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GPs must improve recording on near misses

By Nigel Praities

GPs must improve their recording of events that impact on patient safety in their practices says the National Patient Safety Agency.

The NPSA says the current quality of significant events audits was ‘variable and could be improved' and has published the first official NHS guidance on how practices can improve their significant event audits.

GPs face external review of their significant event audits as part of the RCGP revalidation plans due to rolled out from 2010 and practices are rewarded through QOF for conducting a minimum of twelve significant event reviews in the past three years, such as any deaths occurring on the practice premises, new cancer diagnoses or medication errors.

But the NPSA says these reviews must be tightened up and there should be more systematic reporting of any event alongside any changes that could lead to improvements in care.

Joanna Parker, head of primary Care at the NPSA, said: ‘[This guidance] provides a clear, structured approach to help general practice teams turn significant event audits into a routine team learning activity to the benefit of all their patients and with potential to share that learning across the service'

Dr John Holden, a GP in Merseyside who conducted an audit of significant events in his area, welcomed the NPSA advice, but said that recording of events could never be completely standardised.

‘As long as there are human beings then there is the potential for these things to happen. But there are often lessons to be learnt and systems can be changed to make care better and safer,' he said.

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