Adverse Events In Primary Care Research Articles

Conhecimento de enfermeiros sobre evento adverso na atenção primária à saúde

Objetivo: analisar o conhecimento dos enfermeiros sobre segurança do paciente e eventos adversos na atenção primária. Método: estudo descritivo, exploratório de abordagem qualitativa realizado com enfermeiros da Estratégia de Saúde da Família, na regional de saúde leste de Teresina-PI. A técnica de coleta de dados foi a entrevista semiestruturada realizadas no período de dezembro de 2017 a junho de 2018. Os dados foram submetidos à Análise de Conteúdo Temática. A pesquisa foi autorizada pelo Comitê de Ética em Pesquisa da Universidade Federal do Piauí sob o número de parecer 2.216.546. Resultados: a partir da análise de conteúdo emergiram duas categorias: Conhecimento das enfermeiras sobre segurança do paciente e eventos adversos; Eventos adversos e estratégias para minimizar seus efeitos na atenção primária. Considerações Finais: identificou-se que os profissionais, em parte, confundem evento adverso com reação adversa relacionada a medicamentos ou vacina, por exemplo. E o conceito de segurança do paciente foi ampliado, dentro da abordagem da Atenção Primária à Saúde. Observou-se uma necessidade de medidas mais efetivas em torno da temática como trabalhar a comunicação interprofissional; melhorar a gestão dos recursos; motivá-los a compartilhar dúvidas e acontecimentos como forma de aprendizagem.

The Accuracy of Trigger Tools to Detect Preventable Adverse Events in Primary Care: A Systematic Review.

To understand the ability of trigger tools to detect preventable adverse events (pAEs) in the primary care outpatient setting using the Institute for Healthcare Improvement's (IHI) Outpatient Adverse Event Trigger Tool (IHI Tool). The OVID MEDLINE and OVID MEDLINE In-process and non-Indexed citations databases were queried using controlled vocabulary and Medical Subject Headings related to the concepts "primary care" and "adverse events." Included articles were conducted in the outpatient setting, used at least 1 of the triggers identified in the IHI Tool, and identified pAEs of any type. Articles were selected for inclusion based first on assessment of titles then abstracts by 2 trained reviewers independently, followed by full text review by 2 authors. Our search identified 6435 unique articles, and we included 15 in our review. The most common studied trigger was laboratory abnormalities. The most common pAEs were medication errors followed by unplanned hospitalizations. The effectiveness of triggers in identifying AEs varied widely. There is insufficient data on the IHI Tool and its use to identify pAEs in the general real-world outpatient setting. Health care providers of the primary care setting may benefit from better trigger tools and other methods to help them detect pAEs. More research is needed to further evaluate the effectiveness of trigger tools to reduce barriers of cost and time and improve patient safety.

Professional, structural and organisational interventions in primary care for reducing medication errors.

Professional, structural and organisational interventions in primary care for reducing medication errors.

Provider Perspectives on Safety in Primary Care in Albania.

The purpose of this study was to determine the safety attitudes of specialist physicians (SPs), general physicians (GPs), and nurses in primary care in Albania. The study was cross-sectional. It involved the SPs, GPs, and nurses from five districts in Albania. A demographic questionnaire and the adapted Safety Attitudes Questionnaire (SAQ)-Long Ambulatory Version A was used to gather critical information regarding the participant's profile, perception of management, working conditions, job satisfaction, stress recognition, safety climate, and perceived teamwork. The onsite data collectors distributed questionnaires at the primary care clinics and then collected them. Descriptive statistics were used to summarize the responses. The significance of mean difference among SPs, GPs, and nurses was tested using analysis of variance. Five hundred twenty-three questionnaires were completed. The concept of patient safety in relation to job satisfaction received the highest ratings. Stress recognition had low ratings. There was a high level of teamwork in SPs, GPs, and nurses. Healthcare staff agreed that it was difficult to discuss errors in their primary healthcare center. Physicians in contrast to nurses were most likely to affirm that they do not make errors in hostile situations. Errors are difficult to discuss. It was clear that primary care staff, such as physicians, never considered the likelihood of errors occurring during tense situations. Staff at primary healthcare centers are used to adverse events and errors. Despite the demand for safety improvement and the existing evidence on the epidemiology of outpatient medical errors, most research has only been conducted in hospital settings. Many patients are put at risk and some are harmed as a result of adverse events in primary care. Adequate communication and technical skills should be utilized by primary care providers (PCPs) for improvement of patient safety. The patient safety measures should include assessment of the safety attitudes of PCPs.

Capsule Commentary on Kroll et al., Benzodiazepines Are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care.

Capsule Commentary on Kroll et al., Benzodiazepines Are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care.

Benzodiazepines are Prescribed More Frequently to Patients Already at Risk for Benzodiazepine-Related Adverse Events in Primary Care.

Benzodiazepine use is associated with adverse drug events and higher mortality. Known risk factors for benzodiazepine-related adverse events include lung disease, substance use, and vulnerability to fracture. To determine whether benzodiazepine prescribing is associated with risk factors for adverse outcomes. Longitudinal cohort study between July 1, 2011, and June 30, 2012. Patients who visited hospital- and community-based practices in a primary care practice-based research network. Odds ratio of having a target medical diagnosis for patients who received standard and high-dose benzodiazepine prescriptions; rates per 100 patients for outpatient and emergency department visits and hospitalizations. Among 65,912 patients, clinicians prescribed at least one benzodiazepine to 15% (9821). Of benzodiazepine recipients, 5% received high doses. Compared to non-recipients, benzodiazepine recipients were more likely to have diagnoses of depression (OR, 2.7; 95% CI, 2.6-2.9), substance abuse (OR, 2.2; 95% CI, 1.9-2.5), tobacco use (OR, 1.7; 95% CI, 1.5-1.8), osteoporosis (OR, 1.6; 95% CI, 1.5-1.7), chronic obstructive pulmonary disease (OR, 1.6; 95% CI, 1.5-1.7), alcohol abuse (OR, 1.5; 95% CI, 1.3-1.7), sleep apnea (OR, 1.5; 95% CI, 1.3-1.6), and asthma (OR, 1.5; 95% CI, 1.4-1.5). Compared to low-dose benzodiazepine recipients, high-dose benzodiazepine recipients were even more likely to have certain medical diagnoses: substance abuse (OR, 7.5; 95% CI, 5.5-10.1), alcohol abuse (OR, 3.2; 95% CI, 2.2-4.5), tobacco use (OR, 2.7; 95% CI, 2.1-3.5), and chronic obstructive pulmonary disease (OR, 1.5; 95% CI, 1.2-1.9). Benzodiazepine recipients had more primary care visits per 100 patients (408 vs. 323), specialist outpatient visits (815 vs. 578), emergency department visits (47 vs. 29), and hospitalizations (26 vs. 15; p < .001 for all comparisons). Clinicians prescribed benzodiazepines and high-dose benzodiazepines more frequently to patients at higher risk for benzodiazepine-related adverse events. Benzodiazepine prescribing was associated with increased healthcare utilization.

Measuring experiences and outcomes of patient safety in primary care: a systematic review of available instruments.

Despite the enormous potential for adverse events in primary care, the knowledge base about patient safety in this context is still sparse. The lack of appropriate measurement methods is a key factor limiting the development of research in this field. To identify and characterize available patient reported instruments to measure patient safety in primary care. We conducted a systematic literature review. We searched in bibliographic sources for empirical studies describing the development, evaluation or use of patient reported instruments assessing patient safety in primary care. Study selection and data extraction were independently conducted by two researchers. We identified 28 studies reporting on 23 different instruments. Fifteen instruments were designed for paper-based self-administration, six for phone interview and two consisted in electronic reporting systems. Most instruments focused on specific aspects of patient safety, most commonly on experiences of adverse drug reactions. Face validity was assessed for 10 instruments (43%), three reported construct validity (13%) and three described reliability (13%). Responsiveness was not ascertained. Although there is evidence of good psychometric properties for a reduced number of patient reported instruments, currently available instruments do not offer a comprehensive set of resources to measure the effects of interventions to improve patient safety in primary care from a patient perspective. Future research in the field should prioritize (i) the evaluation of the performance of already available instruments and (ii) the development of new instruments that enable an comprehensive assessment of patient safety at general practices.

Adverse events recorded in English primary care: observational study using the General Practice Research Database

More accurate and recent estimates of adverse events in primary care are necessary to assign resources for improvement of patient safety, while predictors must be identified to ameliorate patient risk. To determine the incidence of recorded iatrogenic harm in general practice and identify risk factors for these adverse events. Cross-sectional sample of 74,763 patients at 457 English general practices between 1 January 1999 and 31 December 2008, obtained from the General Practice Research Database. Patient age at study entry, sex, ethnicity, deprivation, practice region, duration registered at practice, continuity of care, comorbidities, and health service use were extracted from the data. Adverse events were defined by Read Codes for complications of care (Chapters S, T, and U). Crude and adjusted analyses were performed by Poisson regression, using generalised estimating equations. The incidence was 6.0 adverse events per 1000 person-years (95% confidence interval [CI] = 5.74 to 6.27), equivalent to eight adverse events per 10,000 consultations (n = 2,540,877). After adjustment, patients aged 65-84 years (risk ratio [RR] = 5.62, 95% CI = 4.58 to 6.91; P<0.001), with the most consultations (RR = 2.14, 95% CI = 1.60 to 2.86; P<0.001), five or more emergency admissions (RR = 2.08, 95% CI = 1.66 to 2.60; P<0.001), or the most diseases according to expanded diagnosis clusters (RR = 8.46, 95% CI = 5.68 to 12.6; P<0.001) were at greater risk of adverse events. Patients registered at their practice for the longest periods of time were less at risk of an adverse event (RR = 0.40, 95% CI = 0.35 to 0.47; P<0.001). The low incidence of recorded adverse events is comparable with other studies. Temporal sequencing of risk factors and case ascertainment would benefit from data triangulation. Future studies may explore whether first adverse events predict future incidents.

A study of the prevalence of adverse events in primary healthcare in Spain

Healthcare practices involve risks for patients, but there has been little research to date on the occurrence of adverse events (AE) in primary care (PC). The frequency of AE in PC in Spain, the factors that contribute to their occurrence, their severity and their preventability, were analysed. Observational cross-sectional study was carried out in 48 PC centres in 16 regions of Spain. PC professionals were asked to assess whether the AE was caused by the healthcare or if it was an expectable consequence of the patient's underlying condition. A total of 452 healthcare professionals who attended 96 047 consultations were involved. A total of 773 AE were identified, so that the point prevalence of AE was 0.8% [95% confidence interval (CI) 0.76-0.85]. A majority of AE (64.3%) were considered preventable and only 5.9% were severe, usually related to medication [odds ratio (OR) = 4.6; 95% CI 2.1-10.3]. The most frequent causal factor of the AE was associated with medication (adverse drug reactions and medication errors), but problems in communication and management were at the root of many of the AE. Nurses reported more preventable AE (OR = 1.9; 95% CI 1.2-2.8). In spite of an AE being less damaging in PC, large numbers of patients and professionals suffer their consequences each year. An awareness of the magnitude and impact of AE is the first step on the road to the cultural change necessary for achieving safer healthcare.

Routinely recorded patient safety events in primary care: a literature review

Existing patient-level data can be used to measure and monitor patient safety. Data from sources including electronic patient records are routinely collected in primary care and may be suitable for adverse event screening, such as patient safety indicators. To inform the feasibility of developing primary care measures of patient harm, information about routinely collected data is needed. A literature review was conducted to determine the types of adverse events that are routinely recorded in primary care. We searched ASSIA, Cochrane Library, Embase, HMIC, ISI Web of Science, Medline and PsycInfo databases, grey literature and websites. We included only original research studies in English where routinely collected patient data were used to identify adverse events occurring in primary or ambulatory care settings. Adverse events were defined as unexpected and undesirable patient outcomes arising from health care contact. Of 5029 citations identified, 15 were reviewed. Twelve studies used multiple data sources. Approximately 6.5% of adult emergency admissions were due to drug-related events (n = 1225). Between 0.7% and 2.3% of deaths following adverse events were attributed to treatment in primary care. A large proportion of adverse events resulting in the most severe harm may be preventable. For example, one study estimated that 42% of serious adverse drug events were avoidable. There is limited use of routinely collected data to measure adverse events in primary care despite large volumes of data generated. The potential for using readily available data recorded in primary care for active patient safety surveillance needs further exploration.

Erro médico: Eventos adversos em cuidados de saúde primários: Promover uma cultura de segurança

Patient safety has not been systematically included as a priority in the organization of care in Portuguese primary care health units. The concept of patient safety is not new and includes a group of activities designed to avoid adverse events in primary care. These adverse events include harm to patients, near misses, incidents, accidents and errors. Adverse events are caused by multiple factors and can be prevented. In order to do that, we need to know how anticipate and prevent these events. When they occur, we must be willing to report them, discuss them, share our experiences with others, and learn from them. Portuguese primary care requires a change towards a culture of safety which includes every act of care for the patient from the time of their entry until the time of their exit from the health care system.

Harm caused by adverse events in primary care: a clinical observational study

Patient safety in primary care is important, but not well studied. The aim of our study was to determine the actual and potential harm caused by adverse events in primary care. Observational study in two general practices, including the patients of five doctors. Two methods were used to identify adverse events; (1) a prospective registration of adverse events by the general practitioner and (2) a retrospective audit of medical records. Actual harm was registered and a clinical analysis was made to estimate potential harm. A total of 31 adverse events were collected and analysed. The adverse events were spread over different adverse event categories. About half of the events did not have health consequences, but a third led to worsening of symptoms and a few resulted in unplanned hospital admission. Potential negative health consequences were likely in three-quarters of the events. The identified adverse events had some impact on health outcomes, but a risk for harm existed in a majority of the events. Patient safety programmes in primary care should focus on adverse events and not just on harm.

Missed Diagnoses by Urologists Resulting in Malpractice Payment

Missed diagnoses are a patient safety concern and they can result in malpractice allegation. The specialist physician may be liable for missed or delayed diagnoses even if an abnormality in the physician area of expertise is ruled out. We approached this largely unstudied area of medical malpractice in an effort to increase physician awareness and identify opportunities for prevention. Working with the Medical Liability Mutual Insurance Company of New York State, we evaluated malpractice claims in urology that were closed with indemnity payment between 1985 and 2004. We identified all such claims resulting from alleged missed or delayed diagnoses by urologists. Claims were divided into 2 main categories based on whether the missed diagnosis was primarily urological, ie testis torsion, or not urological, ie appendicitis. A total of 75 missed diagnosis claims were identified, representing 15% of claims overall. The total indemnity payment for missed diagnosis claims was $32,591,013, which represented 27% of all indemnity payments for the study period. They were divided into 58 missed urological diagnoses and 17 missed nonurological diagnoses. Cancer represented 71% of missed urological diagnoses and 41% of missed nonurological diagnoses. Urological cancer missed diagnosis claims were associated with the highest average indemnity payment of $526,460. The average indemnity payment for missed diagnosis claims was 92% greater than the average indemnity payment for all other claims ($434,546 vs $226,133). An increase in the frequency of missed diagnosis claims closed with indemnity payment and in the amount of payment for missed diagnosis claims were observed during the 20-year study period. Indemnity payments resulting from missed diagnosis claims represent a disproportionately high percent of total indemnity payments (27%) due to a high average payment for such claims. Liability for the urologist resulted from missed diagnoses not only of urological conditions, but also of nonurological conditions.

Learning from malpractice claims about negligent, adverse events in primary care in the United States

<b>Background:</b> The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. <b>Methods:</b> Physician Insurers Association of America malpractice claims data (1985–2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. <b>Results:</b> Of 49 345 primary care claims, 26 126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with “diagnosis error” making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). <b>Conclusions:</b> Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.