What do primary care physicians and researchers consider the most important patient safety improvement strategies?

A web-based survey was conducted in a convenience sample of mostly European primary care physicians and researchers with an interest in patient safety. These were recruited in eight countries with a relatively strong primary care system: Austria, Denmark, France, Germany, the Netherlands, New Zealand, Slovenia and the United Kingdom. We identified a key person (from the LINNEAUS collaborative) in each of the countries and asked him or her to provide us with the names of 10 practising primary care physicians with a potential interest in patient safety and 10 researchers or experts in patient safety in their country. All were e-mailed and they received an invitation to the survey using an internet survey software programme. Non-respondents were sent a second invitation after one week and a third invitation one month later. The Medical Ethics Committee of the Radboud University Nijmegen Medical Centre approved this study.

The content of the questionnaire was based on earlier studies which explored what 'patient safety' consists of in primary care [8‐10]. In addition, five telephone interviews with international patient safety experts were conducted to develop this questionnaire. A set of the most salient points was then selected and put into a questionnaire, which was subsequently reviewed by three experts on patient safety in order to fine-tune the questions. The web-based survey comprehended five themes (practice facilities, patient safety management, communication and collaboration, generic conditions for patient safety and education on patient safety), which consisted of 38 patient safety promotion strategies (e.g. incident reporting, medication alerts, patient safety indicators, periodic medication review, training on patient safety or culture conditions). For each strategy, we inquired about current use in their own country (no, no but planned, yes <50% of GPs, yes >50% of GPs), and whether the strategy constituted a promising approach (yes very much, yes to some extent, partly yes/partly no, no probably not, no certainly not). The respondent could also provide comments per theme. Finally, we asked if any other promising approaches were seen, which had not been mentioned in our questionnaire. The data were entered into SPSS 16.0 for analysis. To examine the homogeneity across country samples, we used ANOVA tests to examine the differences of perceptions between countries.

Most of the presented practice facilities were seen as important for patient safety. Highest ranked an up-to-date electronic medical record and good telephone access to the practice. Both items were reported to be widely present. Planned safety checks, access to web based clinical guidance tools, agreements with the pharmacist, electronic reminders and alerts and computerized medication decision support were ranked highly relevant by 60 to 70% of the participants. These items were also seen as widely present. Computerized decision support regarding test ordering was ranked lowest. (table 2)

Practice-based incident reporting was seen as important, also in small educational groups. Measurement and feedback on patient safety indicators, and the presence of hygiene protocols (a protocol with suggestions how to improve hygiene in a practice) also scored above average. Nationwide incident reporting was perceived as less important, and incident reporting weeks were seen as even less important. Periodic audits by an external inspection authority were also considered to be relevant. None of the respondents saw patient consultation and patient reporting as very important for patient safety. Hygiene protocols were mostly present, although all other items (mostly regarding incident reporting) were hardly ever present. (table 2)

Standards for record keeping (ICPC coding) were seen as most relevant, moreover they were quite often present. Electronic prescriptions, periodic review of polypharmacy and decision support systems were seen as very important by approximately half of the respondents, however these items were much less present. Patient-held medical records scored lowest, yet about 40% of the respondents found this item of very relevance for patient safety. (table 2)

A good culture and a mentality to learn from patient safety incidents was seen as most relevant, but was not very much present. An acceptable workload and prevention of burnout was seen as very important by approximately half of the respondents. Yet the presence of these measures was very low. Information technology was not seen as important, although to some extent this was indeed present. (table 2)

Education was seen as the most important factor to improve patient safety. About 70% to 80% of the respondents found educational strategies to enhance patient safety to be very relevant. Highest ranked the education of GPs, but the education of other health care workers involved scored highly as well. Also, the presence of a specific patient safety guideline (a guideline that consists of different strategies and suggestions to improve patient safety in primary care) was perceived to be relevant. Education on patient safety was not widely provided. (table 2)

Lastly we inquired if the respondents found any other items relevant for patient safety, which had not been mentioned in the questionnaire. Eight respondents mentioned additional items. The comments can be divided into a number of categories: more (media) coverage on patient safety, education, a practice/organization assessment tool, and overall healthcare culture improvement.

The response rate for this study was acceptable, but selection bias cannot be ruled out. Due to the selection procedure used (through a contact person), it is likely that we asked the most experienced patient safety practising primary care physicians in the different countries, and patient safety experts, on their opinion. Most of the respondents were actually practising GPs (46/58), which can be seen as a potential bias. Other health care personnel, such as managers or policy makers, could have been asked as well. However, practising GPs are the ones who are most likely to have the most direct view of the field. In earlier studies we noticed that 'regular' practising GPs found patient safety highly relevant, yet they had a very broad idea about patient safety. It is likely that GPs who are somewhat more experienced on patient safety will come up with better ideas to improve patient safety [8]. While the survey used in this study has not been empirically validated due to time restraints (through a Delphi procedure), it was nevertheless based upon the results of previous research [8‐10] and interviews and the insights of experienced GPs with regard to the choice of clinical cases and potential risk factors [8‐10, 18]. Moreover, in order to develop this survey, the items were derived from interviews held with five experts on patient safety.

This study highlights the strategies that are seen as promising for the improvement of patient safety in primary care. Obviously, the effectiveness, efficiency and feasibility of these strategies have yet to be tested in well-designed evaluations. Possibly the most promising approach to improve patient safety (highly important and poorly implemented) is education for health professionals on patient safety. Therefore the need to develop educational tools, such as a prospective risk analysis for a practice, [19] specific guidelines on important patient safety features, or more attention on patient safety in the vocational training of primary care workers, seems a promising approach to improve patient safety. Until now, such a tool has not been present to our knowledge. Our goal in the next phase of the LINNEAUS program is to develop a web-based educational tool on patient safety.