New study reveals insights into ‘significant’ avoidable harm in primary care

A national study in England has revealed the extent of incidents of significant avoidable harm in primary care.

Thirteen GPs reviewed case notes of more than 90,000 patients in three regions across England over a 12-month period as part of the study.

They found the main causes of avoidable harm were diagnostic error (more than 60%), medication incidents (more than 25%) and delayed referrals (nearly 11%), and that 80% of incidents could have been identified sooner or prevented if action had been taken.

When the results were applied to the English population as a whole, the researchers estimated there would be up to 32,000 cases of significant avoidable harm to patients on average per year.

The research, which was funded by the National Institute for Health Research (NIHR) Policy Research Programme, is published today in the BMJ Quality and Safety journal.

GP Dr Andrew Carson-Stevens, a clinical reader at Cardiff University’s School of Medicine and an expert in patient safety, worked on the study.

“Most of these cases of significant harm in general practice could be avoided by improving administrative systems that ensure healthcare professionals can reliably make a referral to another service or clinician, review and action test results, monitor and recall patients that do not attend for important investigations, and, communicate clearly with other clinicians involved in the care of their patients,” said Dr Carson-Stevens, who is also patient safety research leader at the Primary and Emergency Care Research Centre.

The research is one of the largest and most comprehensive studies of avoidable harm in primary care to date. An instance of avoidable harm could be a problem with diagnosis, such as a delay or an incorrect diagnosis or issues with medication, such as a prescribing error or monitoring errors.

The researchers identified a number of factors that contributed to the harm, which included organisational, clinician and patient factors, such as multiple health problems, including frailty.

Dr Carson-Stevens and his Patient Safety Research Group (PISA) was responsible for defining a case of significant avoidable harm for the purposes of this study.

The study then used the PISA Group's internationally-accepted methods for investigating and learning from cases of avoidable healthcare-associated harm. The research group trained GPs to review electronic medical records and identify evidence of potentially unsafe care and the Cardiff team was responsible for identifying the learning from each case of avoidable harm.

The research was led by the NIHR Greater Manchester Patient Safety Translational Research Centre (GM PSTRC), a partnership between the University of Manchester and Salford Royal hospital in collaboration with the University of Nottingham, and was carried out in 2015/16.

Tony Avery, Professor of Primary Health Care at the University of Nottingham, said: “We can’t hope to tackle this issue unless we can first understand how many incidents are occurring.

“The COVID-19 pandemic has changed the way primary care operates making our recommendations even more relevant in a world where face to face consultations are not always possible.”

The researchers recommended improving the continuity of care for patients in primary care, particularly older people and those with multiple long-term health conditions and identifying and promoting ways in which IT can be used to address some of these improvements.

The population of England is more than 55 million and there are more than 300 million general practice consultations each year.

Professor Avery added: “It is crucial we put this research into context and remember that for 97% of patients who present with significant health problems, there is no evidence that primary care played any part in the cause.”