Family Practice, Vol 14, 101-106, Copyright © 1997 by World Organization of Family Doctors
H Britt, GC Miller, ID Steven, GC Howarth, PA Nicholson, AL Bhasale and KJ Norton
OBJECTIVE: The prediction and subsequent prevention of errors, which are an
integral element of human behaviour, require an understanding of their
cause. The incident monitoring technique was developed in the study of
aviation errors in the Second World War and has been applied more recently
in the field of anaesthetics. This pilot study represents one of the first
attempts to apply the incident monitoring technique in the general practice
environment. METHOD: A total of 297 GPs across Australia anonymously
reported details of unintended events which harmed or could have harmed the
patient. Reports were contemporaneously recorded on prepared forms which
allowed a free text description of the incident, and structured responses
for contributing and mitigating factors, immediate and long-term out-comes,
additional costs etc. RESULTS AND DISCUSSION: The first 500 reports were
analysed using both of qualitative and quantitative methods and a brief
overview of results is presented. The methodological issues arising in the
application of this technique to such a large, widely spread profession, in
which episodes of care are not necessarily confined to a single
consultation, are discussed. This study demonstrated that the incident
monitoring technique can be successfully applied in general practice and
that the resulting information can facilitate the identification of common
factors contributing to such events and allow the development of preventive
interventions.
ORIGINAL CLINICAL RESEARCH
Collecting data on potentially harmful events: a method for monitoring incidents in general practice
Department of General Practice, University of Sydney, Westmead Hospital, NSW, Australia.
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