Study: Most patients helped, most of the time - Looking at safety in general practice

I think we should aim to avoid all preventable harms, but I think it is impossible to do that

Five preventable deaths were detected in a study of New Zealand general practice records between 2011 and 2013.

Nearly 20 per cent of non-fatal patient harm detected could have been prevented, with 81.6 per cent of the non-fatal harms detected considered not preventable.

Says study co-author Susan Dovey via media release: “These results suggest that most of the time, most patients over a random three-year period – all ages, any state of health, whether living in cities or rurally, whether going to large, small, or medium-sized general practices – are going to be helped by the healthcare they receive and not harmed in any noticeable way.”

But Professor Dovey, of the University of Otago Department of General Practice and Rural Health, notes a paradox. “I think that we should aim to avoid all preventable harms, but I think it is impossible to do that. Healthcare is care for humans, by humans. We wouldn’t want anything else really

“People do their best to provide the best care, but people are so variable in how they are formed and what they do, that responses will vary to even the very best care, sometimes with unexpected harm to patients.

“I think that needs to be openly acknowledged, even while we strive not to cause harm or be harmed.”

The researchers, writing in the BMJ Open, found patient harm was common and mostly non-preventable, as it arose from routine care. This should inform shared decision-making when considering investigation and treatment options.

“Clinicians need technologies to reduce cognitive load, such as automatic identification of patients at high risk of patient harm, and prescribing and deprescribing support.”

The review was New Zealand’s first national epidemiological study of harm in general practice records.

Professor Dovey tells New Zealand Doctor Rata Aotearoa that most research in the field, until recently, has investigated adverse events, in which “the care provided was not quite the right care”.

Her group’s study of primary care records was different. It defined harm to include known adverse effects of care properly given, such as when a patient experiences a drug’s datasheet-listed side effect. It also included harms resulting from events in hospitals that are described in general practice records.

Forty-four practices agreed to take part, out of 72 that were randomly selected. The researchers reviewed 9076 randomly chosen patient records from 2011 to 2013. They found 2972 harms affecting 1505 patients aged up to 102.

“After applying weighting, the incidence rate of harm was 123 harms per 1000 patient-years, and the incidence rate of preventable or potentially preventable harm was 26 harms per 1000 patient-years.”

Most harms, 72.4 per cent, were minor, such as nausea or patient inconvenience; 22.8 per cent were moderate, including fractures, unplanned pregnancy or poor diabetic control; and 4.4 per cent were severe, including myocardial infarction, renal failure and morphine overdose.

Eleven patients died. Five of these deaths were considered preventable.

The researchers found a statistically significant association between age and the risk of experiencing harm. Compared with people aged 49 and under, the odds ratio for experiencing harm was 1.77 for those aged 50 to 69, and 3.23 for those aged 70 or older. Even greater risks were found for those who had four or more consultations.

No statistically significant associations were found between harm and gender, ethnicity, deprivation, practice size, or whether a practice was rural or urban.