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New practice guidance on patient safety and “near misses”

7 October 2008

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The National Patient Safety Agency (NPSA) has launched new guidance for general practice teams on patient safety incidents and “near misses”.

The new Significant Event Audit (SEA) guidance aims to improve the quality and safety of patient care in general practice.

SEA was established in the mid-1990s as a quality assurance method in general practice with the aim of improving patients’ experience, care and outcomes, and to identify changes that might improve future care.

These episodes could include a wrongly administered MMR vaccination or wrongly prescribed medication.

SEA was incorporated into the Quality and Outcomes Framework in 2004, as part of the new GMS contract requirements.

An initial scoping exercise by the NPSA found that the quality of SEAs conducted was variable and could be improved. Their new guidance aims to raise awareness of how to conduct an SEA in seven simple stages so that practice teams can learn and improve the quality of patient care.

In collaboration with Professor Mike Pringle, Division of Primary Care, University of Nottingham, and NHS Education for Scotland (NES) with support from the Royal College of General Practitioners (RCGP) and Quality Improvement Scotland, the NPSA has published the SEA guidance for primary care teams in the UK. 

Professor Pringle said: “SEA is an established and effective quality assurance method in general practice. It helps to improve patients’ experience, care and outcomes by facilitating learning from experience and will be part of GP revalidation. This guidance will help encourage and inform existing and new users of SEA.”

Dr Paul Bowie, Associate Adviser, NES, added: “The guidance will act as a key educational resource for many primary care teams, enabling them to undertake much more effective SEA.”

Dr Maureen Baker, Honorary Secretary of the RCGP, said: “SEA is a learning technique that GPs and practice teams are already familiar with. The guidance will help practices improve their use of SEA and lead to greater incident reporting in general practice.”

The Medical Protection Society (MPS) welcomed the guidance. Dr Priya Singh, MPS Medical Director, said: “In our experience, many general practices would like greater knowledge about what they should be reporting, who they should be reporting to and how to take positive steps to prevent similar incidents recurring.”

A recent study of clinical risk sssessments carried out by MPS found that 56% percent of participating general practices had no fully developed formal system for incident reporting and dealing with patient safety incidents and “near misses”.

Dr Singh said “This is not surprising given the lack of accessible training, no comprehensive definition of a significant event and the arbitrary and interchangeable use of phraseology to describe a patient safety incident.”

“We hope that the guidance will encourage and enable general practices to report significant events. We recognise, however, that there remains a real fear that reporting these adverse events could lead to disciplinary action and multiple jeopardy.”

The fear of disciplinary action following disclosure was highlighted in a survey of 700 doctors conducted by MPS in August 2008, in which 90% recognised that patients are less likely to complain or sue if they receive an explanation and apology. However, only 67% were willing to be open with patients when something has gone wrong.

The number of complaints reported to the GMC over the past five years to 2007 increased by 24%.



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