Assessing risk by analysing significant events in primary care

Authors: Murie J.; McGhee C.

Source: Quality in Primary Care, Volume 11, Number 3, 1 September 2003 , pp. 205-210(6)

Publisher: Radcliffe Publishing Ltd.

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Abstract:

Risk assessment in one local healthcare cooperative (LHCC) was conducted by applying a national incident grading matrix (CNORIS) to 56 significant event analyses (SEAs) undertaken by 32/39 (82%) general practitioners (GPs) as a voluntary and educational activity.

Analysis demonstrated a ratio of 'near miss' to actual adverse event of 1:6 and a wide range and combination of categories. In 40% of incidents reported, the severity was assessed to be 'major' or 'catastrophic'. In 78% of incidents, the risk of recurrence was considered 'possible', 'likely' or 'almost certain'. Risk assessment for recurrence of incidents was described as 'high' in 25%, 'moderate' in 31% and 'low' in 44% of cases.

The study demonstrates that GPs can work within a national framework for risk assessment. However, the process identified a need for consistency in terms of definitions and coding, dedicated software, a managed reporting system, practical guidance and possibly incentives for GPs.

Keywords: DIAGNOSTIC ERRORS; GENERAL PRACTICE; MEDICAL ERRORS; MEDICATION ERRORS; RISK ASSESSMENT; RISK FACTORS

Document Type: Research article

Publication date: 2003-09-01

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