Al. Bhasale et al., ANALYZING POTENTIAL HARM IN AUSTRALIAN GENERAL-PRACTICE - AN INCIDENT-MONITORING STUDY, Medical journal of Australia, 169(2), 1998, pp. 73-76
Objective: To collect data on incidents of potential or actual harm to
general practice patients and to evaluate the possible causes of thes
e incidents. Design: An observational study of incidents of potential
harm based on a modified critical incidents technique. A non-random sa
mple of general practitioners (GPs) anonymously submitted incident rep
orts contemporaneously. Setting and participants: Australian general p
ractices between October 1993 and June 1995. During the study period,
324 GPs participated at some time. Main outcome measures: GP-reported
free-text descriptions of incidents and structured responses for preve
ntability, potential for harm, immediate consequences, predicted long-
term outcomes, type of incident, contributing factors, mitigating fact
ors, and additional resource use. Results: 805 incidents were reported
- 76% were preventable; 27% had potential for severe harm. No long te
rm harm was predicted for 66% of incidents. Incidents could relate to
pharmacological management (51 per 100 incidents), nonpharmacological
management (42 per 100 incidents), diagnosis (34 per 100 incidents) or
equipment (5 per 100 incidents). The most common contributory factors
were poor communication between patients and healthcare professionals
and actions of others (23 per 100 incidents each) and errors in judge
ment (22 per 100 incidents). Conclusion: Human errors and preventable
system problems were identified. The incident monitoring technique pro
vided useful data which could be applied to incident prevention strate
gies.