Patient Safety Incident
Classification in Primary Care
Preliminary recommendations of an expert
advisory group
Kerstin Klemp, Barbara Hoffmann, Ferdinand M. Gerlach
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Learning from International Networks about Errors and
Understanding Safety in Primary Care
Focus on primary and generalist care
To develop a network of practitioners and researchers
UK, NL, DK, D, A, PL, E
Classification, medication and diagnostic errors,
learning, safety culture, patient involvement, nascent
organisations
http://www.linneaus-pc.eu
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
The expert group
Who?
- GP‘s , Family Physicians & Psychologist
- Practicioner & Scientists
What?
- Recommendations on the content and structure of a
classification system
How?
- Meetings
- Web-based discussions
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
The results
Definition
“A patient safety incident in primary care is any unintended event
or hazardous condition resulting from the process of care,
rather than due to the patient‘s underlying disease, that led or
could have led to unintended health consequences for the
Patient.“
Recommendations
-
13 paragraphs regarding object, aim, content and structure
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Object of classification
Focus on ‘patient safety incidents’ rather than on
‘errors’ to avoid the presumption that a single person is
mainly responsible for the occurrence of the event.
- do not stop investigation by finding one “cause”
- use systems approach
- not only actions but also conditions and circumstances
- focus on consequences in terms of no (but potential) harm as
well as of actual harm
- We found five systems to focus on errors.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Aim of the classification system
Support such tasks as monitoring organisational
change and learning, conducting reviews and audits,
carrying out epidemiological studies, and analysing
litigation data.
Be usable within the different European health care
systems.
- Serve several purposes:
- Aggregation
- learning,
- improvement,
- comparison
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Flexibility of the system
Be feasible for application with different levels of
granularity.
Have a modular structure in order to ensure adaptation
is possible.
- different user with different aims and demands
- We found six to be applicable in a user defined mode.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Application of the system
Be applicable to and support the analysis of all patient
safety data that are generated in primary care: staff
reports, patient reports, malpractice claims, case notes
reviews etc.
Contain categories that indicate a lack of information, or
unclassifiable data.
Patient
- blind spots in data
- tool is always in change
- We found eight to be used for
reports and case notes review.
MC
Staff
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Basis of the system
Be based on a model, theory or framework of human
behaviour, as well as on empirical data and evidence.
- Swiss cheese model by Reason
- S-R-K model by Rasmussen
- Organisation of tasks in practice
- We found eight to be empirical based, four to be theory based
and three to be based on a mixed approach.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Compatibility of the system
Include comprehensive modules for analysing incidents
in such a way that they allow cross referencing to well
developed and tested systems.
- tool development is expensive
- diagnostic errors
- medication errors
- severity scale
- We found cross referencing or adoptions in four systems.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Factors leading to an incident
Allow for the classification of contributing factors to a
patient safety incident but also enable factors to be
labelled causal if possible.
- variety of factors
- Hindsight bias
- Fundamental attribution error
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Dimensions of the system
Involve modules for the type of incident, the
contributing/causal factors to the incident, the outcome
of the incident, details of the patient safety incident, and
incident prevention strategies for future events.
- Use depends on aims
- We found 16 systems to have a class “causal/contributing
factors”. Eight have additional classes such as type, setting,
persons involved, outcome, prevention and mitigation.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Definition of terms
Provide a definition for every class in the system to
facilitate the unambiguous allocation of information to a
class.
- What is meant by “incident type”?
- What exactly is an outcome?
- We found six classification systems to have definitions, at least
for high level classes.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Structure of the system
Include a hierarchy with a limited number of levels.
- reduce burden
- time
- cognitive effort
- decreasing reliability
- We found numbers of levels from three up to seven.
No single system meets all recommendations.
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Next steps
Development of a classification system
-
Web-based modified Delphi Survey
Development of a model reporting system
[email protected]
Arbeitsbereich Patientensicherheit, Kerstin Klemp
Johann Wolfgang Goethe-Universität, Frankfurt am Main
Thank you!