Study design and setting

Design of the survey

For each of the clinical cases, the respondent was asked to judge the impact of the specific situation on patient safety along a five-point Likert scale which ranged from 'patient safety not at all at stake' to 'patient safety is greatly at stake.' The respondent could also provide comments. For the list of potential risk factors, the respondent was also asked to judge these risk factors along a five-point Likert scale which ranged from 'no increased risk for patient safety' to 'greatly increased risk for patient safety.' Finally, the survey also included some questions to determine the demographic characteristics of the general practice.

The data were entered into SPSS 16.0 for analysis. The response frequencies for the GPs were calculated. No significant differences (p < 0.05) were found between the answers provided by the GPs from different geographic areas, male versus female GPs or different aged GPs (i.e., those 50 or over versus those under 50). The comments provided by the GPs were analyzed qualitatively per clinical case. One comment per clinical case was used as enlightening quote.

Judged safety of specific clinical practices

Five of the 10 clinical cases presented to the GPs were judged to be unsafe by a majority of them (>50%). The other five cases were judged to be safe by a majority of the GPs (Table 2).

Medical record systems

Medication

Error discussion

Telephone accessibility

Miscommunication

PSA testing

Diagnostic process

Hygiene

Potential risk factors

The percentages of the GPs who scored the potential risk factors as constituting 'much' or 'very much' of a risk to patient safety were next calculated (Table 3). The highest ranked factors were not keeping up one's medical knowledge (42.6%), a poor doctor-patient relationship (41.2%) and patient age over 75 years (41.2%). The existence of a language barrier (36.8%) and polypharmacy (33.8%) were also judged to place patient safety at risk although somewhat less than the aforementioned factors. Patients presenting with unexplained symptoms and repeat visits by patients for the same symptoms were not viewed as much of a risk factor by the GPs (13.2% and 7.4%, respectively). Deviation from the evidence-based guidelines provided by the Dutch College of General practitioners (which is a well-known primary care organization in the Netherlands which has made evidence based guidelines on the most prevailing complaints in primary care) was judge to be unsafe by only 2.9% of the GPs, and none of the GPs correlated lack of privacy in the waiting room with patient safety.

Perceptions of patient safety

Out of the 10 clinical cases responded to by the GPs in our study, failure to record or inadequate notation of information in the medical records of patients was judged to constitute the greatest threat to patient safety. This finding is consistent with the results of other studies which show missing information to be common and possibly harmful for patients in primary care [12]. One of the lessons from the Threats to Australian Patient Safety (TAPS) study, moreover, is the importance of complete and accurate medical records. Errors can arise from missing clinical information (missing lab results) and/or suboptimal recording of contacts within an episode of care [13]. Our findings confirm this. The GPs in our study considered good record keeping to be highly important for patient safety.

Medication safety was also perceived by the GPs in our study to be highly critical for the safety of their primary care patients. This included the clinical cases of overruling medical alerts, nonresponse to possibly dangerous interactions of hospital prescribed medications and the prescription of a NSAID without gastric protection for an elderly patient. Medication safety is probably the best studied aspect of patient safety. The results of a recent study in the Netherlands, for example, showed adverse drug events to be an important cause of unplanned hospitalization with almost 50% of the hospitalizations potentially preventable [14]. The clinical case which concerned the overruling of medical warnings generated by an electronic dossier in our study was judged by 85% of the GPs to be quite risky; nevertheless, recent research shows clinicians to override most medication alerts, which suggests that the system does not function adequately and protect patients [15]. In a different study, few physicians were found to change their prescriptions in response to drug allergy or interaction alerts [16]. The GPs in our survey study placed a greater emphasis on medication monitoring than in our interview study [8].

The case in which a practice did not discuss errors on a regular base was only judged to pose a moderate risk for patient safety. The reporting of incidents can help healthcare professionals learn from mistakes and thereby improve the delivery of healthcare in the future [17]. Broad implementation of incident reporting is one of the targets of health policy in many countries including the Netherlands. However, in the present study, only 50% of the GPs viewed this as an issue for patient safety, which appears to be in line with research providing limited evidence for the effectiveness of incident reporting to improve patient safety. Of course, our finding may also indicate reluctance on the part of GPs to undertake incident reporting due to time constraints and/or the challenge which such reporting could present for their professional competence.

Telephone waiting time was judged low in terms of posing a threat to patient safety. While the Dutch Healthcare Inspectorate [9] reports a wait of 2 minutes for contact via a regular telephone line to be acceptable, the GPs in our study generally considered a wait of as much as 10 minutes to not constitute a threat to patient safety. The GPs in our survey study may have judged a long wait as less than optimal but not unsafe although this contradicts the results of our interview study in which both doctors and nurses suggested that telephone accessibility of the primary care practice is important for patient safety [8]. Accessibility may, of course, refer to the availability of an emergency telephone line, which almost all GPs consider a necessity, but the Dutch Healthcare Inspectorate reports more than 25% of patients calling an emergency telephone line to not receive an answer from the primary care practice [9].

The clinical case judged to pose the least of a threat to patient safety in the present study was suturing without sterile gloves. Many of the GPs explicitly stated that no use of sterile gloves is safe - despite a Dutch clinical guideline which says that the use of sterile gloves is mandatory for the prevention of infection [18]. Hand hygiene is an area in which physicians have been found to be remarkably resistant to procedures recommended for the prevention of major infection [19], and our own findings are thus consistent with this. A wide range of barriers to change in the direction of prevention has also been identified and found to include, among other things, insufficient knowledge of evidence regarding infection prevention and insufficient availability of the necessary devices.

Perceptions of risk factors

Failure to keep one's medical knowledge up-to-date scored high as a risk factor for patient safety. Medical knowledge is of obvious importance, and insufficient knowledge can result in inadequate decision-making for both diagnostic and treatment purposes [20]. Interestingly, a poor doctor-patient relationship scored equally high as a risk factor for patient safety. A poor doctor-patient relationship can have negative outcomes for patient satisfaction, treatment compliance and even the health status of the patient [21]. The diagnostic process can also be complicated by a poor doctor-patient relationship and communication problems, with inadequate diagnosis as a result.

In contrast, deviation from evidence-based guidelines and hygiene (i.e., the case of suturing without sterile gloves) were not viewed as a major threat to patient safety by the GPs in our study. We can only speculate that physicians consider deviation from evidence-based guidelines as suboptimal treatment but not harmful to the patient. This suggests that undertreatment or failure to provide the treatment recommended by a guideline may not be part of the physician's concept of patient safety. It is also possible that physicians clearly see their deviation from evidence-based guidelines to be based upon adequate clinical decision-making and careful consideration.

Strengths and weaknesses of this study

The response rate for this study was acceptable, but selection bias cannot be ruled out. In light of the involvement of all our respondents in the Nijmegen University Network of General Practitioners (i.e., training of medical students), the respondents in our study were perhaps more interested in patient safety than the average GP in the Netherlands. However, the demographic characteristics of the respondents in our study were representative for the population of GPs in the Netherlands and the answers provided by the GPs in our study did not differ systematically across subgroups. While the survey used in this study was not empirically validated, it was nevertheless based upon the results of interviews and the insights of experienced GPs with regard to the choice of clinical cases and potential risk factors. The primary care cases we presented as part of the survey were actually presented to us by the GPs in our previous interview study. Such cases indeed occur frequently in daily practice, which is supported by not only our own clinical experience but also the comments of the respondents in our survey study. That is, many of GPs used the comment box to explicate the score they assigned and a number of these comments indicated that the case in question was indeed a problem in their own clinical practice as well.

Implications for future research

The results of this study highlight which aspects of general practice care are viewed as most important for patient safety from the perspective of the GPs themselves. Nevertheless, the scope of patient safety is broader than the perspective of only the GP [4]. The GPs in our study judged well-known medication factors (e.g., prescription and monitoring, adherence to alerts) as critical for patient safety but also less well-known factors such as a good doctor-patient relationship. The Manchester Patient Safety Framework for Primary Care is available to chart the safety of the healthcare culture [22]. However, for adequate implementation of such a monitoring system into primary care, it is important that what the GPs themselves consider most important for patient safety in actual practice be taken into consideration as well. Obviously, strategies to improve patient safety are needed. Organizational culture may play an important role in patient safety improvements [23]. It would be inappropriate to narrow down patient safety programs to the monitoring of medication and prevention of infection in primary care, for instance, but the necessary breadth poses a major challenge for the development of patient safety programmes and the actual measurement of patient safety because valid measurement and improvement trajectories require specificity. Further research should be conducted on the implementation of the present findings into useful patient safety programs. Finally, it might be useful to investigate the correspondence between the definitions and perception of patient safety provided by patients and GPs.