Improve the patient safety record

GPs must stay aware of threats to patient safety in primary care, says Dr John Sandars


How to improve patient safety

  • Being positive is essential to improving patient care.
  • Always ask yourself: 'How can I ensure that this patient is unlikely to be harmed by what I am doing?' This requires a proactive approach that recognises the common causes of threats to patient safety and the contributory factors.
  • It is important to be more vigilant when both active and latent failures are more likely.
  • We should not blame, or expect infallibility of, healthcare professionals. There should be appropriate healthcare systems that help to reduce errors caused by human factors and this is where our energies should be spent on trying to improve patient safety.

Patient safety is a priority for all healthcare providers. The sad reality is that some patients are harmed, sometimes severely

and permanently, during the care that they receive. Although primary care only rarely has high-profile cases, there is no reason for complacency.

Patient safety is not about avoiding getting sued for negligence or appearing in front of the GMC. These are rare events and most threats to patient safety do not cause actual harm, and those that do only rarely have such a consequence. However, the frequency of threats to patient safety in primary care is still relatively high.

Risks to patients in primary care
An accurate estimate of the extent and causes of harm to patients is difficult to obtain since different methods have been used to collect the data. A recent review of the published literature noted that there were between five and 80 threats to patient safety per 100,000 consultations. Most threats did not result in actual patient harm but had the potential to do so.

The most common factors were related to diagnosis (26-78 per cent) and treatment, especially medication-related (11-42 per cent).

Systematic identification of prescription and prescribing errors has identified rates between less than one and 11 per cent of all prescriptions. Fifty-four per cent of events that harmed patients are due to failure or delay in diagnosis, and 25 per cent due to a wrong diagnosis. The largest category was malignant neoplasms and septicaemia, including meningococcal.

In adverse drug events as a cause of hospital admission, 72 per cent were definitely avoidable, and were considered to be inconsistent with present-day best medical practice. The most common causes of admission were gastrointestinal haemorrhage related to aspirin and NSAIDs, and adverse events caused by diuretics and ACE inhibitors.

Using steroids is commonly identified from medico-legal databases as a cause of adverse drug events. Antibiotic allergies are another common cause of adverse drug events.

The investigation of threats to patient safety has shown that there are usually multiple causes and they tend to occur when there is an unfortunate combination of 'active failures' and 'latent failures'.

Active failures
The majority of threats to patient safety are caused by human factors. All healthcare workers are at the 'sharp end' and it is at this patient interface that 'active failures' occur.

Decisions, actions and inactions contribute to unsafe patient care. These 'failures' are more likely if the healthcare professional is dealing with complex events, high levels of uncertainty, time pressures and fatigue.

It is important to remember that all humans are prone to cause errors. It is part of human nature.

The main human factor events are slips, lapses, mistakes and violation. Slips occur when there is a distraction during a routine task. An example is being interrupted when giving an injection.

Lapses occur when a rule-based activity is not followed. An example is when a protocol or guideline is too complex and does not apply to a particular individual.

Mistakes occur when there is a failure in judgment. Mistakes often occur when the healthcare professional has insufficient knowledge about a problem, either in diagnosis or treatment.

Violation occurs when there is a deliberate attempt not to follow accepted approaches. These events are rare.

Latent failures
The majority of threats to patient safety are also caused by factors in the healthcare system. This may sound a bit but strange but healthcare systems are at the 'blunt end' - they decide on how the care is delivered through policies, financial controls and management of the work of the healthcare professionals. At the blunt end, 'latent failures' occur.

A working environment is created that increases the probability that there will be a sharp-end failure caused by human factors.

The main latent conditions for failure are inadequate training, unworkable procedures, low standards of quality, poor or inadequate technology, unrealistic time pressures and understaffing.


  • Sandars J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Family Practice 2003; 20(3): 231–6.
  • Haynes K, Thomas M, eds. Clinical risk management in primary care. Radcliffe Medical Press: Oxford, 2005.
  • Sandars J. Medical errors in primary care: how to prevent them. BMJ Learning 2004.
  • Sandars J. Avoiding drug errors in primary care. BMJ Learning 2004.
  • Online postgraduate certificate in Patient Safety and Clinical Risk Management at the University of Leeds:

- Dr Sandars is a senior lecturer in community-based education in the medical education unit at the University of Leeds, West Yorkshire

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