BMJ Qual Saf: first published as 10.1136/bmjqs-2015-005006 on 16 December 2015. Downloaded from http://qualitysafety.bmj.com/ on September 15, 2019 by guest.

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EDITORIAL

Tip of the iceberg: patient safety

incidents in primary care
Urmimala Sarkar

Correspondence to Primary care in the US model is fraught definition, however, the authors chose to
Associate Professor Urmimala
with safety hazards. Visits are brief and include only incidents of commission
Sarkar, Division of General
Internal Medicine, University of infrequent, patients are largely self- rather than omission. In effect, they
California, San Francisco, Center managing, often with multiple comorbid counted events where the wrong thing
for Vulnerable Populations, conditions, the extent of healthcare was done, but did not count events
San Francisco General Hospital,
1001 Potrero Avenue, Building
teams varies widely, and the fragmenta- where the right thing was not done. The
10, 3rd floor, San Francisco CA tion of health systems and lack of inter- fast pace and frequent interruptions asso-
94110, USA; operability among electronic health ciated with primary care are known to
[email protected] records (EHRs) means that primary care lead to errors of omission,10 and omis-
Accepted 13 November 2015 providers may not have timely, accurate sions are a major culprit in missed and
Published Online First data about patients.1 Despite these mul- delayed diagnoses,11 which Panesar et al
16 December 2015 tiple vulnerabilities, significant gaps found to be among the most harmful of
remain in our understanding of the safety primary care safety incidents. Therefore,
of primary care.2–4 this analysis likely shows us only the tip
The patient safety movement began in of the iceberg. The included studies
acute-care settings, where adverse events under-represent the frequency of patient
resulting from medical care are more safety incidents, and may especially
immediately apparent. Even though undercount diagnostic errors. It is critical
primary care is the cornerstone of health- that, going forward, safety surveillance
care delivery, relatively less is known efforts in primary care include incidents
about the epidemiology of adverse events involving errors of both commission and
in primary care settings.5 In an effort to omission.
address this gap, Panesar et al6 conducted The ascertainment methods for patient
a systematic review of patient safety inci- safety incidents require further examin-
dents in primary care. ation.12 Most of these studies employed
This paper makes a major contribution record review, while other used incident
to the field by providing an overview of reporting systems or surveys. Each of
the burden of patient safety incidents in these ascertainment methods has limita-
primary care. They found that patient tions. Record review leads to lower esti-
safety incidents are slightly less common mates of incidents because of suboptimal
in primary care, around 2%–3% of visits, documentation13; incident reporting
compared with approximately 10% of systems are underused,14 particularly by
hospitalisations.7–9 Given how much physicians15 and surveys can include inci-
larger and healthier the populations using dents which are not related to safety per
primary care are compared with hospita- se.16 Future studies should employ mul-
lised patients, the frequency of safety tiple ascertainment methods for primary
incidents in primary care is staggeringly care patient safety incidents and contrast
high. Fortunately, only a small proportion the resulting estimates.
of these incidents result in severe harm. Evaluating the extent of harm to
▸ http://dx.doi.org/10.1136/ This systematic review highlights mul- primary care patients remains a thorny
bmjqs-2015-004178 tiple challenges in studying the safety of issue. Expert record review does not
primary care. First, even more than a always yield agreement about harm.17
decade into the patient safety movement, While the authors used a clear definition
definitional challenges remained. Panesar from the UK National Patient Safety
et al6 defined patient safety incident as Agency,18 the variation in the underlying
‘any unintended or unexpected incident studies suggests that the definition may
To cite: Sarkar U. BMJ Qual that could have or were judged to have not have been applied consistently. One
Saf 2016;25:477–479. led to patient harm’. Within this broad example of an incident without harm is

Sarkar U. BMJ Qual Saf 2016;25:477–479. doi:10.1136/bmjqs-2015-005006 477

 BMJ Qual Saf: first published as 10.1136/bmjqs-2015-005006 on 16 December 2015. Downloaded from http://qualitysafety.bmj.com/ on September 15, 2019 by guest. Protected by copyright.
Editorial

an illegible handwritten prescription which does not funders in order to improve safety for all populations
impact a patient—perhaps because the pharmacist receiving primary care.
contacted the physician to clarify. However, an erro- Because most primary care safety incidents do not
neous/harmful medication prescribed by a physician lead to immediate harm, they do not seem to carry
but identified and intercepted by a pharmacist, there- the same urgency as adverse events in the hospital.
fore, not reaching the patient, also represents an inci- But, even if the consequences of a missed cancer diag-
dent without harm. These two incidents are nosis or dangerous medication combination error take
conceptually distinct. Developing effective interven- months to years to manifest, they remain just as
tions requires precision in describing harm. morbid and just as important to patients as any pre-
Many things can go wrong in primary care. The ventable adverse event in the hospital. Even if most
types of incidents that emerged from this synthesis are patient safety incidents in primary care carry a low
medication events, diagnostic errors and communica- potential for lasting harm, as Panesar et al show, the
tion failures, which I infer includes handoffs among sheer volume of service delivery translates into a sub-
outpatient providers. These results underscore the stantial public health burden from patient safety inci-
importance of these three areas as the three pillars of dents in primary care. The time has thus come to
primary care safety. All require substantive investment broaden our focus in patient safety accordingly. The
in improvement and evaluation. While electronic pre- tip of the iceberg is a place to start.
scribing has eliminated certain medication-related inci-
Competing interests None declared.
dents,19 abundant evidence indicates that medication
Provenance and peer review Commissioned; internally peer
use remains a locus of safety problems in primary reviewed.
care.20 Regarding diagnosis, a recent Institute of
Medicine report estimated that every American will REFERENCES
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Editorial
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