'The big buzz': a qualitative study of how safe care is perceived, understood and improved in general practice

Background: Exploring frontline staff perceptions of patient safety is important, because they largely determine how improvement interventions are understood and implemented. However, research evidence in this area is very limited. This study therefore: explores participants’ understanding of patient safety as a concept; describes the factors thought to contribute to patient safety incidents (PSIs); and identifies existing improvement actions and potential opportunities for future interventions to help mitigate risks. Methods: A total of 34 semi-structured interviews were conducted with 11 general practitioners, 12 practice nurses and 11 practice managers in the West of Scotland. The data were thematically analysed. Results: Patient safety was considered an important and integral part of routine practice. Participants perceived a proportion of PSIs as being inevitable and therefore not preventable. However, there was consensus that most factors contributing to PSIs are amenable to improvement efforts and acknolwedgement that the potential exists for further enhancements in care procedures and systems. Most were aware of, or already using, a wide range of safety improvement tools for this purpose. While the vast majority was able to identify specific, safety-critical areas requiring further action, this was counter-balanced by the reality that additional resources were a decisive requirment. Conclusion: The perceptions of participants in this study are comparable with the international patient safety literature: frontline staff and clinicians are aware of and potentially able to address a wide range of safety threats. However, they require additional resources and support to do so

A mixed-methods study of the implementation of the Trigger Review Method in general medical practice

Introduction : There is now compelling evidence that a significant minority of patients suffer preventable iatrogenic harm during their interactions with health care, including in UK general practice. While our understanding of the extent of the problem and the contributing factors continues to increase, it remains incomplete. Further patient safety research is therefore urgently required, particularly to develop, test and successfully implement effective improvement strategies, methods and tools. Of the main approaches currently available for improving patient safety, the general practice Trigger Review Method (TRM) is of particular interest and the main focus of this study. The TRM is, quite simply, a structured way to rapidly screen samples of random electronic patient records for undetected patient safety incidents (PSIs). It is essentially an adaptation of clinical record review, with the same underlying principles of learning from error and improving care. Development of the TRM commenced in 2007 in Scottish general practice, with subsequent testing in The Health Foundation-funded Safety and Improvement in Primary Care (SIPC) programme. In 2013, the TRM was included as one of the three core components of the Scottish Government’s Patient Safety Programme for Primary Care (SPSP-PC). Scottish general practices were also financially incentivised through the Quality and Outcomes Framework (QOF) to routinely apply the TRM and report their findings. However, despite the increasing and national interest in the TRM, many unanswered questions remained: what is its potential value, how acceptable and feasible is it and to what extent (if any) will, or should, it become part of routine general practice? The aims of this study were therefore to: (i) describe the patient safety perceptions of general practice clinicians and staff; (ii) determine the usefulness of the TRM; (iii) explain how the TRM worked; and (iv) identify the main factors that facilitated or hindered its implementation. Methods: This study has a mixed-methods design. It was undertaken in the West of Scotland region in two NHS Health Boards: Greater Glasgow and Clyde (GGC) and Ayrshire and Arran (A&A). Convenience samples of 12 general practice teams and 25 GP Specialty Trainees (GPST) were recruited. Data were collected through: semi-structured interviews (n=62) with a range of general practice clinicians and staff; and cross-sectional trigger reviews of selected electronic patient records. Normalisation Process Theory (NPT) underpinned all stages of the research. NPT is a socio-technical, middle-range theory about the ‘work’ people do collectively and as individuals to implement and sustain complex health care interventions such as the TRM. The majority of the qualitative data were analyzed thematically and a NPT framework was applied to the remaining data. Quantitative data were analysed using recognised statistical tests. Results: A total of 47 primary care clinicians reviewed 1659 electronic patient records and detected 216 PSIs. A substantial minority of these were considered to have led to moderate or more substantial harm (29.2%), while the majority (54.8%) were rated as being preventable or potentially preventable. The most common type of PSI related to ‘medication’ (40.7%) and the most commonly implicated drug was Warfarin. The participants reported considering or undertaking specific improvement actions during and after approximately two thirds of trigger reviews. The most common action was ‘feedback to colleagues’. More specific actions included: undertaking significant event analyses (SEAs) and clinical audits, designing or redesigning practice protocols and including their findings in their appraisal documentation. The vast majority of participants identified four main factors as being particularly important for the successful implementation of the TRM, and by extension its potential normalisation. The first and most important factor was provision of adequate resources and protected time to conduct trigger reviews. The second factor was whether senior leaders in the practice teams, the government and professional bodies practically demonstrated their support for the TRM through, for example, contextually integrating it into existing general practice processes. The third and fourth factors related to the characteristics of participants. Successful implementation required knowledgeable clinicians to remain engaged with the TRM, and to perceive it as useful, acceptable and feasible – which the vast majority of participants were, and did. Discussion: This study is the first known attempt to investigate how the TRM is implemented and perceived from the perspective of general practice clinicians and staff. The main findings are that most participants experienced the method as acceptable, feasible and useful. It is clear that the TRM is uncovering important patient safety concerns and also driving improvements in related care systems and processes at the individual practice level. The implication is that this is making significant and demonstrable differences to patient care, while impacting positively on local safety culture. On the evidence presented, normalisation of the TRM in general practice can therefore be recommended. However, while the usefulness of an intervention is an important factor in determining whether it is normalised or not, the study findings also clearly indicate – consistent with the international literature – that there are other factors that are at least equally important for normalisation. At the time of writing, there are no formal mandates or financial incentives for general practice clinicians or teams to perform regular trigger reviews. It therefore seems likely that normalisation of the TRM in Scottish general practice will be gradual and piecemeal, if it happens at all. Nevertheless, the lessons learnt from this study can be incorporated in the ongoing efforts to further improve the safety of care in general medical practice. In particular, researchers and policy makers should pro-actively identify and address the main factors that are known to facilitate or hinder the implementation of improvement initiatives; the existing knowledge and ‘engagement’ of clinicians should be recognised and harnessed; and the lessons learnt from PSIs should be more widely disseminated

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes

BACKGROUND: Root cause analysis (RCA) originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning. Despite the limitations of the RCA evidence base, healthcare authorities and decision makers in NHS Scotland – similar to those internationally - have invested heavily in developing training programmes to build local capacity and capability, and this is a cornerstone of many organizational policies for investigating safety-critical issues. However, to our knowledge there has been no systematic attempt to follow-up and evaluate post-training experiences of RCA-trained staff in Scotland. Given the significant investment in people, time and funding we aimed to capture and learn from the reported experiences, benefits and attitudes of RCA-trained staff and the perceived impact on healthcare systems and safety. METHODS: We adapted a questionnaire used in a published Australian research study to undertake a cross sectional online survey of health care professionals (e.g. nursing & midwifery, medical doctors and pharmacists) formally trained in RCA by a single territorial health board region in NHS Scotland. RESULTS: A total of 228/469 of invited staff completed the survey (48%). A majority of respondents had yet to participate in a post-training RCA investigation (n=127, 55.7%). Of RCA-experience staff, 71 had assumed a lead investigator role (70.3%) on one or more occasions. A clear majority indicated that their improvement recommendations were generally or partly implemented (82%). The top three barriers to RCA success were cited as: lack of time (54.6%), unwilling colleagues (34%) and inter-professional differences (31%). Differences in agreement levels between RCA-experienced and inexperienced respondents were noted on whether a follow-up session would be beneficial after conducting RCA (65.3% v 39.4%) and if peer feedback on RCA reports would be of educational value (83.2% v 37.0%). Comparisons with the previous research highlighted significant differences such as less reported difficulties within RCA teams (P<0.001) and a greater proportion of respondents taking on RCA leadership roles in this study (P<0.001). CONCLUSION: This study adds to our knowledge and understanding of the need to improve the effectiveness of RCA training and frontline practices in healthcare settings. The overall evidence points to a potential organisational learning need to provide RCA-trained staff with continuous development opportunities and performance feedback. Healthcare authorities may wish to look more critically at whom they train in RCA, and how this is delivered and supported educationally to maximize cost-benefits, organizational learning and safer patient care

Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory

Objectives: Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting. Design: Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT). Setting: Scottish general practice. Participants: We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland. Results: We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants’ involvement; (3) the characteristics of the reviewers—implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful. Conclusions: This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors

The past, present and future of patient safety education and research in primary care

In the first series of related articles, we describe how assurance of patient safety in primary care was traditionally viewed by the medical profession hierarchy as being wholly dependent at the individual level upon a combination of education and training, knowledge, skill, experience and commitment to professional development. As well as summarising the evidence underpinning what we know about patient safety in primary care, we outline how contemporary thinking has evolved to recognise that the safety issue is complex, problematic and systemic, and that it is now beginning to attract the attention of national policymakers, educators and research funders in some countries. We also describe a range of recently developed educational safety concepts and methods that have been implemented as part of current national programme initiatives in the United Kingdom and internationally. Finally, we reflect on international progress on patient safety in primary care thus far; propose a future direction for related education, development and research; and briefly introduce the Human Factors based topics to be addressed in the forthcoming series of interrelated articles in this journal

Never events in UK general practice: a survey of the views of general practitioners on their frequency and acceptability as a safety improvement approach

Background: Never events (NEs) are serious preventable patient safety incidents and are a component of formal quality and safety improvement (Q&amp;SI) policies in the United Kingdom and elsewhere. A preliminary list of NEs for UK general practice has been developed, but the frequency of these events, or their acceptability to general practitioner (GPs) as a Q&amp;SI approach, is currently unknown. The study aims to estimate (1) the frequency of 10 NEs occurring within GPs' own practices and (2) the extent to which the NE approach is perceived as acceptable for use. Methods: General practitioners were surveyed, and mixed-effects logistic regression models examined the relationship between GP opinions of NE, estimates of NE frequency, and the characteristics of the GPs and their practices. Results: Responses from 556 GPs in 412 practices were analyzed. Most participants (70%-88%, depending on the NE) agreed that the described incident should be designated as a NE. Three NEs were estimated to have occurred in less than 4% of practices in the last year; however, two NEs were estimated to have occurred in 45% to 61% of the practices. General practitioners reporting that a NE had occurred in their practice in the last year were significantly less likely to agree with the designation as a NE compared with GPs not reporting a NE (odds ratio, 0.42; 95% CI = 0.36-0.49). Conclusions: The NE approach may have Q&amp;SI potential for general practice, but further work to adapt the concept and content is required

Development and psychometric testing of an instrument to measure safety climate perceptions in community pharmacy

A positive and strong safety culture underpins effective learning from patient safety incidents in health care, including the community pharmacy (CP) setting. To build this culture, perceptions of safety climate must be measured with context-specific and reliable instruments. No pre-existing instruments were specifically designed or suitable for CP within Scotland. We therefore aimed to develop a psychometrically sound instrument to measure perceptions of safety climate within Scottish CPs.  The first stage, development of a preliminary instrument, comprised three steps: (i) a literature review; (ii) focus group feedback; and (iii) content validation. The second stage, psychometric testing, consisted of three further steps: (iv) a pilot survey; (v) a survey of all CP staff within a single health board in NHS Scotland; and (vi) application of statistical methods, including principal components analysis and calculation of Cronbach's reliability coefficients, to derive the final instrument.  The preliminary questionnaire was developed through a process of literature review and feedback. This questionnaire was completed by staff in 50 CPs from the 131 (38%) sampled. 250 completed questionnaires were suitable for analysis. Psychometric evaluation resulted in a 30-item instrument with five positively correlated safety climate factors: leadership, teamwork, safety systems, communication and working conditions. Reliability coefficients were satisfactory for the safety climate factors (α > 0.7) and overall (α = 0.93).  The robust nature of the technical design and testing process has resulted in the development of an instrument with sufficient psychometric properties, which can be implemented in the community pharmacy setting in NHS Scotland

Applying the trigger review method after a brief educational intervention: potential for teaching and improving safety in GP specialty training?

&lt;p&gt;Background: The Trigger Review Method (TRM) is a structured approach to screening clinical records for undetected patient safety incidents (PSIs) and identifying learning and improvement opportunities. In Scotland, TRM participation can inform GP appraisal and has been included as a core component of the national primary care patient safety programme that was launched in March 2013. However, the clinical workforce needs up-skilled and the potential of TRM in GP training has yet to be tested. Current TRM training utilizes a workplace face-to-face session by a GP expert, which is not feasible. A less costly, more sustainable educational intervention is necessary to build capability at scale. We aimed to determine the feasibility and impact of TRM and a related training intervention in GP training.&lt;/p&gt; Methods We recruited 25 west of Scotland GP trainees to attend a 2-hour TRM workshop. Trainees then applied TRM to 25 clinical records and returned findings within 4-weeks. A follow-up feedback workshop was held. &lt;p&gt;Results: 21/25 trainees (84%) completed the task. 520 records yielded 80 undetected PSIs (15.4%). 36/80 were judged potentially preventable (45%) with 35/80 classified as causing moderate to severe harm (44%). Trainees described a range of potential learning and improvement plans. Training was positively received and appeared to be successful given these findings. TRM was valued as a safety improvement tool by most participants.&lt;/p&gt; &lt;p&gt;Conclusion: This small study provides further evidence of TRM utility and how to teach it pragmatically. TRM is of potential value in GP patient safety curriculum delivery and preparing trainees for future safety improvement expectations.&lt;/p&gt

Implementing decision aids for cardiovascular disease prevention: stakeholder interviews and case studies in Australian primary care

BACKGROUND: Australian cardiovascular disease (CVD) prevention guidelines recommend absolute CVD risk assessment, but less than half of eligible patients have the required risk factors recorded due to fragmented implementation over the last decade. Co-designed decision aids for general practitioners (GPs) and consumers have been developed that improve knowledge barriers to guideline-recommended CVD risk assessment and management. This study used a stakeholder consultation process to identify and pilot test the feasibility of implementation strategies for these decision aids in Australian primary care.METHODS: This mixed methods study included: (1) stakeholder consultation to map existing implementation strategies (2018-20); (2) interviews with 29 Primary Health Network (PHN) staff from all Australian states and territories to identify new implementation opportunities (2021); (3) pilot testing the feasibility of low, medium, and high resource implementation strategies (2019-21). Framework Analysis was used for qualitative data and Google analytics provided decision support usage data over time.RESULTS: Informal stakeholder discussions indicated a need to partner with existing programs delivered by the Heart Foundation and PHNs. PHN interviews identified the importance of linking decision aids with GP education resources, quality improvement activities, and consumer-focused prevention programs. Participants highlighted the importance of integration with general practice processes, such as business models, workflows, medical records and clinical audit software. Specific implementation strategies were identified as feasible to pilot during COVID-19: (1) low resource: adding website links to local health area guidelines for clinicians and a Heart Foundation toolkit for primary care providers; (2) medium resource: presenting at GP education conferences and integrating the resources into audit and feedback reports; (3) high resource: auto-populate the risk assessment and decision aids from patient records via clinical audit software.CONCLUSIONS: This research identified a wide range of feasible strategies to implement decision aids for CVD risk assessment and management. The findings will inform the translation of new CVD guidelines in primary care. Future research will use economic evaluation to explore the added value of higher versus lower resource implementation strategies.</p