Dr Meredith Makeham Project: School of Public Health and Community Medicine, University of New South Wales Funding: National Health and Medical Research Council Project Grant; National Health and Medical Research Council Scholarship; and Primary Health Care Research, Evaluation and Development Strategy Research Development Program Fellowship

Although more than two million GP services are provided each week in Australia, patient safety research and policy has so far been mainly focussed outside the primary health care setting.

A team at the University of Sydney including Professor Michael Kidd, Dr Chris Cooper and Clinical Professor Michael Mira conducted this major study which sought to fi ll local and international evidence gaps by developing a suitable error reporting system, calculating the incidence of reported error from GPs in the community setting, and developing a new general practice classification system to describe threats to patient safety.

The Threats to Australian Patient Safety (TAPS) study involved a representative sample of NSW GPs anonymously reporting errors using a secure website. In the first 12 months, 433 submissions were lodged, containing 418 error reports. Analysis of the rich collection of reports demonstrated there was about one error per 1,000 patients seen per year, and that the majority of errors related to health care systems rather than professional knowledge or skill.

The study’s findings represent the first known validated calculations of the incidence of reported error in general practice. The successful new error reporting and classification systems will inform further investigations and initiatives in primary health care safety and quality.

The research has been translated into a series of clinical lessons for general practice. The study also found a recurring patient safety risk related to a failure to constitute a commonly used vaccine correctly due to its packaging. NSW Health alerted GPs, and distribution in this form was ceased.

View the project abstract on ROAR