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System errors putting patient safety at risk

Patients are being left at serious safety risk by failures in the management systems connecting primary and secondary care, a new analysis reveals.

Key flaws were exposed in access to diagnostic tests and policies for determining who was responsible for patients on long-term medication.The analysis identified a series of patient safety incidents caused by faults in current systems, some of which had serious consequences and in one case resulted in death.It warned that 'primary care cannot be assumed to be safe for patients' and called for more attention to be paid 'to improving safety and risk assessment'.In some cases, unclear policies led to patients receiving dangerous medication without being monitored because they fell through the gaps between primary and secondary care.Other problems occurred around the ordering of tests – one serious incident could have been avoided by GP direct access – and time pressures and demands on workload were also often involved.Study leader Dr Olga Kostopoulou, a research fellow in primary care at the University of Birmingham, said: 'Most of the reported events were near misses, but events with serious patient consequences were reported.'Creating more of a safety culture in primary care could help deal with these issues, she said.The study, published in the latest issue of Quality and Safety in Health Care, analysed 78 confidential reports of patient safety events from five practices over a period of 16 months. Only 13 had serious patient consequences but 75 per cent had potential for serious harm.GPs said there was a series of problems with the current systems managing patients across primary and secondary care.Dr David Roberts, a GP in Llandysul, Ceredigion, said: 'Primary care is supposed to receive handwritten discharges within 48 hours and typed summaries within 28 days, but this requirement is barely met 50 per cent of the time.'Dr Steve McCabe, a GP in Portree, Skye, said: 'Immediate discharge information is usually inadequate and formal discharge letters still take weeks to arrive. Sometimes important investigations are carried out and we never get copies of the results.'Dr Peter Fellows, chair of the GPC prescribing subcommittee and a GP in Lydney, Gloucestershire, said he did not have access to pelvic ultrasound and would like to be able to refer directly.

How patients were put at risk

• A 67-year-old man with diabetes and high blood pressure was referred by GP to a dementia open-access clinic for rapid onset of memory loss.The psychiatrist treated the patient – but did not perform a CT scan, despite GP's request, and did not review the patient again.The patient's condition deteriorated, but the GP was refused a request to order a scan directly. The patient was eventually diagnosed with an inoperable meningioma.• A young mother started developing a fever, but the midwife decided not to visit her at home owing to workload. The patient eventually saw her GP, who diagnosed septicaemia and admitted her urgently to hospital, where she received intravenous antibiotic treatment.

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