Mistakes happen: developing a patient safety collaborative


Article published in the Snapshot of Australian Primary Health Care Research 2014 by the Primary Health Care Research and Information Service (PHCRIS), page 14

There are over 700 000 avoidable hospital admissions per year in Australia, many of which could be reduced by: fewer medication errors in the frail and elderly, improved communication between general practitioners (GPs) and the wider health care community, and improved recording systems.

In GP clinics there is rarely a systematic approach for the detection of errors that may have
caused harm to patients, and without data on the number and type of safety incidents occurring in Australian general practice, there is no way to track problems or make improvements.

To address this issue Dr Mark Morgan and his peers developed a manual to inform the basis of a patient safety collaborative to improve safety in primary care. Due to an absence of established guidelines, research for the manual relied on literature reviews and feedback from a broad range of national and international experts, researchers and policy makers.
To identify patient harm, as well as prioritise and record safety events, a digital auditing tool was developed to identify clinical notes that might represent high-risk of harm, and a safety incident event log was also designed. In addition to the digital auditor and event log, further reporting methods were implemented to improve patient safety, including: team meetings to identify the root causes of safety events, automated audits of the accuracy of electronic medical records, and medication reviews focusing on high-risk medication classes.

The completed patient safety collaborative manual will now be used by the Australian Primary Care Collaboratives program supported by Medicare Locals. For the first time in Australia, participating clinics will engage in the open and systematic identification of internal safety incidents, with the aim of developing and sharing solutions to reduce patient harm.

August 04, 2014

Suite 1, Level 3, 12 Pirie Street, Adelaide SA 5000 | PO Box 3645
T: 08 8100 8700 | TOLL FREE (within Aust): 1800 771 522 | E: enquiries@improve.org.au

The Improvement Foundation acknowledges the Traditional Custodians past and present on whose land we walk and we live.

TQCSI Quality Certified