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

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, Eva M. Satué-Gracia, Cristina Rey-Reñones and Francisco M. Martín-Luján
Additional contact information
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
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
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
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
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

IJERPH, 2021, vol. 18, issue 17, 1-21

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.

Keywords: primary care; patient safety; incident notification; risk management (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2021
References: View references in EconPapers View complete reference list from CitEc
Citations: View citations in EconPapers (1)

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