ID-5184 Wonca Abstracts supplement A-K 13-10-23 - Flipbook - Page 52
WONCA 2023 Supplement 1: WONCA 2023 abstracts (A–K)
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In-depth analysis of adverse events in Spanish primary
healthcare (PCH) area considering contributing factors to
build a PHC risk map
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Ms Maria Pilar Astier-Peña1, Montserrat Gens-Barbera2, David Ayala-Villuendas2, Ferran BejaranoRomero2, Angel Vila-Rovira2, Inmaculada Hospital-Guardiola2, Nuria Hernandez-Vidal2, Francisco
Martin-Lujan2, Yolanda Mengibar-Garcia2, Eva Maria Oya Girona2
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WONCA World Executive Board, 2Healthcare Quality Territorial Unit Healthcare Directorate of Camp
de Tarragona Healthcare Institute of Catalonia
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Background
A crucial tool for improving quality and patient safety is to inform patient safety incidents (PSI) which
may happen in any step of the patient’s journey in the health system to the reporting and learning
systems (RLS). In-depth analysis of PSI reported by professionals from primary care practices (PCP)
in the RLS is a key element in defining a primary care risk map. The identification of contributing
factors, particularly from incidents involving harm or adverse events (AE) will be useful to implement
improvements in factors described in these maps.
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Materials and methods
The Camp de Tarragona health area has 26 PCP (901 professionals; 326,000 inhabitants). We
identified all AE from primary care in the RLS, named SNISPCat, of the health region between 2013
and 2022. The contributing factors described in the analysis carried out by the RLS managers were
analysed in-depth identifying in each factor the issues which account for almost 80% of all.
Results
There were 1320 AE out of a total of 9825 PSI reported. Professional factors included the wrong
application of regulations, distraction and lack of information. Patient factors included negative attitude,
complex patient and communication issues. Environmental factors included equipment, infrastructure,
environmental assessment and safety. Finally, organisational factors included: a lack of implementation
of policies, protocols; team organisation; and overload of work. External factors included: services,
systems; and policies and products technologies and infrastructure.
There were some patient mitigating factors: presentation of apologies, patient-detected incident and
requested help. Professional mitigating factors were leadership and good supervision.
Conclusion
The in-depth analysis of AE in primary care makes it possible to describe the primary care risk map in
a dynamic way over time and throughout the patient’s journey in the healthcare system.
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