Read the article and only answer the highlighted questions on the worksheet please use the patient safety reference to complete the questions.ONLY THE QUESTIONS HIGHLIGHTED NEEDED TO BE COMPLETEHere is an example of how question 6 should be answered 4What type of statistical analysis was used?Example: The research used quantitative data collected by the American Red Cross, the Centers for Disease Control and Prevention (CDC), and National Institute of Allergy and Infectious Diseases. Data collection occurred over a five-year period with help from six West African governments. The data tracked 100 residents from each country and monitored the spread of the disease among the citizens. Data analyses analyzed disease prevalence for decreases. Depending on Ebola prevalence, the research question can be answered. If Ebola prevalence decreased after implementing the CDC protocol, the hypothesis would be rejected.
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InnovAiT, Vol. 4, No. 8, pp. 472–477, 2011
Advance access publication 25 March 2011
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 2007–09 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
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.
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
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
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:
OO Outcomes of unsafe medical care
Patient safety—freedom 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 solution—any system design or
intervention that has demonstrated the ability to prevent
or mitigate patient harm stemming from the processes of
Organizational resilience—the positive side of safety,
defined as the system’s intrinsic resistance to its
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Measuring patient safety
developed under academic review but the evidence for the
validation of the tool has not yet been published.
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
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.
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
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.
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 practitioner’s knowledge
is important and patient safety is now included in Tomorrow’s
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 individual’s 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
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.
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.
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
Patient safety: evidence
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).
Understanding clinical risk
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
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
Clinical risk is an avoidable increase in the probability of
harm occurring to a patient.
Significant event audit
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.
Patient safety: evidence
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
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’.
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.
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
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.
Other research relevant to
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
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
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
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 Agency’s National Reporting
and Learning Service’s 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
6. Learn and share safety lessons
7. Implement solutions to prevent harm
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.
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 ot …
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