), and usability (readability and burden) of the measure. RESULTS A total of 584 general practice patients completed the measure. The exploratory factor analysis identified five factors pertaining to safety climate in general practice: Feeling of Safety with GP; Practice Staff Efficiency and Teamwork; Staff Stress and Workload; Patient Knowledge and Accountability, and; Safety Systems and Behaviours. These factors strongly correlated with two global safety measures, demonstrating convergent validity. The measure showed strong internal consistency, and was considered usable for patients as indicated by readability and duration of completion. CONCLUSION Our novel measure of safety climate for use in general practice demonstrates favourable markers of validity, reliability and usability. This measure will provide a mechanism for the patient voice to be heard in patient safety measurement, and to be used to improve patient safety in general practice.
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Affiliation(s)
- Caoimhe Madden
- Department of General Practice, School of Medicine, National University of Ireland Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland
| | - Sinéad Lydon
- Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland.,School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Andrew W Murphy
- Department of General Practice, School of Medicine, National University of Ireland Galway, Ireland
| | - Paul O'Connor
- Department of General Practice, School of Medicine, National University of Ireland Galway, Ireland.,Irish Centre for Applied Patient Safety and Simulation, Galway University Hospital, Galway, Ireland
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Intensive Care Unit Decision-Making in Uncertain and Stressful Conditions Part 2: Cognitive Errors, Debiasing Strategies, and Enhancing Critical Thinking. Crit Care Clin 2021; 38:89-101. [PMID: 34794633 DOI: 10.1016/j.ccc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Diagnostic errors are considered a blind spot of health care delivery and occur in up to 15% of patient cases. Cognitive failures are a leading cause of diagnostic error and often occur as a result of overreliance on system 1 thinking. This narrative review describes why diagnostic errors occur by shedding additional light on systems 1 and 2 forms of thinking, reviews literature on debiasing strategies in medicine, and provides a framework for teaching critical thinking in the intensive care unit as a strategy to promote learner development and minimize cognitive failures.
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Continuous, risk-based, consultation peer review in out-of-hours general practice: a qualitative interview study of the benefits and limitations. Br J Gen Pract 2021; 71:e797-e805. [PMID: 33979302 PMCID: PMC8366781 DOI: 10.3399/bjgp.2021.0076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/26/2021] [Indexed: 12/21/2022] Open
Abstract
Background Systems to detect and minimise unwarranted variation in clinician practice are crucial to ensure increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care. Aim To evaluate the benefits and limitations of a continuous, risk-based, consultation peer-review system used for 10 years by an out-of-hours general practice service in Bristol, UK. Design and setting A qualitative study in South West England. Method Semi-structured interviews with intervention users (clinicians, peer reviewers, and clinical management), analysed by inductive thematic analysis and integrated into a programme theory. Results Twenty clinicians were interviewed between September 2018 and January 2019. Interviewees indicated that the intervention supported clinician learning through improved peer feedback, highlighting learning needs and validating practice. It was compared favourably with existing structures of ensuring clinician competence, supporting standardisation of supervision, clinical governance, and learning culture. These benefits were potentially limited by intervention factors such as differential feedback quality between clinician groups, the efficiency of methods to identify learning needs, and limitations of assessments based on written clinical notes. Contextual factors such as clinician experience, motivation, and organisational learning culture influenced the perception of the intervention as a support or a stressor. Conclusion The findings demonstrate the potential of continuous, risk-based, consultation peer review to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential. The programme theory provides a theoretical basis to maximise the benefits and accommodate the potential limitations of this methodology
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Abstract
OBJECTIVE Major gaps remain in our understanding of primary care patient safety. We describe a toolkit for measuring patient safety in family practices. METHODS Six tools were used in 46 practices. These tools were as follows: National Health Service Education for Scotland Trigger Tool, National Health Service Education for Scotland Medicines Reconciliation Tool, Primary Care Safequest, Prescribing Safety Indicators, Patient Reported Experiences and Outcomes of Safety in Primary Care, and Concise Safe Systems Checklist. RESULTS Primary Care Safequest showed that most practices had a well-developed safety climate. However, the trigger tool revealed that a quarter of events identified were associated with moderate or substantial harm, with a third originating in primary care and avoidable. Although medicines reconciliation was undertaken within 2 days in more than 70% of cases, necessary discussions with a patient/carer did not always occur. The prescribing safety indicators identified 1435 instances of potentially hazardous prescribing or lack of recommended monitoring (from 92,649 patients). The Concise Safe Systems Checklist found that 25% of staff thought that their practice provided inadequate follow-up for vulnerable patients discharged from hospital and inadequate monitoring of noncollection of prescriptions. Most patients had a positive perception of the safety of their practice although 45% identified at least one safety problem in the past year. CONCLUSIONS Patient safety is complex and multidimensional. The Patient Safety Toolkit is easy to use and hosted on a single platform with a collection of tools generating practical and actionable information. It enables family practices to identify safety deficits that they can review and change procedures to improve their patient safety across a key sets of patient safety issues.
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O'Dowd E, Lydon S, Madden C, O'Connor P. A systematic review of patient complaints about general practice. Fam Pract 2020; 37:297-305. [PMID: 31742596 DOI: 10.1093/fampra/cmz082] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Health care complaints are an underutilized resource for quality and safety improvement. Most research on health care complaints is focused on secondary care. However, there is also a need to consider patient safety in general practice, and complaints could inform quality and safety improvement. OBJECTIVE This review aimed to synthesize the extant research on complaints in general practice. METHODS Five electronic databases were searched: Medline, Web of Science, CINAHL, PsycINFO and Academic Search Complete. Peer-reviewed studies describing the content, impact of and motivation for complaints were included and data extracted. Framework synthesis was conducted using the Healthcare Complaints Analysis Tool (HCAT) as an organizing framework. Methodological quality was appraised using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). RESULTS The search identified 2960 records, with 21 studies meeting inclusion criteria. Methodological quality was found to be variable. The contents of complaints were classified using the HCAT, with 126 complaints (54%) classified in the Clinical domain, 55 (23%) classified as Management and 54 (23%) classified as Relationships. Motivations identified for making complaints included quality improvement for other patients and monetary compensation. Complaints had both positive and negative impacts on individuals and systems involved. CONCLUSION This review highlighted the high proportion of clinical complaints in general practice compared to secondary care, patients' motivations for making complaints and the positive and negative impacts that complaints can have on health care systems. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice is required.
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Affiliation(s)
- Emily O'Dowd
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Sinéad Lydon
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Caoimhe Madden
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
| | - Paul O'Connor
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
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Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. BMJ Qual Saf 2020; 29:265-270. [DOI: 10.1136/bmjqs-2019-009731] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 12/16/2022]
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Agor JK, Sir MY, Pasupathy KS, Foley DA, Scott CG, Elrashidi MY, Young NP, McKie PM. Getting to the Heart of the Matter: A Triage Model to Improve Utilization of Cardiology Consultative Services. MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES 2019; 3:476-482. [PMID: 31993566 PMCID: PMC6978585 DOI: 10.1016/j.mayocpiqo.2019.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/07/2019] [Accepted: 08/23/2019] [Indexed: 11/30/2022] Open
Abstract
Objective Patient and Methods Results Conclusion
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Affiliation(s)
- Joseph K. Agor
- School of Mechanical, Industrial, and Manufacturing Engineering, Oregon State University, Corvallis
| | - Mustafa Y. Sir
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Kalyan S. Pasupathy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David A. Foley
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | - Paul M. McKie
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Correspondence: Address to Paul M. McKie, MD, Department of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55902.
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Curran C, Lydon S, Kelly ME, Murphy AW, O'Connor P. An analysis of general practitioners' perspectives on patient safety incidents using critical incident technique interviews. Fam Pract 2019; 36:736-742. [PMID: 30926981 DOI: 10.1093/fampra/cmz012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND General practitioners report difficulty in knowing how to improve patient safety. OBJECTIVES To analyse general practitioners' perspectives of contributing factors to patient safety incidents by collecting accounts of incidents, identifying the contributory factors to these incidents, assessing the impact and likelihood of occurrence of these incidents and examining whether certain categories of contributory factors were associated with the occurrence of high-risk incidents. METHODS Critical incident technique interviews were carried out with 30 general practitioners in Ireland about a patient safety incident they had experienced. The Yorkshire Contributory Factors Framework was used to classify the contributory factors to incidents. Seven subject matter experts rated the impact and likelihood of occurrence of each incident. RESULTS A total of 26 interviews were analysed. Almost two-thirds of the patient safety incidents were rated as having a major-to-extreme impact on the patient, and over a third were judged as having at least a bimonthly likelihood of occurrence. The most commonly described active failures were 'Medication Error' (34.6%) and 'Diagnostic Error' (30.8%). 'Situational Domain' was identified as a contributory domain in all patient safety incidents. 'Communication' breakdown at both practice and other healthcare-provider interfaces (69.2%) was also a commonly cited contributory factor. There were no significant differences in the levels of risk associated with the contributory factors. CONCLUSIONS Critical incident technique interviews support the identification of contributory factors to patient safety incidents. There is a need to explore the use of the resulting data for quality and safety improvement in general practice.
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Affiliation(s)
- Ciara Curran
- Department of General Practice, School of Medicine, Ireland.,Irish Centre for Applied Patient Safety and Simulation, Ireland
| | - Sinéad Lydon
- Irish Centre for Applied Patient Safety and Simulation, Ireland.,School of Medicine, National University of Ireland Galway, Galway, Ireland
| | | | | | - Paul O'Connor
- Department of General Practice, School of Medicine, Ireland.,Irish Centre for Applied Patient Safety and Simulation, Ireland
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de Wet C, Bowie P, O'Donnell CA. Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory. BMJ Open 2019; 9:e029914. [PMID: 31537569 PMCID: PMC6756363 DOI: 10.1136/bmjopen-2019-029914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting. DESIGN Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT). SETTING Scottish general practice. PARTICIPANTS We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland. RESULTS We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants' involvement; (3) the characteristics of the reviewers-implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful. CONCLUSIONS This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors.
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Affiliation(s)
- Carl de Wet
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Paul Bowie
- Patient Safety Research, NHS Education for Scotland, Glasgow, UK
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Abimanyi-Ochom J, Bohingamu Mudiyanselage S, Catchpool M, Firipis M, Wanni Arachchige Dona S, Watts JJ. Strategies to reduce diagnostic errors: a systematic review. BMC Med Inform Decis Mak 2019; 19:174. [PMID: 31470839 PMCID: PMC6716834 DOI: 10.1186/s12911-019-0901-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 08/22/2019] [Indexed: 12/18/2022] Open
Abstract
Background To evaluate the effectiveness of audit and communication strategies to reduce diagnostic errors made by clinicians. Methods MEDLINE complete, CINHAL complete, EMBASE, PSNet and Google Advanced. Electronic and manual search of articles on audit systems and communication strategies or interventions, searched for papers published between January 1990 and April 2017. We included studies with interventions implemented by clinicians in a clinical environment with real patients. Results A total of 2431 articles were screened of which 26 studies met inclusion criteria. Data extraction was conducted by two groups, each group comprising two independent reviewers. Articles were classified by communication (6) or audit strategies (20) to reduce diagnostic error in clinical settings. The most common interventions were delivered as technology-based systems n = 16 (62%) and within an acute care setting n = 15 (57%). Nine studies reported randomised controlled trials. Three RCT studies on communication interventions and 3 RCTs on audit strategies found the interventions to be effective in reducing diagnostic errors. Conclusion Despite numerous studies on interventions targeting diagnostic errors, our analyses revealed limited evidence on interventions being practically used in clinical settings and a bias of studies originating from the US (n = 19, 73% of included studies). There is some evidence that trigger algorithms, including computer based and alert systems, may reduce delayed diagnosis and improve diagnostic accuracy. In trauma settings, strategies such as additional patient review (e.g. trauma teams) reduced missed diagnosis and in radiology departments review strategies such as team meetings and error documentation may reduce diagnostic error rates over time. Trial registration The systematic review was registered in the PROSPERO database under registration number CRD42017067056. Electronic supplementary material The online version of this article (10.1186/s12911-019-0901-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julie Abimanyi-Ochom
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia
| | - Shalika Bohingamu Mudiyanselage
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia
| | - Max Catchpool
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia.,Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie St, Carlton, VIC, 3053, Australia
| | - Marnie Firipis
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia
| | - Sithara Wanni Arachchige Dona
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia
| | - Jennifer J Watts
- Deakin Health Economics, Centre for Population Health Research, Deakin University, Locked Bag 20000, Geelong, Victoria, 3220, Australia.
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Madden C, Lydon S, Cupples ME, Hart ND, Curran C, Murphy AW, O’Connor P. Safety in primary care (SAP-C): a randomised, controlled feasibility study in two different healthcare systems. BMC FAMILY PRACTICE 2019; 20:22. [PMID: 30700257 PMCID: PMC6352328 DOI: 10.1186/s12875-019-0909-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 01/16/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Patient safety research is conducted predominantly in hospital settings, with a dearth of insight from primary care, despite suggestions that 2.2% of primary care consultations result in a patient safety incident. This study aimed to assess the feasibility of an intervention intended to improve patient safety in general practice. METHODS A randomised controlled feasibility study was conducted with general practices in the Republic of Ireland (N = 9) and Northern Ireland (N = 2), randomly assigned to the intervention (N = 5) or control (N = 6) group. The nine-month intervention consisted of: 1) repeated safety climate (SC) measurement (using GP-SafeQuest questionnaire) and feedback (comparative anonymised practice-level SC data), and 2) patient record reviews using a specialised trigger tool to identify instances of undetected patient harm. For control practices, SC was measured at baseline and study end only. The intervention's perceived usefulness and feasibility were explored via an end-of-study questionnaire and semi-structured interviews. RESULTS Thirteen practices were invited; 11 participated; 10 completed the study. At baseline, 84.8% of intervention practice staff (39/46) and 77.8% (42/54) of control practice staff completed the SC questionnaire; at the study terminus, 78.3% (36/46) of intervention practice staff and 68.5% (37/54) of control practice staff did so. Changes in SC scores, indicating improvement, were observed among the intervention practices but not in the control group. The trigger tool was applied to 188 patient records; patient safety incidents of varying severity were detected in 19.1% (36/188). Overall, 59% of intervention practice team members completed the end-of-study questionnaire, with the majority in both healthcare systems responding positively about the intervention. Interviews (N = 9) identified the intervention's usefulness in informing practice management and patient safety issues, time as a barrier to its use, and the value of group discussion of feedback. CONCLUSION This feasibility study suggests that a definitive randomised controlled trial of the intervention is warranted. Our findings suggest that the intervention is feasible, useful, and sustainable. Practices were willing to be recruited into the study, response and retention rates were acceptable, and there is possible evidence of a positive effect of the intervention. TRIAL REGISTRATION The trial registration number is: ISRCTN11426121 (retrospectively registered 12th June 2018).
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Affiliation(s)
- Caoimhe Madden
- Department of General Practice, School of Medicine, National University of Ireland, Galway, Galway, Ireland
- HRB Primary Care Clinical Trial Network Ireland, National University of Ireland, Galway, Galway, Ireland
| | - Sinéad Lydon
- School of Medicine, National University of Ireland, Galway, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, NUI Galway, Galway, Ireland
| | - Margaret E. Cupples
- HRB Primary Care Clinical Trial Network Ireland, National University of Ireland, Galway, Galway, Ireland
- UK Clinical Research Collaboration Centre of Excellence for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ UK
- Centre for Public Health, School of Medicine, Dentristry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Nigel D. Hart
- Centre for Medical Education, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Ciara Curran
- Department of General Practice, School of Medicine, National University of Ireland, Galway, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, NUI Galway, Galway, Ireland
| | - Andrew W. Murphy
- Department of General Practice, School of Medicine, National University of Ireland, Galway, Galway, Ireland
- HRB Primary Care Clinical Trial Network Ireland, National University of Ireland, Galway, Galway, Ireland
| | - Paul O’Connor
- Department of General Practice, School of Medicine, National University of Ireland, Galway, Galway, Ireland
- HRB Primary Care Clinical Trial Network Ireland, National University of Ireland, Galway, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, NUI Galway, Galway, Ireland
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Madden C, Lydon S, Curran C, Murphy AW, O'Connor P. Potential value of patient record review to assess and improve patient safety in general practice: A systematic review. Eur J Gen Pract 2019; 24:192-201. [PMID: 30112925 PMCID: PMC6104614 DOI: 10.1080/13814788.2018.1491963] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background: There is limited research, and guidance, on how to address safety in general practice proactively. Objectives: This review aimed to synthesize the literature describing the use of patient record review (PRR) to measure and improve patient safety in primary care. The PRR methodologies utilized and the resulting outcomes were examined. Methods: Searches were conducted using Medline, Embase, CINAHL and PsycINFO in February 2017. Reference lists of included studies and existing review papers were also screened. English language, peer-reviewed studies that utilized PRR to identify patient safety incidents (PSIs) occurring in general practice were included. Two researchers independently extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs. Results: A total of 3265 studies were screened, with 15 included. Trigger tools were the most frequent method used for the PRRs (n = 6). The mean number of safety incidents per 100 records was 12.6. Within studies, a mean of 30.6% of incidents were associated with severe harm (range 8.6–50%), and a mean of 55.6% of incidents was considered preventable (range 32.7–93.5%). The most commonly identified types of PSIs related to medication and prescribing, diagnosis, communication and treatment. Three studies reported on improvement actions taken after the PRRs. Conclusion: This review suggests that PRR may be a promising means of proactively identifying patient safety incidents and informing improvements.
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Affiliation(s)
- Caoimhe Madden
- a Department of General Practice, School of Medicine , National University of Ireland Galway , Galway , Ireland.,b HRB Primary Care Clinical Trials Network Ireland , National University of Ireland Galway , Galway , Ireland
| | - Sinéad Lydon
- c School of Medicine , National University of Ireland Galway , Galway , Ireland
| | - Ciara Curran
- a Department of General Practice, School of Medicine , National University of Ireland Galway , Galway , Ireland
| | - Andrew W Murphy
- a Department of General Practice, School of Medicine , National University of Ireland Galway , Galway , Ireland.,b HRB Primary Care Clinical Trials Network Ireland , National University of Ireland Galway , Galway , Ireland
| | - Paul O'Connor
- a Department of General Practice, School of Medicine , National University of Ireland Galway , Galway , Ireland.,b HRB Primary Care Clinical Trials Network Ireland , National University of Ireland Galway , Galway , Ireland
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Chatburn E, Macrae C, Carthey J, Vincent C. Measurement and monitoring of safety: impact and challenges of putting a conceptual framework into practice. BMJ Qual Saf 2018; 27:818-826. [PMID: 29511091 PMCID: PMC6166594 DOI: 10.1136/bmjqs-2017-007175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 02/12/2018] [Accepted: 02/17/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Measurement and Monitoring of Safety Framework provides a conceptual model to guide organisations in assessing safety. The Health Foundation funded a large-scale programme to assess the value and impact of applying the Framework in regional and frontline care settings. We explored the experiences and reflections of key participants in the programme. METHODS The study was conducted in the nine healthcare organisations in England and Scotland testing the Framework (three regional improvement bodies, six frontline settings). Post hoc interviews with clinical and managerial staff were analysed using template analysis. FINDINGS Participants reported that the Framework promoted a substantial shift in their thinking about how safety is actively managed in their environment. It provided a common language, facilitated a more inquisitive approach and encouraged a more holistic view of the components of safety. These changes in conceptual understanding, however, did not always translate into broader changes in practice, with many sites only addressing some aspects of the Framework. One of the three regions did embrace the Framework in its entirety and achieved wider impact with a range of interventions. This region had committed leaders who took time to fully understand the concepts, who maintained a flexible approach to exploring the utility of the Framework and who worked with frontline staff to translate the concepts for local settings. CONCLUSIONS The Measuring and Monitoring of Safety Framework has the potential to support a broader and richer approach to organisational safety. Such a conceptually based initiative requires both committed leaders who themselves understand the concepts and more time to establish understanding and aims than might be needed in a standard improvement programme.
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Affiliation(s)
- Eleanor Chatburn
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Carl Macrae
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | | | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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de Wet C, Bowie P, O'Donnell C. 'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice. BMC FAMILY PRACTICE 2018; 19:83. [PMID: 29885654 PMCID: PMC5994252 DOI: 10.1186/s12875-018-0772-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/21/2018] [Indexed: 12/04/2022]
Abstract
Background Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks. Methods A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed. Results Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment. Conclusion The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so.
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Affiliation(s)
- Carl de Wet
- Medical Directorate, NHS Education for Scotland, Glasgow, UK. .,General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland. .,School of Medicine, Griffith University, Southport, Gold Coast, Australia.
| | - Paul Bowie
- Medical Directorate, NHS Education for Scotland, Glasgow, UK.,General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland
| | - Catherine O'Donnell
- General Practice & Primary Care, Institute of Health & Wellbeing, College of Medical, Veterinary and Life Science, University of Glasgow, Glasgow, Scotland
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Lydon S, Cupples ME, Hart N, Murphy AW, Faherty A, O'Connor P. The safety climate in primary care (SAP-C) study: study protocol for a randomised controlled feasibility study. Pilot Feasibility Stud 2016; 2:56. [PMID: 27965872 PMCID: PMC5154125 DOI: 10.1186/s40814-016-0096-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 09/07/2016] [Indexed: 11/10/2022] Open
Abstract
Background Research on patient safety has focused largely on secondary care settings, and there is a dearth of knowledge relating to safety culture or climate, and safety climate improvement strategies, in the context of primary care. This is problematic given the high rates of usage of primary care services and the myriad of opportunities for clinical errors daily. The current research programme aimed to assess the effectiveness of an intervention derived from the Scottish Patient Safety Programme in Primary Care. The intervention consists of safety climate measurement and feedback and patient chart audit using the trigger review method. The purpose of this paper is to describe the background to this research and to present the methodology of this feasibility study in preparation for a future definitive RCT. Methods The SAP-C study is a feasibility study employing a randomised controlled pretest-posttest design that will be conducted in 10 general practices in the Republic of Ireland and Northern Ireland. Five practices will receive the safety climate intervention over a 9-month period. The five practices in the control group will continue care as usual but will complete the GP-SafeQuest safety climate questionnaire at baseline (month 1) and at the terminus of the intervention (month 9). The outcomes of the study include process evaluation metrics (i.e. rates of participant recruitment and retention, rates of completion of safety climate measures, qualitative data regarding participants’ perceptions of the intervention’s potential efficacy, acceptability, and sustainability), patient safety culture in intervention and control group practices at posttest, and instances of undetected patient harm identified through patient chart audit using the trigger review method. Discussion The planned study investigates an intervention to improve safety climate in Irish primary care settings. The resulting data may inform our knowledge of the frequency of undetected patient safety incidents in primary care, may contribute to improved patient safety practices in primary care settings, and may inform future research on patient safety improvement initiatives. Electronic supplementary material The online version of this article (doi:10.1186/s40814-016-0096-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sinéad Lydon
- Discipline of General Practice, National University of Ireland, Galway, Ireland
| | - Margaret E Cupples
- Department of General Practice and Primary Care, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK ; UKCRC Centre of Excellence for Public Health Research (NI), Queen's University, Belfast, UK
| | - Nigel Hart
- Department of General Practice and Primary Care, School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Andrew W Murphy
- Discipline of General Practice, National University of Ireland, Galway, Ireland
| | - Aileen Faherty
- Discipline of General Practice, National University of Ireland, Galway, Ireland
| | - Paul O'Connor
- Discipline of General Practice, National University of Ireland, Galway, Ireland
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