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Patient safety in Primary Care

Why are we focusing on patient safety in primary care?

There is an increasing understanding of the importance of patient safety in the delivery of health care. Landmark studies in the USA, Australia, the UK, Denmark and the Netherlands have attempted to assess the contribution of adverse events causing harm to patients and have resulted in major initiatives for improving patient safety in many countries. However, no country can claim to have fully come to grips with the problem of patient safety.

The importance of primary care in health care systems

It is important to recognise that in many countries in Europe, access to specialist care occurs through the medium of primary or generalist care. Using the UK as an example, 85% of contacts with the National Health Service take place in primary care and there are 300 million general practice appointments each year. This means that nearly 750,000 patient consult their GP each day. In Germany the contact rates are even higher – approximately 1.5 million visits per day to primary care physicians with GPs and general internists issuing 550 million prescriptions per year (representing more than 73% of all prescriptions issued outside hospital). It is estimated that in the Netherlands, every citizen has 2.6 general practitioner consultations per year. The simple point that we would make is that primary care is a vast organised sector for health care with millions of interactions occurring every day throughout the European Union.

Why we need to study patient safety in primary care

Currently, the greatest focus in all member countries active in the field of patient safety is primarily focused on hospital and specialist care with little activity in primary/generalist care. Whilst there is also an appropriate focus on systems and organisations with an increasing emphasis on safety culture, leadership and clinical governance, much of this activity is again concentrated on hospital and regional organisations and not on clinicians and teams working at the primary care level. This is even the case in countries where there are national organisations responsible for patient safety – for example neither the UK , the Netherlands, Denmark or Germany have developed sustained initiatives which have focused on and developed improvements for patient safety in Primary Care. There is also currently a lack of synergy between research groups working in this area and this probably contributes to the relative lack of research related to primary care and the primary/secondary interface.

The potential for adverse events in primary care is huge but the knowledge base about patient safety in this context is minimal. A literature review of the nature and frequency of error in primary care suggested that there are between 5-80 safety incidents per 100,000 consultations which in the UK would translate to between 37-600 incidents per day. The vast majority of incidents can be categorised into 4 main areas covering diagnosis, prescribing, communication between health care providers and patients, and organisational (administrative problems fall within this category). So although the potential for error is great, our analysis of medico-legal databases suggests that 50% are of no consequence, 20% result in non-clinically relevant delays in diagnosis, 10% result in upset patients but more significantly 20% of errors could have serious consequences16. Set within the context of a large number of healthcare interactions, this becomes a significant problem, even if we accept the limitations of transposing information from studies of medico-legal databases to the generality of care.

The lack of focus on primary care is not unusual. Although there has been an explosion of interest in patient safety in the last decade and a half with many governments responding with major initiatives as described above, an analysis of citations shows that the vast majority of research focusing on patient safety – whether it be on issues of epidemiology, on psychology or sociology or on much rarer interventions - have focused almost exclusively on hospital/specialist care3. There are several reasons for this:

• Firstly, there is a perception of primary care as a low technology environment where safety is not a problem and which therefore engenders a lower profile than the acute sector.
• Secondly, primary care is much more heterogeneous in its organisational arrangements. In virtually all European countries the organisational arrangements between primary and secondary care are different and complex and there is a multiplicity of sites where primary care is carried out (the clinician’s office, the telephone and the patients’ home).
• Thirdly, the interfaces between primary and specialist care are hugely important and vary widely between European countries, making the study of patient safety at the interface problematic.
• Finally, consultation and interpersonal skills are critical to the delivery of primary care and exploring issues related to patient safety in this area raises specific challenges. All these factors make the study of patient safety in primary care difficult. Primary care accounts for more than 75 to 80% of the health concerns reported to a physician, while hospital care does only for about 5%. Even if the risk is lower in primary care, the magnitude makes primary care a significant area of concern.

Primary care of course also does not solely focus on general practitioners. Community nurses, community pharmacists, mental health care workers all interact with patients in the primary care setting. Patient safety issues therefore transcend professional boundaries but more importantly may contribute to problems that occur down the line when the patient enters specialist care. Delayed diagnosis, failures of co-ordination of care, medication errors are examples of errors which may have their genesis in the primary care setting but which can have significant ramifications for the patients in more specialised settings. The need to study patient safety in this context is in our view incontrovertible.