Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application

Abstract

Objectives: (1) To describe the epidemiology of patient safety (PS) incidents registered in an electronic notification system in primary care (PC) health centres; (2) to define a risk map; and (3) to identify the critical areas where intervention is needed.

Design: Descriptive analytical study of incidents reported from 1 January to 31 December 2018, on the TPSC Cloud™ platform (The Patient Safety Company) accessible from the corporate website (Intranet) of the regional public health service.

Setting: 24 Catalan Institute of Health PC health centres of the Tarragona region (Spain).

Participants: Professionals from the PC health centres and a Patient Safety Functional Unit.

Measurements: Data obtained from records voluntarily submitted to an electronic, standardised and anonymised form. Data recorded: healthcare unit, notifier, type of incident, risk matrix, causal and contributing factors, preventability, level of resolution and improvement actions.

Results: A total of 1544 reports were reviewed and 1129 PS incidents were analysed: 25.0% of incidents did not reach the patient; 66.5% reached the patient without causing harm, and 8.5% caused adverse events. Nurses provided half of the reports (48.5%), while doctors reported more adverse events (70.8%; p < 0.01). Of the 96 adverse events, 46.9% only required observation, 34.4% caused temporary damage that required treatment, 13.5% required (or prolonged) hospitalization, and 5.2% caused severe permanent damage and/or a situation close to death. Notably, 99.2% were considered preventable. The main critical areas were: communication (27.8%), clinical-administrative management (25.1%), care delivery (23.5%) and medicines (18.4%); few incidents were related to diagnosis (3.6%).

Conclusions: PS incident notification applications are adequate for reporting incidents and adverse events associated with healthcare. Approximately 75% and 10% of incidents reach the patient and cause some damage, respectively, and most cases are considered preventable. Adequate and strengthened risk management of critical areas is required to improve PS.

Keywords: incident notification; patient safety; primary care; risk management.

Figure 1

Flowchart illustrating how patient safety (PS) reports were selected, included, and excluded.

Figure 2

Pareto chart of the frequency of incidents according to WHO categorization. (a) Total PS incidents. (b) Adverse events. WHO 10-categories: C1: falls and other accidents; C2: patient behaviour; C3: clinical equipment and devices; C4: analogue and digital documentation; C5: clinical management and procedures; C6: clinical-administrative management; C7: infection associated with healthcare; C8: severe nosocomial pressure ulcers; C9: infrastructures and facilities, and C10: medication [30].

Figure 3

Risk map of the causal factors of the patient safety incidents. The figure shows the causal factors according to the APEAS model of the total patient safety incidents notified (section A; n = 1129) and adverse events notified (section B; n = 96) [19].

Figure 4

Pareto diagram of contributing factors frequencies in relation to the severity of the patient safety incident. The figure shows the contributing factors according to the WHO classification of the total patient safety incidents notified (n = 1129) [7]. Each incident can have one or more contributing factors. PROF: professional, ORG: organisation; EXTER: external; PAT: patient; ENVIR: environment.