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

Author

Listed:
  • Montserrat Gens-Barberà

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Núria Hernández-Vidal

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Elisa Vidal-Esteve

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Yolanda Mengíbar-García

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Immaculada Hospital-Guardiola

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain
    Primary Health-Care Centre, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Eva M. Oya-Girona

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain
    Primary Health-Care Centre, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Ferran Bejarano-Romero

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain
    Pharmacy Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Carles Castro-Muniain

    (Quality and Patient Safety Central Functional Unit, Gerència d’Atenció Primària Camp de Tarragona, Institut Català de la Salut, 43005 Tarragona, Spain)

  • Eva M. Satué-Gracia

    (Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain)

  • Cristina Rey-Reñones

    (Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain
    Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain)

  • Francisco M. Martín-Luján

    (Research Support Unit Tarragona-Reus, Institut Universitari D’investigació en L’atenció Primària Jordi Gol, (IDIAP Jordi Gol), Institut Català de la Salut, 43202 Reus, Spain
    Faculty of Medicine and Health Sciences, Universitat Rovira i Virgili, 43201 Reus, Spain
    Senior supervisory author.)

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.

Suggested Citation

  • Montserrat Gens-Barberà & Núria Hernández-Vidal & Elisa Vidal-Esteve & Yolanda Mengíbar-García & Immaculada Hospital-Guardiola & Eva M. Oya-Girona & Ferran Bejarano-Romero & Carles Castro-Muniain & Ev, 2021. "Analysis of Patient Safety Incidents in Primary Care Reported in an Electronic Registry Application," IJERPH, MDPI, vol. 18(17), pages 1-21, August.
  • Handle: RePEc:gam:jijerp:v:18:y:2021:i:17:p:8941-:d:621510
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    References listed on IDEAS

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    1. Kathrin M Cresswell & Sukhmeet S Panesar & Sarah A Salvilla & Andrew Carson-Stevens & Itziar Larizgoitia & Liam J Donaldson & David Bates & Aziz Sheikh & on behalf of the World Health Organization's (, 2013. "Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise," PLOS Medicine, Public Library of Science, vol. 10(11), pages 1-6, November.
    2. Davide Ferorelli & Biagio Solarino & Silvia Trotta & Gabriele Mandarelli & Lucia Tattoli & Pasquale Stefanizzi & Francesco Paolo Bianchi & Silvio Tafuri & Fiorenza Zotti & Alessandro Dell’Erba, 2020. "Incident Reporting System in an Italian University Hospital: A New Tool for Improving Patient Safety," IJERPH, MDPI, vol. 17(17), pages 1-12, August.
    3. Ann-Marie Howell & Elaine M Burns & George Bouras & Liam J Donaldson & Thanos Athanasiou & Ara Darzi, 2015. "Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data," PLOS ONE, Public Library of Science, vol. 10(12), pages 1-15, December.
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    Cited by:

    1. Marlene Manuela Moreira Ferreira & Andreia Sofia Costa Teixeira & Tiago Salgado de Magalhães Taveira-Gomes, 2022. "Safety Climate Evaluation in Primary Health Care: A Cross-Sectional Study," IJERPH, MDPI, vol. 19(21), pages 1-20, November.

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