Patient safety reporting is a key element of management within diagnostics, therapy, rehabilitation and care. Well done constitutes example of good clinical practice. This allows not only for feedback (lessons learned) and increasing level of services, but widely: for more holistic approach to patient. But there can be observed also pressure to achieve better statistically significant results (=tendency to decreasing the number of incidents), and omitting direct responsibility (= health care center in not guilty), to achieve increased effectivity. This way clinical center can focus on financial results and issues  reflected in reports, not whole therapy as continuous process. Answer lies in proper rating and financing of the health care services: is the health care center "factory" or not.

I would say lack of awareness is a important barrier. In general practice, the basic aim is to provide relief for the patients. If a said patient does experience any events, he or she mostly does not report it. He may seek alternative treatment or change the physician altogether. If the patient does report it, how many physicians follow up with the report is also an important consideration. The physician many a times may say that this things happen with the drug and may change the therapy; the patient is satisfied with this. Also, there might be a fear of jeopardising his practice if a physician reports the event, as it may give out wrong signals that the physician is not a good one. One of the remedies for this can be an form provided to the patient, who can then fill it out, if he or she experiences any events. There can be box kept at all physicians clinic and then the reports could be gathered by authorities for further follow-up. The physician should not have access to the box and this could be done may be once a month. This would preserve the anonymity of both patients and physicians. But again the question of logistics and resources does arise.

One other important factor that could explain such lag in general practice is the time constraint.

Reporting an error or an adverse effect like an adverse drug reaction requires time to state the facts and report them to the adequate authority. Such time is often deemed more valuable in a private practice than in the hospital, financially speaking.

In my opinion this could explain a good part of the difference between hospital and general practice.

To further add on what has previously been said, one setback to reporting errors can arise from what has been summarized as "the culture of blame", i.e an environment not prone to error (self) assessment.

" The culture of blame is a major barrier to the openness required if sentinel events are to be reported, lessons learnt and safety improved."

Learning from Bristol. The report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995. London Stationery Office, 2001

For developing countries, it is important to separate patients reporting mechanims and institutional mechanisms (supervision). Concerning, patient side, an exploratory study conducted in RDC in primary care setting showed that patients did not used to report even if there were a lot of concerns or complaints. Associated reasons were the lack of transparent and confidential report system, the fear of reprisals, the lack of awareness and asymetry of Knowledge and information. Most of time, patients who had concerns used intermediaries (if they are confident with them) such as community health workers, local authorities or village chief. 

This is related to social accountability (clients) and bureaucratic accountability (supervisors) and health providers responsiveness.

May I suggest a book "Unsafe to Safe" by Dr. Michael White,

http://www.amazon.com/UnSafe-Safe-Impatient-Proposal-Patient-centered/dp/1479103691

which reviews the barriers and facilitators of reporting medical errors.  It proposes an environment of patient safety from the CEO of the hospital/ medical facility through the staff to the person with the seemingly most mundane position.  How many times has an adverse patient outcome been produced by a person in facilities or CMS not cleaning the environmental surfaces or equipment?  There must be a culture of safety that emphasizes finding a solution to adverse outcomes through root cause analysis.  I've always felt it is better to "Fix the problem, not the blame."

This is a very important question and should be addressed by the establishment of

health systems by encouraging the team approaach . By this  I mean to integrate each primary care physiciian in a team that includes a senior specialist and meets on a regular basis to discuss each new case and selected  other cases . This is close to what is going on in the hospital system . It will not eradicate all errors in primary care but is a step toward improvement  will somehoww  mitigate the feeling of professional loneliness of GP's in community practice.

Dr. Panesar - patients are more likely to know if something is wrong when they are in a serious condition (hospitalized) as opposed to when they are out-patients. This is primarily due to the urgent nature of treatment in a hospital setting versus more routine visits in primary care. I agree with Dr. Upadhyay that lack of awareness in many instances may be the reason for lack of reporting. Fear of reprisal is an unfortunate reality for some developing countries; however, I do not believe that is a barrier for patients in Wales or England. I think the latitude for physicians to cover-up mistakes is greater in an out-patient setting as opposed to critical care.

Having spent over 20 years analysing medication clinical incidents individually and the trends over time in NHS hospital and Community Health Services settings I would offer the following experiences: 

To begin to understand this question, one has to turn it over and ask "why are hospitals better?" Nurses are by far the best reporters of incidents in hospitals. Drs in hospitals are not good at reporting incidents and errors.Drs, over the years, have improved their attitude in looking at prescribing incidents and changing behaviours.

Drs in Primary Care in the UK are poor reporters in terms of numbers of incidents.

The key to the question may be to link up the structure-process-outcome model. NRLS reporting is a process. Assuming the outcome desired is improvement in safety for patients then report the trends. The Government abolished the NPSA (bad move in terms of this question) as it was a "QUANGO" so we lost momentum. The structure should be one where incidents are analysed and fed back to keep the incident reports coming in.

The NPSA indicated that a good safety culture is indicated by high reporting rates (somewhat counter-intuitive for some perhaps) with low levels of reported harm to patients.

What's the benefits? High reporting rates in hospitals has facilitated NPSA Safety reports, now linked in to CQC standards, which have caused NHS organisational changes to improve safety.

A potentially intractable problem may be that UK GPs are contracted to, but not part of, the NHS so the culture is different.

The GMC has recognised the problem with medicines incidents (the most frequent by numbers in NRLS data) in the results of the Practice Study which interestingly was conducted for them by Pharmacists http://www.gmc-uk.org/Investigating_the_prevalence_and_causes_of_prescribing_errors_in_general_practice___The_PRACtICe_study_Reoprt_May_2012_48605085.pdf

Perhaps the barriers are GPs themselves and the potential facilitators are within provisison of an analytical and reporting system that encourages further reporting? GPs will need to be more receptive and responsive to Patient Safety Alerts.

Thanks for the stimulating discussion. Both patient reporting and institutional reporting systems in a rural primary health care system in South Africa are dependent on the health personnel. It is the duty of the health personnel to educate and inform the patient of the possible adverse effects e.g. when taking drugs or undergoing a procedure. What happens in the case of the adverse event once again depends on

a) the identification of the event as an adverse one- by patient or health care professional

b) Root cause analysis to find out who did what, what,when, where and why it went wrong. here it is important to differentiate between incompetence, negligence and system failures e.g. shortage of personnel, drugs etc

c) Consequences- what happens if they find out that the woman delivered alone while the only midwife on duty was attending to another patient.

Do they fire the midwife who was ding all she could under the circumstances, does the midwife blame the woman for pushing when she had told her to wait, do the politicians come in and say this is unacceptable without ensuring that the staff shortage that led to this event is a responsibility of theirs.

It starts with defining the goals, ensuring the resources are in place (human , material), making sure systems are in place to identify health care workers with a knowledge and skills deficit ( if knowledgeable they can inform the patients well on what to expect and will also identify the adverse event early and act accordingly), responding to their concerns of safety and service delivery, trust, mentoring and supportive supervision and not policing.

The role of managers in this regard is indispensable

Another factor is knowing how/ where to report, and ease of reporting. When you work for a trust, reporting a significant event is easy, the form/ pathway is clear, and a manager handles the rest. In General Practice the pathway is less clear. GPs are used to handling their own significant events within the practice. Discussing significant events at partners meetings and at one's appraisal is a recent development. The significant event does not travel beyond that. Some GPs have a very low threshold for picking up significant events, including prescriptions errors caught in time, out of date equipment, etc. Others have a much higher threshold, reporting only when something goes wrong, e.g. a missed diagnosis. I think that a clear pathway, standards of what to report, an easy reporting procedure, and feedback on what others are reporting and how it has improved safety, may increase reporting. 

I agree. The ease of reporting, how to report, what to report all boils done to systems in place, people working in the system, tools, standard operating procedure and guidelines and this needs to be supervised, evaluated and re-evaluated by staff and management and what is obsolete needs to replaced and ways to improve efficiency and effectiveness sought. This is not a once off action but continuous (TQM) and systems thinking is indispensable in this.

Hi,

I’m not entirely familiar with the patient safety initiative and the process of error reporting in England & Wales but I would envisage that GPs utilise SEAs within practice as their primary mechanism for reporting errors, i.e. local reporting mechanisms. Could it be that there is a perception the current national system is not responsive to the needs of primary care and hence why it is not used?

It might be worthwhile comparing and contrasting the approach to patient safety in Scotland administered via the Scottish Patient Safety Programme (SSPS).  See http://www.scottishpatientsafetyprogramme.scot.nhs.uk/about-us or contact them to discuss further.

Also Paul Bowie and Carl de Wet have just published a very comprehensive text  'Safety and Improvement in Primary Care' which might provide further insights.

See http://www.amazon.co.uk/Safety-Improvement-Primary-Care-Essential/dp/1846195802

Thanks for your response Clare (and all),

Really impressive work going on in Scotland. In fact Paul and Neil will be sharing some of their lessons in the upcoming WHO Roadmap for Safer Primary Care. 

SEAs do not routinely make it into the National Reporting and Learning System (NRLS) in England and Wales and so there is very little opportunity to aggregate the findings of all SEAs (likely 2 per GP, so about 70,000 in England and Wales per annum at the very least). Keen to explore what the levers and barriers would be for GPs to report more to the NRLS.

Janet: thanks for your very valid point on TQM.

Wj: Perhaps we need to rethink what patient safety means in primary care? You are right, most efforts and hence mechanisms of reporting were aimed at acute settings. Most GP practices have limited capabilities, for example there is no patient safety officer, risk manager, etc.

Emilia: rating might be one option 

Nathan - time constraint is such a problem and there is limited time, if any to do anything else other than seeing patients.

Sudarshan: the box idea seems popular. An alternative might be for GP computer systems and hence electronic patient records to have some sort of ehealth intervention to highlight cases where unsafe care may have occurred and then discuss them monthly, perhaps?

Eric: Great point on differences between LMICs and high-income countries.

In the Netherlands a dissertation was published on this topic by DL Zwart, entitled 'Incident reporting in general practice'. (2011)

By searching this author on Pubmed you find some chapters as articles, that may inform you on aspects that contibute to incidents reporting and patient safety.

The US has the Agency for Healthcare Research and Quality (AHRQ). The following link shows how patient safety errors are complied: http://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html