Incident reporting in primary care: epidemiology or culture change?

As in most other areas of human experience, fashions in healthcare and in healthcare research come and go. They come about because a good idea is articulated, often as a sound bite that makes intrinsic sense, and they go because a few intrepid researchers are prepared to investigate the substance behind the sound bite and they come to realise that the logic is not supported by the reality. The original logic is supplanted. Over the last 20e30 years, there have been some notable fashions in healthcare that have lit up the globe like a comet and then died. Just as there have been passing fashions in surgery (eg, routine tonsillectomies) and medications (eg, hormone replacement therapy), so also have there been passing fashions in quality improvement (QI) and QI research. Kieran Walshe in his bibliometric research tracked the frequency paths of different QI terms used between 1988 and 2007. ‘Patient safety’ was a relatively low frequency term (along with ‘clinical governance’ and ‘six sigma’) from 1988 to 1999, when suddenly it took off following the release of the Institute of Medicine’s ‘To Err is Human’ report, surpassing almost all the other QI terms, along with ‘six sigma’. The rise in evidence-based medicine, arguably itself a fashion, is largely responsible for deposing fashionable good ideas. Evidence-based medicine, although not immune to criticism, is different from other fashions in that it has infiltrated every part of every health systemdthe idea, at least, if not always the practiced and it has not gone away. It is a concept that has captured health systems globally and become embedded as a value, an aspiration and an expectation of healthcare, even more now than it was when the idea first lit up the world more than 40 years ago. Epidemiological research that measures, compares, tests and exposes is the key scientific approach used to create most of the evidence underpinning evidencebased medicine. Epidemiology is so important to medicine now that we are challenged to imagine life before the evidence-based medicine comet. There may be some justification for viewing the patient safety phenomenon as a paradigm changing one, like evidence-based medicine, but we wonder if the relatively recent focus on incident reporting systems in primary care patient safety research may be a passing (or even passed) fashion. We propose that it is time for patient safety incident reporting to move from being a research tool to being embedded in health systems. Governments, organisations and institutions have invested huge financial, personnel and time resources in establishing incident reporting systems with a view to identify and remedy threats to patient safety. Processes have been redesigned to make healthcare safer and tested (eg, physician order entry), and efforts have been made to understand why known safe practices (eg, handwashing) are not always used. However, there is little evidence to show that, overall, health systems are safer places for patients to engage with now than they were 10 years ago. The early studies identifying particular patient harms, their likelihood of occurrence and degree of preventability were all based in hospitals. These studies have had an impact far in excess of what would seem possible from their size or design. They raised awareness of the harm that healthcare processes can generate and forced critical reviews of health services. They established an epidemiological foundation for threats to patient safety in hospital care, provided an essential foundation for focused patient safety research and prompted health services to investigate and learn from safety management processes in other industries. The aviation industry, in particular, had a history of incident reporting systems that seemed transferable to the health sector and such systems became widely adopted into hospital safety management practices. Primary care escaped the attentions of patient safety promoters in the early 2000s. The step of establishing an epidemiological description of the patient safety landscape was skipped in primary care. For some, this meant that patient safety was not a primary care issue; for others, it meant that the research just had not been done yet. Taking the latter view, a cohort of primary care researchers, including the authors, set about trying to find out whether people involved in primary care provision should be included when patient safety was being talked about. Emulating the hospital records review studies was considered not only ‘cumbersome and costly’ but also impractical. Primary care does not operate in time-limited events like a hospital admission. Primary Department of General Practice and Rural Health, University of Otago, Dunedin, New Zealand