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Table 2 Development of Items for inclusion in prototype checklist

From: Development of the prototype concise safe systems checklist tool for general practice

Development of draft checklist Prototype Checklist
Description Item (s) Rationale Evidence Refinement Item
Information flow
The practice has a systems based approach to processing incoming results* and information in to and out of the practice, which prevents human and electronic error in data handling.
*results = lab results, reports or investigations, and letters.
All incoming clinical information is seen by a GP in the practice to view and action before or after being filed, scanned or coded in the patient’s medical record. The practice has a systems based approach to processing incoming results* and information into and out of the practice, which prevents human and electronic error in data handling [* results: lab results, reports or investigations]and letters) [12]. (PMCPA) [22] (Premises Records Equipment/Devices and Medicines management section) (http://www.rcgp-practiceaccreditation.org.uk Wording changes - in order to allow practices to nominate appropriately trained staff to handle mail rather than just GPs All incoming clinical information is seen by nominated members of the team trained (or with relevant clinical experience) to deal appropriately with this information before the information is filed in the patient’s record.
Where an incoming result, report or investigation requires follow-up or a diarised activity, it is recorded in the patient’s medical record and acted upon [for example follow up of blood tests such as PSA, INR etc.] Where an incoming result, report or investigation requires follow-up there are systems in place to ensure it occurs. Adapted from PCMPA [22] and informed by Casalino et al. [23]. These items were combined as they were felt to be too similar Where a clinician decides it is indicated, the patient (or where appropriate the patient’s representative) is informed of abnormal investigation results in an appropriately and timely manner and this contact is documented in the patient’s record.
The patient (or where appropriate, families and carers) is informed of an abnormal investigation results in an appropriate and timely manner and this is documented in the patient’s record. The provider has a written policy for informing patients, or where appropriate, families and carers, of the results of investigations and the policy is explained to them. Adapted from PMCPA [22].
The practice keeps a record or log of their minor operations which will have the following information recorded; 1) date; 2) patient name; 3) procedure performed; 4) team members involved; 5) whether a specimen was sent for histology; 6) patient consent; 7) complications; 8) patient informed of result. This log represents the basic safety information required about any surgery performed Taken direct from PMCPA [22] (provider management), a template could easily be designed to collect this information   The practice keeps a log of minor operations
Safety information about the practice
The practice has a systems based approach to supplying information about safety procedures required by permanent and temporary staff.
Up-to-date information on the practice policies and procedures, and local facilities and services is provided to guide locums and other temporary clinical staff who work in the premises, in the form of a clinical staff handbook (hard copy). There is no current legislative requirement specifically directed at trainees or temporary staff. Dutch consensus process exploring safe working conditions from locum staff [24]. Items combined as seen as too similar.
Requirement for hard copy information was removed after discussion within our project team, considering the change to paper-light practices.
Up-to-date information on practice policies, procedures and local facilities/services is provided to guide all temporary clinical staff (including GP registrars).
There is an up-to-date office procedure manual (hard copy and/or electronic copy) covering the administrative procedures and systems for the daily running of the practice to which team members have access. These policies are discussed and agreed by team members and are reviewed at least annually. There is no central policy document of safety procedures readily available to all staff. Review of factors supporting successful teamwork in primary care [25].   
Working with patients for safe prescribing
The practice has a systems based approach to working with patients to improve the safety of prescribing practices.
The practice works with patients to ensure medication list accuracy (medication reconciliation) upon hospital referral. No such process for medicine reconciliation exists despite the potential impact on patient safety. Review of reconciliation issues [26, 27]. Removed as seen as being beyond practice’s control.  
Non-collection of prescriptions held by the practice are monitored and followed-up by the practice and medications which are not claimed by patients are a trigger for review and audit in partnership with local pharmacies.d Non-collection might reflect medication error, poor compliance or other patient safety issues. A study of medication reviewing in primary care27 and is also included in PMCPA [22]. Wording changes - in order to simplify the item. Non-collection of prescriptions is monitored or followed-up and is a trigger for review and audit in partnership with local pharmacies.
Patients discharged from hospital should have a recorded follow up appointment with a member of the practice clinical team within 1 month. Patients at high risk of patient safety incidents should be followed-up at risky care transitions. Originally from a US process mapping study [28]. Clinicians believed that it was unrealistic to follow-up all of the discharges within one month so we added the word ‘vulnerable’ to this item. Vulnerable patients discharged from hospital are followed-up by a member of the clinical team within 1 month.
IT indicators for prescribing
The practice has fit for purpose IT systems for prescribing which work with prescribers to make prescribing a safer activity.
The practice uses an electronic prescribing system for all prescriptions (Computerized Physician Order Entry (CPOE)). Drive to implement CPOE primarily comes from its presumed benefit in reducing medical errors. Evidence of CPOE can reduce medication errors [29]. Removed - did not allow practices enough flexibility to serve patients.  
Prescribers code the indication for the drug with each prescription using the electronic prescribing system (with the exception of topical medications without active ingredients). This is good practice and there is currently no legislative requirement for it to be done. Canadian study of electronic coding of prescription indication [30]. Wording changed for clarity. The indication for all repeat medications is coded within the electronic record (excluding topical preparations).
The practice has and uses, the most up-to-date alerting software available, routinely on all computers used for prescribing in relation to allergies and duplicates, drug-drug interactions, contraindications in terms of drug –disease, drug-age and potentially drug-lab value interactions. The safety features of software systems are effective in alerting users about potential clinical hazards and errors during medication order entry. Delphi study on electronic safety systems [31]. Felt to be imbedded in the computer systems.  
All staff (including GPs) are trained to make safe use of the prescribing elements of their clinical IT systems. Specific training in IT prescribing systems is not a mandatory requirement and yet is essential for all team members involved in prescribing. Delphi study on electronic safety systems [31]. Wording changed for clarity. All staff are trained to make safe use of the prescribing elements of the clinical IT system which are relevant to their role.