Epidemiology of Patient Harms in New Zealand: Protocol of a General Practice Records Review Study

Abstract

Background: Knowing where and why harm occurs in general practice will assist patients, doctors, and others in making informed decisions about the risks and benefits of treatment options. Research to date has been unable to verify the safety of primary health care and epidemiological research about patient harms in general practice is now a top priority for advancing health systems safety.

Objective: We aim to study the incidence, distribution, severity, and preventability of the harms patients experience due to their health care, from the whole-of-health-system lens afforded by electronic general practice patient records.

Methods: "Harm" is defined as disease, injury, disability, suffering, and death, arising from the health system. The study design is a stratified, 2-level cluster, retrospective records review study. Both general practices and patients will be randomly selected so that the study's results will apply nationally, after weighting. Stratification by practice size and rurality will allow comparisons between 6 study groups (large, medium-sized, small; urban and rural practices). Records of equal numbers of patients from each study group will be included in the study because there may be systematic differences in patient harms in different types of practices. Eight general practitioner investigators will review 3 years of electronic general practice health records (consultation notes, prescriptions, investigations, referrals, and summaries of hospital care) from 9000 patients registered in 60 general practices. Double-blinded reviews will check the concordance of reviewers' assessments. Study data will comprise demographic data of all 9000 patients and reviewers' assessments of whether patients experienced harm arising from health care. Where patient harm is identified, their types, preventability, severity, and outcomes will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 18.0.

Results: We have recruited practices and collected electronic records from 9078 patients. Reviews of these records are under way. The study is expected to be completed in August 2017.

Conclusions: The design of this complex study is presented with discussion on data collection methods, sampling weights, power analysis, and statistical approach. This study will show the epidemiology of patient harms recorded in general practice records for all of New Zealand and will show whether this epidemiology differs by rural location and clinic size.

Keywords: New Zealand; electronic health records; general practice; patient harm; retrospective studies; safety.

Figure 1

Study design using Primary Health Organization data from the third quarter, 2013.

Figure 2

Relationship between patient safety terms. Red arrows indicate relationships between key terms addressed in this study. Blue arrows and opaque boxes indicate definitions and relationships between terms that are not the subject of this study. Yellow arrows indicate where terms are used to describe both “incidents” and “harm.”

Figure 3

Flowchart of study processes. Color key: yellow=practice engagement, orange=data extraction, blue=data review, and green=analysis. GP: general practitioner; PI: principal investigator.