PT - JOURNAL ARTICLE AU - Anthony J Avery AU - Christina Sheehan AU - Brian Bell AU - Sarah Armstrong AU - Darren M Ashcroft AU - Matthew J Boyd AU - Antony Chuter AU - Alison Cooper AU - Ailsa Donnelly AU - Adrian Edwards AU - Huw Prosser Evans AU - Stuart Hellard AU - Joanne Lymn AU - Rajnikant Mehta AU - Sarah Rodgers AU - Aziz Sheikh AU - Pam Smith AU - Huw Williams AU - Stephen M Campbell AU - Andrew Carson-Stevens TI - Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review AID - 10.1136/bmjqs-2020-011405 DP - 2021 Dec 01 TA - BMJ Quality & Safety PG - 961--976 VI - 30 IP - 12 4099 - http://qualitysafety.bmj.com/content/30/12/961.short 4100 - http://qualitysafety.bmj.com/content/30/12/961.full SO - BMJ Qual Saf2021 Dec 01; 30 AB - Objective To estimate the incidence of avoidable significant harm in primary care in England; describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents.Design Retrospective case note review. Patients with significant health problems were identified and clinical judgements were made on avoidability and severity of harm. Factors contributing to avoidable harm were identified and recorded.Setting Primary care.Participants Thirteen general practitioners (GPs) undertook a retrospective case note review of a sample of 14 407 primary care patients registered with 12 randomly selected general practices from three regions in England (total list size: 92 255 patients).Main outcome measures The incidence of significant harm considered at least ‘probably avoidable’ and the nature of the safety incidents.Results The rate of significant harm considered at least probably avoidable was 35.6 (95% CI 23.3 to 48.0) per 100 000 patient-years (57.9, 95% CI 42.2 to 73.7, per 100 000 based on a sensitivity analysis). Overall, 74 cases of avoidable harm were detected, involving 72 patients. Three types of incident accounted for more than 90% of the problems: problems with diagnosis accounted for 45/74 (60.8%) primary incidents, followed by medication-related problems (n=19, 25.7%) and delayed referrals (n=8, 10.8%). In 59 (79.7%) cases, the significant harm could have been identified sooner (n=48) or prevented (n=11) if the GP had taken actions aligned with evidence-based guidelines.Conclusion There is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.Data are available upon reasonable request. Anonymised summary data extracted from patient records regarding the avoidable harms detected in this study will be available upon reasonable request.