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Objective To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. Design Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded. Setting Primary care. Participants Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients). Main outcome measures The incidence of significant harm considered at least 'probably avoidable' and the nature of the safety incidents. Results The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines. Conclusion There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care. [ABSTRACT FROM AUTHOR]

Background Relatively little is known about prescribing errors in general practice, or the factors associated with error. Aim To determine the prevalence and nature of prescribing and monitoring errors in general practices in England. Design and setting Retrospective case-note review of unique medication items prescribed over a 12-month period to a 2% random sample of patients. Fifteen general practices across three primary care trusts in England. Method A total of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients were examined. The data were analysed by mixed effects logistic regression. The main outcome measures were prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions. Results Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval [CI] = 4.4% to 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age <15 years (odds ratio [OR] = 1.87, 95% CI = 1.19 to 2.94, P = 0.006) or >64 years (OR = 1.68, 95% CI = 1.04 to 2.73, P = 0.035), and higher numbers of unique medication items prescribed (OR = 1.16, 95% CI = 1.12 to 1.19, P<0.001). Conclusion Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed, based on the study findings. [ABSTRACT FROM AUTHOR]

Background: Health care-related harm is an internationally recognized threat to public health. The United Kingdom's national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods: We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of 'significant harm'. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define "avoidable harm" within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results: Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion: The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion: We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients. [ABSTRACT FROM AUTHOR]

Objectives: To compare prevalence and types of dispensing errors and pharmacists' labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions., Design: Naturalistic stepped wedge study., Setting: 15 English community pharmacies., Intervention: Electronic transmission of prescriptions between prescriber and pharmacy., Main Outcome Measures: Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy., Results: Overall, we identified labelling errors in 5.4% of 16,357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12,624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types., Conclusions: We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice., Methods: RESEARCH SUBJECT GROUP: "At-risk" patients registered with computerised general practices in two geographical regions in England., Design: Parallel group pragmatic cluster randomised trial., Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support., Primary Outcome Measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs; - with a computer-recorded diagnosis of asthma being prescribed beta-blockers; - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. SECONDARY OUTCOME MEASURES; These relate to a number of other examples of potentially hazardous prescribing and medicines management., Economic Analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. QUALITATIVE ANALYSIS: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective., Sample Size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm., Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

Aims: To examine the relationship between hormone replacement therapy (HRT) and acute myocardial infarction (AMI) adjusting for coronary risk factors and social and behavioural confounders that might indicate a healthy user effect and could account for the discrepancy between randomized and observational studies of HRT use., Methods: A case-control study of 864 women aged between 35-65 suffering an AMI with two age matched community controls from the same geographical area. Information was collected by interview and from general practitioner records. Conditional logistic regression was used to calculate odds ratios (OR) adjusted for diabetes, hypertension, smoking, alcohol, social class, family history and a health conscious behaviour score., Results: HRT use was recorded for 34% of non-fatal AMI cases and 39% of controls with the adjusted OR for ever-use of HRT versus never-use being 0.74 (95% CI 0.55-0.99). The pattern of risk of AMI was similar for oestrogen only and combined HRT. During the first 12 months of HRT use there was a small increase in risk of AMI with the adjusted OR being 1.14 (0.72-1.80). HRT use for 13-60 months was associated with a small reduction in AMI risk (adjusted OR 0.85, 0.55-1.29). Only HRT used for >60 months was associated with a substantial risk reduction (adjusted OR 0.42, 0.24-0.73). Data for deceased cases and controls showed a similar pattern., Conclusions: HRT use whether as oestrogen only or combined hormones was only associated with a significant reduction in risk when used for greater than 60 months. These findings could reflect a dual effect of HRT on AMI risk by prothrombotic and anti-atherogenic mechanisms. Neither oestrogen only or combined HRT can be recommended for prevention of coronary artery disease.

The role of nurse practitioner (NP) is increasingly integrated into the primary healthcare team, yet there remains some confusion among general practitioners about what the role entails. Following on from previous work (Carr et al, 2001), this study indicates that the majority of GPs surveyed were supportive of the integration of the NP role in primary care, both to help reduce the GPs' workload and more importantly to give the patient a choice of who to consult. However, there was some difference in opinion as to what tasks were most appropriately linked to the NP role. This may be due to the GPs' lack of knowledge and experience of the role. There were also some reservations about the financial cost of training and employing NPs. If the health needs of the population are to be met and high quality, seamless care provided, the NP could provide a solution.