Patient safety incidents are common in primary care: A national prospective active incident reporting survey.

BACKGROUND: The study objectives were to describe the incidence and the nature of patient safety incidents (PSIs) in primary care general practice settings, and to explore the association between these incidents and practice or organizational characteristics. METHODS: GPs, randomly selected from a national influenza surveillance network (n = 800) across France, prospectively reported any incidents observed each day over a one-week period between May and July 2013. An incident was an event or circumstance that could have resulted, or did result, in harm to a patient, which the GP would not wish to recur. Primary outcome was the incidence of PSIs which was determined by counting reports per total number of patient encounters. Reports were categorized using existing taxonomies. The association with practice and organizational characteristics was calculated using a negative binomial regression model. RESULTS: 127 GPs (participation rate 79%) reported 317 incidents of which 270 were deemed to be a posteriori judged preventable, among 12,348 encounters. 77% had no consequences for the patient. The incidence of reported PSIs was 26 per 1000 patient encounters per week (95% CI [23‰ -28‰]). Incidents were three times more frequently related to the organization of healthcare than to knowledge and skills of health professionals, and especially to the workflow in the GPs' offices and to the communication between providers and with patients. Among GP characteristics, three were related with an increased incidence in the final multivariable model: length of consultation higher than 15 minutes, method of receiving radiological results (by fax compared to paper or email), and being in a multidisciplinary clinic compared with sole practitioners. CONCLUSIONS: Patient safety incidents (PSIs) occurred in mean once every two days in the sampled GPs and 2% of them were associated with a definite possibility for harm. Studying the association between organizational features of general practices and PSIs remains a major challenge and one of the most important issues for safety in primary care.

[Adverse events in general medicine, the national primary care study]. / Événements indésirables en médecine générale, enquête nationale en soins primaires.

Carried out in France in 2013, the national primary care study on adverse events enabled the average frequency of such events in outpatient care to be estimated. General practitioners identified an occurrence of an adverse event every two days, without consequence for the patients in three quarters of the cases.

Patient safety and the control of time in primary care: A review of the French tempos framework by the LINNEAUS collaboration on patient safety in primary care.

BACKGROUND: The tempos framework provides GPs with a flexible and practical guide to reflect on their organization and practices in the analysis of adverse events and supplement existing classification systems. The tempos framework specifies five timescales that need to be managed by physicians: the disease's tempo (unexpected rapid changes, slow reaction to treatment); the office's tempo (day-to-day agenda and interruptions); the patient's tempo (time to express symptoms, compliance, and emotion); the system's tempo (time for appointments, exams, and feedback); and the time to access to knowledge. OBJECTIVE: This paper reviews the tempos framework and two studies that underpin its conceptual development. METHODS: Two databases were used. RESULTS: The use of the framework as a mechanism for analysing insurance claims is described. A comparison of using the tempos framework and standard patient safety classifications for analysing insurance claims is also described and showed that the concordance among coders was better for the tempos framework. The tempos framework fits closely with key principles of general practice and has potentially high relevance for analysing a patient's journey and continuity of care. The tempos framework seems most useful for GPs when analysing adverse events in their practice. CONCLUSION: Further work needs to be done to assess its generalizability and to formally assess its validity and reliability.

Evaluation of an interactive program for preventing adverse drug events in primary care: study protocol of the InPAct cluster randomised stepped wedge trial.

BACKGROUND: Adverse drug events could often be prevented. One of their main causes is that patients rarely know how to detect them. Another cause is inadequate communication between patients and physicians. If patients were to be effectively trained in detecting and reporting adverse drug events, this should help to prevent their occurrence and subsequent complications. Our purpose is to present the protocol of the InPAct trial, which aims to evaluate an interactive program that encourages patients to report adverse drug events in primary care. METHODS/DESIGN: We will conduct a cluster randomised controlled stepped wedge trial, with eight clusters of 10 general practitioners each. The physicians will suggest to all of their antihypertensive-treated patients that they take part in this study. The InPAct program will be implemented in the clusters in random order along five successive three-month periods. Two new clusters will be trained in implementing the program at each step. The program features: an interactive patient booklet including informative paragraphs, several care plans and adverse drug event report forms; and standardised training of physicians in how to present the booklet to the patient. The primary outcome will be the reporting of adverse drug events by patients to their physician within three months. We assume that the number of patients reporting at least one adverse drug event will increase from 3% before program implementation to 7.5% afterward (coefficient of variation = 0.5, α = 0.05, ß = 0.2), which means that 1,200 patients must be included. The effect of the intervention on the main outcome will be quantified and tested using a mixed logistic model to integrate cluster and time effects. DISCUSSION: Our choice of a stepped wedge design is particularly appropriate for evaluating the implementation of a patient safety program within the constraints of general practice. We describe the InPAct intervention, which is an original program that is intended to improve communication between patients and physicians. Indeed, none of the previously published intervention studies has combined a patient education program and a patient reporting system for adverse drug events with the aim of improving patient safety in primary care. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov NCT01610817.

Twelve-year follow-up of a population-based primary care diabetes program in Israel.

OBJECTIVE: To describe the effects of a long-term intervention including 72% of Israeli diabetes patients, aimed at improving diabetes care in a primary care setting. DESIGN: A retrospective periodic population-based cross-sectional study. SETTING: Two health maintenance organizations (HMOs) in Israel-intervention and control. PARTICIPANTS: All diagnosed diabetes patients enrolled in both HMOs. INTERVENTION: Multifaceted interventions directed toward primary care providers, including educational strategies, registries, clinical pathways, care quality indicators, computerized reminders and feedback. MAIN OUTCOME MEASURES: Performance in quality indicators, compared with an HMO that did not implement an intervention program. RESULTS: The prevalence of diabetes increased from 20.2/1000 in 1995 to 63.7/1000 in 2007. Annual testing of hemoglobin A1c (HbA1c) rose from 22% in 1995 to 88% in 2007. The corresponding figures for low-density lipoprotein (LDL) were 23 and 89%, and for microalbumin 10 and 69%, respectively (P< 0.0001 for all comparisons). The proportion of HbA1c ≤7% increased from 10 to 53%, while HbA1c >9% decreased from 40 to 13% (P< 0.0001). Good control of LDL ≤100 mg/dl increased from 26 to 59% (P< 0.0001). In the comparison HMO, subtle increases in the performance of HbA1c (55.8-63.4%), LDL (59.7-67.0%) and microalbumin (55.1-67.6%) were noted between 2005 and 2007, respectively. HbA1c ≤7 and >9% remained stable (36 and 13%, respectively), while LDL ≤100 mg/dl rose from 38 to 44% in the control HMO. CONCLUSION: A community-oriented program for diabetes care led to improvements in performance of tests, as well as control of HbA1c and LDL among 72% of diabetes patients in Israel.

Improving general practitioner records in France by a two-round medical audit.

RATIONALE, AIMS AND OBJECTIVES: The effectiveness of clinical audits in changing the practice of health care professionals is a moot point. Methods of implementation impinge directly upon outcomes. We investigated whether a network of local opinion leaders could contribute towards a successful audit. Our objectives were to: (i) bring about an improvement in record keeping in general practice; and (ii) increase GPs awareness of medical evaluation. METHODS: The GPs were recruited by local opinion leaders who had been briefed by the French National Agency for Accreditation and Evaluation in Health Care (ANAES, formerly ANDEM). On a given day (first round of the audit) they were invited to examine whether the medical records of their 10 first patients met 13 set criteria. Overall results were analysed by ANAES. Each GP was informed of how well they had fared compared with the regional and national averages and was provided with a standard set of recommendations. Anonymity was ensured by the local leaders. A second round was conducted 6 months later. RESULTS: A total of 244 GPs took part in both rounds of the audit; 32 dropped out after the first round. Their results were of a significantly lower standard. A significant improvement in results (P<0.025) was recorded between the two rounds for all 13 criteria of the questionnaire. Overall scores improved between the two rounds for 69 of the GPs and improved above average for 49. The greatest scatter in results was noted for items relating to medical history rather than to personal identity (administrative data). CONCLUSIONS: Self-assessment can help improve general standards of medical record keeping. A network of local opinion leaders, briefed by a national agency whose mission is to promote quality improvement in health care, seems to be an effective means of inducing participation in self-assessment.