A review of significant events analysed in general practice: Implications for the quality and safety of patient care

BMC Family Practice

Volumn 10, Issue , 2009, Pages

  McKay, John ^a   Bradley, Nick ^b   Lough, Murray ^b   Bowie, Paul ^b  

^a UNIVERSITY OF GLASGOW   (United Kingdom)

^b NHS EDUCATION FOR SCOTLAND   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONFIDENTIALITY; GENERAL PRACTICE; HEALTH CARE QUALITY; HEALTH PERSONNEL ATTITUDE; HUMAN; INCIDENT REPORT; LEARNING; MEDICAL ERROR; PATIENT ATTITUDE; PATIENT CARE; PATIENT SAFETY; TERMINALLY ILL PATIENT; CLINICAL COMPETENCE; CLINICAL PRACTICE; DRUG UTILIZATION; EDUCATION; GENERAL PRACTITIONER; MEDICAL AUDIT; MEDICAL EDUCATION; METHODOLOGY; PEER REVIEW; PSYCHOLOGICAL ASPECT; SAFETY; STANDARD; STATISTICS; UNITED KINGDOM;

ATTITUDE OF HEALTH PERSONNEL; CLINICAL COMPETENCE; DRUG UTILIZATION; EDUCATION, MEDICAL, GRADUATE; FAMILY PRACTICE; HUMANS; LEARNING; MEDICAL AUDIT; PATIENT CARE TEAM; PEER REVIEW; PHYSICIAN'S PRACTICE PATTERNS; PHYSICIANS, FAMILY; QUALITY OF HEALTH CARE; SAFETY MANAGEMENT; SCOTLAND;

EID: 70349569973     PISSN: None     EISSN: 14712296     Source Type: Journal    
DOI: 10.1186/1471-2296-10-61     Document Type: Article

References (49)

1. An organisation with a memory: learning from adverse events in the NHS. Department of Health, The Stationery Office London: Department of Health 2001
2. Doing Less Harm: Improving the safety and quality of care through reporting, analysing and learning from adverse incidents involving NHS patients - Key requirements for health care provider. Department of Health, Department of Health, London 2001
3. Incidence of adverse events and negligence in hospitalized patients. TA Brennan LL Leape NM Laird L Herbert AR Localio AG Lawthers JP Newhouse PC Weiler HH Hiatt, New Eng J Med 1991 324 370 6 1987460
4. To err is human. Building a safer health system. LT Kohn JM Corrigan MS Donaldson eds, Washington, DC: National Academy Press 1999 1 16
5. The Quality in Australian Health Care Study. RM Wilson WB Runciman RW Gibber BT Harrison L Newby JD Hamilton, Med J Aust 1995 163 458 71 7476634
6. Adverse events in British hospitals: preliminary retrospective record review. C Vincent G Neale M Woloshynowych, BMJ 2001 322 517 19 10.1136/bmj.322.7285.517 11230064
7. The Canadian Adverse Events study: the incidence of adverse events among hospital patients in Canada. GR Baker PG Norton V Flintoft R Blais A Brown J Cox, Canadian Medical Association Journal 2004 170 11 1678 86 10.1503/cmaj.1040498 15159366
8. Perceived causes of family physicians' errors. JW Ely W Levinson NC Elder AG Mainous DC Vinson, J Fam Prac 1995 40 337 44
9. Collecting data on potentially harmful events: a method for monitoring incidents in general practice. H Britt GC Miller ID Steven GC Howarth PA Nicholson AL Bhasale KJ Norton, Family Practice 1997 14 101 06 10.1093/fampra/14.2.101 9137946
10. Adverse events in primary care identified from a risk management database. G Fischer MD Fetters AP Munro EB Goldman, J Fam Prac 1997 45 40 7
11. The wrong diagnosis: identifying causes of potentially adverse events in general practice using incident monitoring. A Bhasale, Family Practice 1998 15 308 18 10.1093/fampra/15.4.308 9792345
12. An international taxonomy for errors in general practice: a pilot study. MAB Makeham SM Dovey M County MR Kidd, Med J Aust 2002 177 68 72 12098341
13. A preliminary taxonomy of medical errors in family practice. S Dovey D Meyers RJ Philips LA Green GE Fryer JM Galliher J Kappus P Grob, Qual Saf Health Care 2002 11 233 8 10.1136/qhc.11.3.233 12486987
14. The frequency and nature of medical errors in primary care:understanding the diversity across studies. J Sanders A Esmail, Family Practice 2003 20 231 6 10.1093/fampra/cmg301 12738689
15. Errors in general practice: development of an error classification and pilot study of a method for detecting errors. G Rubin A George D Chin C Richardson, Qual Saf Health Care 2003 12 443 7 10.1136/qhc.12.6.443 14645760
16. The identification of medical errors by family physicians during outpatient visits. N Elder MV Vonder Meulin A Cassidy, Annals of Family Medicine 2004 2 125 9 10.1370/afm.16 15083851
17. Case studies in litigation: claims reviews in four specialities. A Esmail G Neale M Elstein J Firthcozens C Davy C Vincent, Report published by the Manchester Centre for Healthcare Management. Manchester: University of Manchester 2004
18. The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice. MAB Makeham MR Kidd DC Saltman M Mira C bridges-Webb C Cooper S Stromer, Med J Aust 2006 185 2 95 98 16842067
19. Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors. O Kostopoulou B Delaney, Qual Saf Health Care 2007 16 95 100 10.1136/qshc.2006.020909 17403753
20. Error and safety in primary care: no clear boundaries. L Jacobson G Elwyn M Robling RT Jones, Family Practice 2003 20 3 237 41 10.1093/fampra/cmg302 12738690
21. Enhancing public safety in primary care. T Wilson A Sheikh, BMJ 2002 324 584 7 10.1136/bmj.324.7337.584 11884325
22. Deliberate departures from good general practice: a study of motives among Dutch general practitioners. M Veldhuis L Wigersma I Okkes, Br J Gen Practice 1998 48 1833 6
23. Promoting patient safety in primary care: research, action, and Leadership are required (editorial). T Wilson M Pringle A Sheikh, BMJ 2001 323 583 4 10.1136/bmj.323.7313.583 11557689
24. M Pringle CP Bradley CM Carmichael H Wallis A Moore, Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care Occasional Paper No 70, London, Royal College of General Practitioners 1995
25. Review of the current evidence base for significant event analysis. P Bowie L Pope M Lough, Journal of Evaluation in Clinical Practice 2008 14 520 36 10.1111/j.1365-2753.2007.00908.x 18462290
26. The investigation and analysis of critical incidents and adverse events in healthcare (review). M Woloshynowych S Rogers S Taylor-Adams C Vincent, Health Technology Assessment. (Winchester, England) 2005 9 19 1 43 15890139
27. Seven steps to patient safety for primary care. The National Patient Safety Agency. (NPSA), London: NPSA 2005
28. Appraisal: A Brief Guide. Scottish Executive, NHS Education for Scotland, RCGP (Scotland) and BMA (Scotland). GP, Edinburgh: Scottish Executive 2003
29. New GMS contract 2006/7. Department of Health, London Stationery Office 2006
30. Data Summary Issue 8 1 Jan 2007 to 31 March 2008. National Patient Safety Agency, http://www.npsa.nhs.uk/patientsafety/patient-safety-incident-data/ quarterly-data-reports/ (accessed 17 June 2008)
31. A qualitative study of why general practitioners may participate in significant event analysis and peer assessment. P Bowie J McKay E Dalgetty M Lough, Qual Saf Health Care 2005 14 185 9 10.1136/qshc.2004.010983 15933315
32. Development and testing of an assessment instrument for the formative peer review of significant event analyses. J McKay D Murphy P Bowie M-L Schmuck M Lough K Eva, Qual Saf Health Care 2007 16 150 3 10.1136/qshc.2006.020750 17403765
33. Learning issues raised by the educational peer review of significant event analyses in general practice. P Bowie S McCoy J McKay M Lough, Quality in Primary Care 2005 13 75 84
34. A retrospective review of significant events reported in one district in 2004-2005. SJ Cox JD Holden, Br J Gen Prac 2000 57 732 6
35. Significant event auditing and root cause analysis. M Pringle, Health Care Errors and Patient Safety Chichester: Blackwell Publishing, Hurwitz B, Sheikh A, 2009 193 206
36. Understanding adverse events: the human factor. JT Reason, Clinical Risk Management enhancing patient safety Blackwell BMJ books: London, Vincent CA, Second 2001 9 30
37. Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature. NC Elder SM Dovey, The Journal of Family Practice 2002 51 927 32 12485545
38. Patient safety and patient error. S Buetow G Elwyn, The lancet 2007 369 158 161 10.1016/S0140-6736(07)60077-4 (Pubitemid 46073135)
39. Are patients morally responsible for their errors? S Buetow G Elwyn, J Med Ethics 2006 32 260 2 10.1136/jme.2005.012245 16648274
40. WHO draft guidelines for adverse event reporting and learning systems. World Health Organisation, World Alliance For Patient Safety Geneva, Switzerland, WHO 2005 8 9
41. Variation in the ability of general medical practitioners to apply two methods of clinical audit: a 5-year study of assessment by peer review. J McKay P Bowie JRM Lough, Journal of Evaluation in Clinical Practice 2006 12 622 629 10.1111/j.1365-2753.2005.00630.x 17100861
42. Root Cause Analysis. National Patient Safety Agency, http://www.npsa.nhs. uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/ rootcauseanalysis/rcatoolkit/ (accessed 20 August 20, 2009)
43. Methodology and rationale for the measurement of harm with trigger tools. RK Resar JD Rozich D Classen, Quality & Safety in Health Care 2003 12 Suppl 2 39 45
44. Mix of methods is needed to identify adverse events in general practice; a prospective observational study. R Wetzels R Wolters R van weel M Wensing, BMC Family Practice 2008 9 35 18554418
45. Shame: the elephant in the room. F Davidoff, BMJ 2002 324 623 24 11895807
46. The science of improvement. D Berwick, JAMA 2008 299 1182 4 18334694
47. Reporting and learning systems. C Vincent, Patient Safety London: Elsevier. Churchill Livingstone, Vincent C, 2006 57 74
48. Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross sectional study. J McKay P Bowie L Murray M Lough, Qual Saf Health Care 2008 17 339 45 18842972
49. Patient safety events reported in general practice: a taxonomy. MAB Makeham S Stromer C Bridges-Webb M Mira DC Saltman C Cooper MR Kidd, Qual Saf Health Care 2008 17 53 7 18245220