Future research directions for patient safety in primary care Michel Wensing Wim Verstappen Sander Gaal

Aims of this workshop 1. To provide ideas and inspiration for research on patient safety in primary care 2. To identify shared interests and explore opportunities for collaboration 3. To inform the research agenda in the field and guide research funders

Outline 1.Introduction 2.Aspects of primary care to be targeted (intro: Sander Gaal) 3.Interventions/measures to be developed (intro: Wim Verstappen) 4.Experiences in research funding across countries

Structure of group work 1. Clarification and individual completion of questionnaire (10 min) 2. Moderated discussion in group (40-60 min) 3. Add/change responses to questionnaires individually (10 min) 4. Provide complete questionnaire (1 min) 5. Plenary discussion (not feedback from all groups) (10-30 min)  Create groups  Session 1: 9.10 – hours  Session 2: hours

Outline 1.Introduction 2.Aspects of primary care to be targeted (intro: Sander Gaal) 3.Interventions/measures to be developed (intro: Wim Verstappen) 4.Experiences in research funding across countries

Patient safety is a very broad definition (29 practitioners mentioned 274 different items) (Scientific) definitions were not mentioned Most named: medication safety and telephonic accessibility When an incident occurred; most GPs took an ‘ad hoc’ improvement Patient safety according to GPs Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pract.J Eval Clin Pract Jun;16(3):639-43

1.Not keeping one’s medical knowledge up-to-date (42,6%) 2.Poor doctor-patient relationship (41,2%) 3.Patient age >75 year(41,2%) 4.Language barrier (36,8%) 5.Patient with more than 5 medicaments (33,8%) 6.Patients who ‘shops’ between different GPs (23,5%) 7.No telephonic triage (22,1%) 8.Delayed receipt of information about patients from hospital (17,6%) Questionnaire risk factors (1) Patient safety in primary care: a survey of general practitioners in The Netherlands. BMC Health Serv Res.BMC Health Serv Res Jan 21;10:21.

9.Patient who frequently comes for medical unexplained complaints (13,2%) 10.Patient age >70 year (10,3%) 11.Patient with a chronic disease (10,3) 12.Patient who has consulted more than twice during GPs office hours for the same complaint (7,4%) 13.Need to make an emergency visit during regular office hours (7,4%) 14.Deviating from guidelines provided by Dutch College of General Practitioners (2,9%) 15.Lack of privacy at reception or in waiting room (0%) Questionnaire risk factors (2) Patient safety in primary care: a survey of general practitioners in The Netherlands. BMC Health Serv Res.BMC Health Serv Res Jan 21;10:21.

“The electronical medical record of a GP produces a lot of medication interaction warnings. The GP often ignores these without reading the medication warnings carefully.“ Examples

“In a general practice, small surgical procedures which require suturing are done without sterile gloves. “ Examples

“A practice does not discuss errors made in the practice on a regular basis. Errors are resolved on an ad hoc basis by the healthcare workers involved.“ Examples

“A patient is admitted to the hospital with a perforated appendix. Earlier that day, the patient was seen by a GP. The GP gave clear instructions on when the patient should return to see him, and the patient indeed returned to see him..“ Examples

Outline 1.Introduction 2.Aspects of primary care to be targeted (intro: Sander Gaal) 3.Interventions/measures to be developed (intro: Wim Verstappen) 4.Experiences in research funding across countries

RESEARCH WORKSHOP II Wim Verstappen Sander Gaal Michel Wensing

Possible improvement interventions Patient safety incidentsDeterminants (examples)Interventions (examples) Missed diagnoses Poor access to primary care Incompetent providers Inappropriate acceptance of symptoms Improving telephone triage Decision support systems Patient education Incident reporting Prospective risk analysis Treatment risks Incompetent providers Inadequate patient records Poor interprofessional communication Decisions support systems Pharmacist involvement Shared patient records Incident reporting Prospective risk analysis Inadequate monitoring of patients Inadequate patient records Inadequate practice organization Reminder systems Restructuring of clinical process Incident reporting Prospective risk analysis Hygiene risksAbsence of preventive measures Vulnerable patients Use of preventive measures Active patient involvement Incident reporting Prospective risk analysis

Feasibility and effectiveness of improvement strategies for patient safety in primary care S. Gaal et al.: What do primary care physicians and researchers consider the most important patient safety improvement strategies? BMC Health Services Research :102.  Purpose: To identify most important strategies.  Methods: Web-based survey in an international panel of 58 GPs and GP researchers in countries with a strong primary care system. 38 (known and used) strategies were presented.  Results:Most strategies were seen as important. Use of these strategies varied widely.

Conclusions  Many different strategies were seen as important.  Highly important strategies with poor implementation were a culture positive for patient safety, education on patient safety and patient safety guidelines.  Educational items ranked high, with low presence scores.

Second websurvey  To identify most important constituents of educational programs to enhance patient safety.  Hygienic procedures, emergency primary care, medication, IT, handover, (telephonic) accessibility.

Methods  Developing and experience with educational practice assessment tool  At the internet practices fill in a questionnaire about 8 most important patient safety themes.  If answering ‘No’ they receive (national) guidelines automatically.  A pilot in three GP practices in the Netherlands

Results  Assessment of patient safety by webtool  Improvement actions on base of this assessment  Process evaluation of the introduction of webtool

National research programs What are experiences in other countries ? What can we learn from experiences in research? How to enhance research in countries with little research? How to to enhance research in countries with more research?

Conclusions …