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Primary care safety incidents occurring 'due to system weaknesses'

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Improved electronic systems could help to eliminate poor communication and drug administration errors that harm older patients treated by GP practices, according to a new study looking at primary care safety incidents.

The research, by Cardiff University School of Medicine, is based on nearly 1,600 reports of patient safety incidents in England and Wales over an eight-year period - all relating to people aged over 65 who were seen in primary care.

Just under a third of incidents – 31% – were down to drug prescribing, dispensing and administration errors, with 15% of those causing serious harm.

”Human factors and system weaknesses were more commonly described to contribute to incidents than patient-related factors such as multi-morbidity”

Research on primary care safety incidents

Communication issues – such as information not being passed between primary and secondary care – accounted for a quarter of patient safety incidents with 12% of those causing serious harm.

Meanwhile some of the most serious incidents were down to clinical decision-making errors – 203 incidents in all, with 41% of those causing serious harm.

The research paper, called Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports, was published in journal Age & Ageing, owned by the British Geriatrics Society.

Study author Dr Andrew Carson-Stevens, who is patient safety research lead at Cardiff University’s primary and emergency care research centre, said the findings highlighted “weaknesses in the current healthcare system”.

“Safe, high quality care is delivered in primary care every day. However, patient safety incident reports provide us with a means of learning about what changes could be needed, and how we might go about designing safer systems of care delivery for older patients,” he said.

“The study highlights weaknesses in the current healthcare system that must now form the basis of further research and improvement activity.

”As more older adults are being treated in community settings, healthcare systems must be designed to meet the needs of the population served”

Dr Andrew Carson-Stevens

“As more older adults are being treated in community settings, healthcare systems must be designed to meet the needs of the population served,” he added

The paper suggests wider use of standard electronic communication systems in the community could help prevent human errors being made.

These include bar code-based systems that send out automatic alerts to help reduce drug administration errors.

Meanwhile ensuring GPs and practice nurses have access to specialist geriatric advice would also help improve decision-making and the management of complex multiple conditions in the elderly.

This study highlights how dependent older adults are on the healthcare system to document and communicate essential information regarding their care,” said the paper.

“Human factors - such as misread drug names - and system weaknesses, such as poor communication systems or inadequate protocols, were more commonly described to contribute to the incidents than patient-related factors such as multi-morbidity and polypharmacy,” it added.

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