Incident reporting in general practice

Background and aim An incident reporting procedure (IRP) is an important part of patient safety management in healthcare. Currently, patient safety efforts are mainly guided by the ‘systems approach’: incidents, defined as ‘unintended or unexpected events which could have led or did lead to harm for patients’, may teach healthcare providers about the risks and possible flaws of their healthcare system. Hence, incidents should not only be detected and recorded, but also profoundly analysed, in order to avert future recurrence of similar events and/or prevent future harm for patients. Furthermore, an important condition to put the systems approach into practice is a constructive ‘patient safety culture’; at a minimum this entails a trustful and open culture, in which adverse events and possible medical errors can be freely discussed. The general aim of this thesis was to explore whether the ‘systems approach’ can be applied in general practice by investigating the feasibility of IRP in the three general practice settings: day care, out-of-hours care and GP vocational training. Design and methods In the first two chapters of this thesis the development and clinimetric properties of a questionnaire for patient safety culture measurement in general practice (SCOPE) and the results of the first cross sectional survey in Dutch general practice are described. Subsequently, in five chapters the research on the introduction of IRP in Dutch general practice is presented. First, in a prospective, observational study on IRP in five large GP health care centres the number and nature of reported incidents as well as the actual implementation and acceptability of IRP were studied. Next, in a non-equivalent controlled, quasi-experimental, before/after designed field study, we compared the results of centrally organised versus locally organised incident reporting in GP out-of-hours care. Also, we qualitatively analysed the introduction of IRP in general practice aiming at understanding how IRP becomes part of the way the professionals deal with safety issues. Furthermore, we systematically reviewed the literature on the different reporting procedures that have actually been applied in primary care. And finally, we studied the number and nature of incidents reported by GP trainees during their vocational training, focussing on possible relations between the training situation and incident reporting. Main findings and conclusions The systems approach to incidents is feasible and useful in general practice. However, although perceptions of a considerable part of Dutch primary care workers about aspects of safety culture are positive, self-reported safety behaviour, i.e., incident reporting, is hardly present yet. In addition, several obstacles and challenges were encountered during the implementation of IRP. First, the yield of IRP was limited; primary care professionals mostly reported work process related incidents. Second, the desired ‘safety behaviour’ within the IRP in daily GP practice appeared complicated; we observed reluctance to report, hesitancy to discuss incidents with colleagues, problems with implementing new safety measures and difficulties in providing and sustaining a safe climate for all potential reporters. Finally, several directions for improving IRP in general practice are proposed in the general discussion of this thesis.