Validation of a Reduced Set of High-Performance Triggers for Identifying Patient Safety Incidents with Harm in Primary Care: TriggerPrim Project.

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.

Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable.

Knowing the frequency and characteristics of adverse events (AEs) is key to implementing actions that can prevent their occurrence. However, reporting systems are insufficient for this purpose and epidemiological studies are also required. Currently, the reviewing of clinical records is the gold standard method for knowing the frequency and characteristics of AEs. Research on AEs in a primary care setting has been limited and primarily focuses on specific types of events (medication errors, etc.) or patients. Large studies that search for any kind of AE in all patients are scarce. This study aimed to estimate the prevalence of AEs in the primary care setting and their characteristics. SETTING: all 262 primary health-care centres in the Madrid region (Spain) during the last quarter of 2018. DESIGN: cross-sectional descriptive study. Eligible population: subjects over 18 years of age who attended medical consultation over the last year (N = 2 743 719); a randomized sample stratified by age. MAIN OUTCOMES: age, sex, occurrence of an AE, number of consultations in the study period, avoidability, severity, place of occurrence, type of event, and contributory factors. The clinical records were reviewed by three teams, each composed of one doctor and one nurse trained and with expertise in patient safety. The SPSS software package (version 26) was used for the statistical analyses. The evaluators reviewed 1797 clinical records. The prevalence of AEs over the study period was 5.0% [95% confidence interval (CI): 4.0%‒6.0%], with higher values in women (5.7%; 95% CI: 4.6%‒6.8%;P = 0.10) and patients over 75 years of age (10.3%; 95% CI: 8.9%‒11.7%; P < 0.001). The overall occurrence per hundred consultations was estimated to be 1.58% (95% CI: 1.28%‒1.94%). Of the detected AEs, 71.3% (95% CI: 62.1%‒80.5%) were avoidable. Additionally, 60.6% (95% CI: 50.7%‒70.5%) were categorized as mild, 31.9% (95% CI: 22.4%‒41.4%) as moderate, and 7.4% (95% CI: 2.1%‒12.7%) as severe. Primary care was the occurrence setting in 76.6% (95% CI: 68.0%‒85.2%) of cases. The overall incidence of AEs related to medication was 53.2% (95% CI: 50.9%‒55.5%). The most frequent types of AEs were prescription errors (28.7%; 95% CI: 19.5%‒37.9%), followed by drug administration errors by patients (17.0%; 95% CI: 9.4%‒24.6%), and clinical assessment errors (11.7%; 95% CI: 5.2%‒18.2%). The most common contributory factors were those related to the patient (80.6%; 95% CI: 71.1%‒90.1%) and tasks (59.7%; 95% CI: 48.0%‒71.4%). A high prevalence of AEs (1 in 66 consultations) was observed, which was slightly higher than that reported in similar studies. About 3 out of 4 such events were considered to be avoidable and 1 out of 13 was severe. Prescription errors, drug administration errors by patients, and clinical assessment errors were the most frequent types of AEs. Graphical Abstract.

[Prevention of infections related to health care in primary care. Lessons from the pandemic]. / Prevención de infecciones relacionadas con la asistencia sanitaria en atención primaria. Lecciones de la pandemia.

The health system failed to guarantee the safety of both professionals and citizens who came to the centers at the beginning of the pandemic. The lack of materials and guidelines for the prevention of infections caused in Spain the worst catastrophe in the history of patient safety and occupational health in healthcare. It also happened in other countries but Spain had the highest rates of infected health workers in the world. It was a largely avoidable event. We review what measures have been taken to prevent infections in primary care centers, such as hand hygiene, masks and personal protection material or the maintenance of social distance, among others. We update the recommendations and raise the perspectives in a situation that requires flexibility and adaptability to maintain quality and safe care.

[Primary care organization in pandemic times]. / Organización de la Atención Primaria en tiempos de pandemia.

The COVID-19 pandemic has forced the adoption of drastic changes in primary care, modifying the organization and work dynamics previously established. From one day to the next, professionals had to adapt to the new situation to be able to attend cases and contacts tracing, to avoid contagion and to maintain attention to other health problems. At the beginning of the pandemic, professionals had to establish new practices and care circuits in primary care in an improvised way, due to lack of updated guidelines, without adequate means of protection, evaluating their risks and benefits on the fly. We present the main organizational changes in the first level of care and describe, from the point of view of patient safety and the consequences for patients and professionals of the priority care for COVID-19. Finally, we consider how to incorporate the knowledge acquired during the pandemic, analyzing the advantages and disadvantages of the adopted measures to maintain as much as possible a safe, accessible and quality primary care.

Enfermería en Atención Primaria: nuestra responsabilidad con la población (experiencia del área 9) / Nursing in Primary Health Care: our responsability with the population (Experience of area 9)

La incorporación de distintos profesionales en los equipos de Atención Primaria de salud en España hace necesaria la definición de la aportación específica de cada uno en la mejora de los servicios a la población. Esta definición en enfermería no ha sido homogénea, encontrándonos distintas situaciones dependiendo del equipo o área de salud. En el área 9 de Atención Primaria de Madrid se inició una experiencia de Gestión por procesos como forma de conseguir la mejora en los servicios ofrecidos por las enfermeras. Tras una autoevaluación se definió la misión, visión y valores de la organización para enfermería. Posteriormente, y compatible con la cartera de servicios del INSALUD, se ha elaborado un listado de procesos/responsabilidades de enfermería agrupados en 4 niveles de intervención: procedimientos técnicos básicos, conductas generadoras de salud/actividades preventivas, promoción del autocuidado y seguimiento y control de problemas de afrontamiento y adaptación. Estos niveles de intervención y procesos de enfermería se relacionan, mediante un esquema, con los servicios del EAP y con las clasificaciones NANDA, NIC y NOC de diagnósticos, intervenciones y resultados de enfermería. Para el conjunto de procesos se han establecido unos diagramas de flujo que muestran las relaciones entre cada uno de los distintos niveles de intervención. Además cada proceso tiene definidos sus criterios de inclusión, lo que permite la medición. El modelo propuesto permite definir la responsabilidad propia de enfermería, desarrollar un sistema de medición del desempeño, lo que redunda en una mejor rentabilidad para el conjunto de la organización. Para su puesta en marcha es necesario el esfuerzo de médicos, directivos, universidades y de las propias enfermeras y enfermeros