A Systematic Review of Patient Safety Measures in Adult Primary Care

Abstruse

Background

A major barrier to safety improvement in primary care is a lack of safe data. The aims of this systematic meta-review (registration: CRD42021224367) were to identify systematic reviews of studies that examine methods of measuring and monitoring safety in primary care; classify the methods of measuring and monitoring safety in the included systematic reviews using the five safety domains of Vincent et al.'s framework and use this data to brand recommendations for improving the measurement and monitoring of safety in primary care.

Methods

Four databases (Medline, Academic Search Complete, Spider web of Science and CINAHL) and the grey literature were screened in November 2020, with searches updated in January 2021. Systematic reviews were included if they addressed the measurement of patient prophylactic in primary care and were published in English language. Studies were assessed using the Disquisitional Appraisal Skills Programme for systematic reviews.

Results

A total of 6904 papers were screened, with thirteen systematic reviews included. A ordinarily reported method of measuring 'past harm' was through patient record review. The near frequent methods for assessing the 'reliability of safety disquisitional processes' were checklists, observations and surveys of staff. Methods used to assess 'sensitivity to operations' included observation, staff surveys, interviews, focus groups, agile monitoring and fake patients. Safety climate surveys were a normally used as an approach to assess 'apprehension and preparedness'. A number of the reviews concluded that safety data could, and should, be used for 'integration and learning'. The master limitation of the meta-review was that it was of systematic reviews simply.

Conclusions

Many of the methods for measuring and monitoring prophylactic are readily available, quick to administer, exercise not require external involvement and are inexpensive. However, there is still a need to ameliorate the psychometric properties of many measures. Researchers must support the evolution of psychometrically sound prophylactic measures that do not over brunt master intendance practitioners. Policymakers must consider how primary care practitioners tin can exist supported to implement these measures.

Introduction

Improving patient safety and reducing preventable harm in healthcare is an ongoing claiming. A barrier to safety improvement is the lack of data to allow organizations, teams and individual healthcare providers to evaluate how they are performing and where there are deficits and risks [1]. Recognizing the challenges of measuring and monitoring safety (MMS), Vincent et al. adult the MMS framework (see Table 1) [2, 3]. The MMS framework provides a useful approach to considering methods of MMS in a particular domain of healthcare and identifying where at that place may be deficiencies in, or opportunities for, MMS [4].

Table 1

Description of the five dimensions of safety (adapted from Vincent et al. [2])

MSS dimension	Purpose	Examples
'Past harm' Has patient care been safe in the past?	Assess rates of past harm to patients	Patient tape review Agin issue reports
'Reliability' Are clinical systems and processes reliable?	Assess the reliability of rubber critical processes and the power of staff to follow these procedures	Observations of safety critical behaviour Practice safety checklist
'Sensitivity to operations' Is care safe today?	Back up the monitoring of safety on an hourly or daily basis	Observations and conversations with practice staff Talking to patients
'Apprehension and preparedness' Will care be safe in the future?	Support the anticipation and respond to time to come threats to safety	Safety climate assessment Structured reflection
'Integrating and learning' Are we responding and improving?	Analyse and use safety information to amend safety	Amass data on patient complaints Feedback and implementation of safety lessons

MSS dimension	Purpose	Examples
'By harm' Has patient care been condom in the past?	Assess rates of past damage to patients	Patient record review Adverse event reports
'Reliability' Are clinical systems and processes reliable?	Appraise the reliability of safety critical processes and the ability of staff to follow these procedures	Observations of rubber critical behaviour Exercise safety checklist
'Sensitivity to operations' Is care safe today?	Support the monitoring of condom on an hourly or daily basis	Observations and conversations with exercise staff Talking to patients
'Anticipation and preparedness' Will intendance be rubber in the hereafter?	Support the anticipation and respond to future threats to safety	Safety climate assessment Structured reflection
'Integrating and learning' Are we responding and improving?	Analyse and use safe information to meliorate rubber	Aggregate data on patient complaints Feedback and implementation of safety lessons

Table ane

Description of the v dimensions of safety (adapted from Vincent et al. [ii])

MSS dimension	Purpose	Examples
'By harm' Has patient care been rubber in the past?	Assess rates of past harm to patients	Patient tape review Adverse event reports
'Reliability' Are clinical systems and processes reliable?	Assess the reliability of safety critical processes and the ability of staff to follow these procedures	Observations of safety critical behaviour Exercise safety checklist
'Sensitivity to operations' Is care safe today?	Support the monitoring of safety on an hourly or daily basis	Observations and conversations with practice staff Talking to patients
'Anticipation and preparedness' Will care be safe in the future?	Support the anticipation and reply to future threats to prophylactic	Safety climate assessment Structured reflection
'Integrating and learning' Are we responding and improving?	Analyse and use prophylactic information to improve rubber	Aggregate data on patient complaints Feedback and implementation of safety lessons

MSS dimension	Purpose	Examples
'Past harm' Has patient intendance been safe in the past?	Assess rates of past impairment to patients	Patient tape review Adverse event reports
'Reliability' Are clinical systems and processes reliable?	Assess the reliability of safety critical processes and the power of staff to follow these procedures	Observations of safety disquisitional behaviour Practice condom checklist
'Sensitivity to operations' Is intendance rubber today?	Support the monitoring of condom on an hourly or daily basis	Observations and conversations with practice staff Talking to patients
'Apprehension and preparedness' Will care be safe in the hereafter?	Back up the anticipation and reply to future threats to safety	Safety climate cess Structured reflection
'Integrating and learning' Are we responding and improving?	Analyse and use safety information to amend safety	Aggregate data on patient complaints Feedback and implementation of condom lessons

Enquiry on patient safety, and MMS, in master care has lagged behind that of secondary intendance. This is arguably due to the perception that principal care is relatively low risk. However, it has been constitute that 2–three% of primary care consultations effect in a patient safety incident (PSI), with ∼iv% of these PSIs associated with severe harm [5]. Given that ∼90% of all healthcare contacts occur in chief care, there is a big potential for patient impairment to occur [half dozen]. Principal care providers have stated that they do not know how to meliorate safety [7]. However, it has been found that when principal care providers are provided with data identifying the safety issue in their practice, they are able to identify and implement methods to effectively address these deficits [8, 9]. Therefore, there is a demand to place valid, reliable, readily available and easily administered methods of MMS. We believe that an effective way to practise this is through a meta-review of systematic reviews of methods of MMS in principal intendance.

A meta-review summarizes the evidence from multiple research syntheses, compares the findings from the systematic reviews and assesses whether the review authors reached similar or contradictory conclusions [ten]. The purpose of a meta-review is not to repeat what was done in the previous systematic reviews (due east.grand. duplicate the searches). Rather, it is to provide an overview of the research evidence on a particular result [10]. Therefore, the aims of our systematic meta-review were to

1. identify systematic reviews of studies of MMS in primary care

2. employ the v dimensions of safety from Vincent et al.'s [2, 3] framework to allocate the methods of MMS in chief care reported in the systematic reviews and

3. based on the classification of the methods of MMS and the conclusions of the authors of the reviews brand recommendations for MMS in main care.

Method

The meta-review was prospectively registered with the International Prospective Register of Systematic Reviews (registration number: CRD42021224367). This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11].

Design

This study was a meta-review of systematic reviews of patient safety measures in primary care.

Inclusion and exclusion criteria

Systematic reviews were included if they focused on studies nearly MMS in main care and were published in English language. Studies were excluded if they were another form of study such equally a narrative review or original enquiry, non published in English, focused on patient prophylactic interventions or any aspects of patient safety other than measurement or monitoring or it was non possible to access the primary intendance-specific information inside a larger synthesis.

Search strategy

A search strategy was developed with the support of a research librarian and adjusted for the unlike databases (meet Supplemental Fabric 1 for the Medline search strategy). Grayness literature was as well searched via Google Scholar, with the terms 'Chief care, mensurate, patient safety, systematic review' and 'full general practice, patient safety, measure, and systematic review'.

Process

Iv databases (Medline, Academic Search Consummate, Web of Science and CINAHL) were screened in November 2020, and searches were re-run in January 2021. The databases were searched by two authors (CM and EOD). Google Scholar was searched by one author (EOD). Titles and abstracts were screened, and total texts were examined of papers about which the authors had queries or which appeared suitable for inclusion. All disagreements on inclusion/exclusion were resolved with the input of all authors. Information were extracted from the systematic reviews by ii authors independently (CM and EOD) and agreed upon. The data extracted were as follows: authors, year, aim, number of included articles, search range, language, database, methods of MMS, quality appraisal findings and a summary of the results. The methods of MMS summarized in the systematic reviews were classified using Vincent et al.'s [2, iii] dimensions of MMS by agreement between two authors (POC and SL).

Critical appraisal

The Critical Appraisement Skills Programme (CASP) systematic review checklist [12] was used to appraise the quality of the included systematic reviews. The rationale for using the CASP systematic review checklist was that it included articulate and explicit guidance for what to consider when responding to the items in the CASP checklist for each study and could exist applied to the types of systematic reviews (i.e. reviews focused on measurement rather than interventions) included in our meta-review with minimal adaptation required to the CASP checklist. The CASP systematic review checklist has three parts: part A, are the results of the report valid? (five items); part B, what are the results? (ii items); and part C, will the results help locally (in the instance of this review interpreted as improving prophylactic in primary intendance; 3 items). 1 item from part B and one from part C were not applied in our appraisal as they are relevant for interventions. For each detail a response of 'yes' (one), 'no' (0) or 'can't tell' (0) was given. Therefore, each systematic review was given a score out of 8. The systematic reviews were independently appraised past two reviewers (POC and EOD), with any disagreements resolved via discussion.

Results

A total of 6904 papers were screened, with 13 systematic reviews included. Examples of systematic reviews that were not included are as follows: Manser et al. [thirteen] (unable to excerpt chief care specific data) and Verbekel et al. [14] (focused on interventions and not methods of MMS). The PRISMA menstruation diagram of included studies can exist found in Effigy i. Tables two and 3 provide a summary of these included reviews, with a more detailed description provided in Supplemental Textile ii.

Table 2

Systematic review characteristics

	N
Number of reviews	xiii
All safety measures	4
Rubber climate measures only	4
Reporting systems only	two
Patient record review just	3
Number of studies included in the reviews
Mean	24.vii
SD	12.0
Range	xiv–56
Number of databases searched
Hateful	four.4
SD	1.9
Range	1–eight

	Northward
Number of reviews	13
All rubber measures	4
Rubber climate measures only	iv
Reporting systems only	2
Patient tape review but	iii
Number of studies included in the reviews
Mean	24.seven
SD	12.0
Range	14–56
Number of databases searched
Mean	four.iv
SD	i.nine
Range	one–8

Table 2

Systematic review characteristics

	Northward
Number of reviews	13
All prophylactic measures	4
Safety climate measures only	4
Reporting systems only	2
Patient record review only	3
Number of studies included in the reviews
Mean	24.vii
SD	12.0
Range	14–56
Number of databases searched
Mean	4.4
SD	1.9
Range	1–8

	N
Number of reviews	13
All rubber measures	iv
Safe climate measures simply	four
Reporting systems merely	two
Patient record review only	three
Number of studies included in the reviews
Hateful	24.7
SD	12.0
Range	14–56
Number of databases searched
Hateful	4.4
SD	1.nine
Range	i–8

Table three

Summary of included systematic reviews

Authors	Twelvemonth	# articles	Aim of review	Summary of findings
All safety measures
Hatoun et al. [18]	2017	21	To identify published articles detailing safety measures applicable to developed primary intendance	– Although numerous measures of patient prophylactic exist, many are not validated and pertain only to a particular research written report or quality comeback project
Lawati et al. [xix]	2018	28	To review the literature on the safety culture and patient safety measures used globally	– The near common theme emerging from 2011 onwards was the cess of safety civilisation – The about commonly used condom culture assessment tool was the Hospital Survey on Patient Safe Civilization
Lydon et al. [15]	2017	56	To identify and review articles that presented or described the utilise of measures of patient safety suitable for use in general practise settings	– There is a demand to improve the psychometric properties of existing tools equally opposed to developing new tools – There is a need to accept a multi-methods arroyo to assessing patient condom
Marchon and Mendes [16]	2014	33	To identify methodologies to evaluate incidents in primary health intendance, types of incidents, contributing factors and solutions to make main care safer	– Highlighted the need for expanding safe culture in primary care in lodge to gear up patients and health professionals to identify and manage agin events
Safety climate measures but
Curran et al. [24]	2018	17	To identify the origins, psychometric backdrop, quality and condom climate domains measured by survey instruments used to assess safety climate in chief intendance settings	– Consideration should be given to selecting an instrument that has safety climate domains relevant to primary care – Need to focus on further establishing the benchmark-related validity of existing surveys, rather than creating new surveys – Questionnaire with the most testify of validity and reliability: PC SafeQuest, Frankfurt Patient Safety Climate Questionnaire and Scope
Desmedt et al. [26]	2018	14	To requite an overview of empirical studies using cocky-reported instruments to appraise patient safety civilization in master care and to synthesize psychometric backdrop of these instruments	– A standard and widely validated survey is needed to increase generalizability and comparability – The SCOPE-PC survey is the about appropriate instrument to appraise patient safety civilisation in primary care – At that place is a need to consider the triangulation of qualitative and quantitative methods to achieve an in-depth assessment of civilisation
Madden et al. [27]	2020	44 (10) a	To identify patient-reported safety climate measures described in the literature and make recommendations for all-time exercise	– Few measures reported satisfactory levels of validity, reliability or usability measurement – Few measures are specifically designed for measuring the attitudes of primary care patients – In that location is value in using a mixed-methods arroyo to measuring patient safety
Vasconcelos et al. [25]	2018	18	To comport an investigation of the tools used to assess safety culture in primary care	– In add-on to reliability, other measures of validity are needed to establish the credibility of an instrument. Research addressing other types of psychometric tests is needed – The domains of communication, management perception and teamwork were present in all instruments. Futurity research on patient rubber should incorporate these attributes
Reporting systems simply
King et al. [22]	2010	17 (5) a	To identify the state of the art in patient reporting systems used in research studies	– When designing a reporting tool, it should exist evaluated in the local setting to ensure appropriate terminology is used. International terminology standards should be adopted. Reports from patients should be actively solicited
Ricci-Cabello et al. [23]	2015	28	To place and characterize bachelor patient-reported instruments to measure out patient safety in master care	– Taxonomies for classifying errors and harm were not consistently used for developing the instruments, impairing the power to make comparisons – There was a lack of valid and reliable instruments specifically designed to provide a comprehensive measurement of the safety of care provided in primary care practices
Patient record review only
Davis et al. [17]	2018	fifteen	To understand the ability of trigger tools to detect preventable adverse events in the primary care outpatient setting	– Consequence measures were heterogenous, precluding the power to quantitatively compare the studies
Madden et al. [xx]	2018	15	This review aimed to synthesize the literature describing the utilize of patient tape review to mensurate and improve patient safety in master intendance	– Studies using trigger tool methodologies tended to detect higher incidences of PSIs, suggesting greater empirical support than other methods – Demand to refine and standardize the methods used in patient record review to amend consistency and validity and facilitate ease of comparing beyond studies – Potent rationale for combining more than one method of studying patient safety
Tsang et al. [21]	2012	fifteen	To decide the types of adverse events that are routinely recorded in primary care	– Measurement of primary intendance adverse events was frequently based on secondary care data in conjunction with other clinical and non-clinical data. This apply of multiple data sources volition enhance the accuracy of measurements and recoup weaknesses inherent to individual information types – Greater attention required on developing indicators and other measures that take advantage of the available Information technology resources to improve quality and safe

Authors	Twelvemonth	# articles	Aim of review	Summary of findings
All safety measures
Hatoun et al. [18]	2017	21	To place published articles detailing prophylactic measures applicable to adult principal care	– Although numerous measures of patient rubber exist, many are not validated and pertain only to a detail enquiry report or quality improvement projection
Lawati et al. [xix]	2018	28	To review the literature on the condom culture and patient rubber measures used globally	– The most mutual theme emerging from 2011 onwards was the assessment of safety culture – The near normally used safety culture assessment tool was the Hospital Survey on Patient Safe Civilisation
Lydon et al. [xv]	2017	56	To identify and review articles that presented or described the apply of measures of patient safety suitable for utilise in general practice settings	– There is a need to improve the psychometric backdrop of existing tools equally opposed to developing new tools – In that location is a need to have a multi-methods approach to assessing patient prophylactic
Marchon and Mendes [16]	2014	33	To identify methodologies to evaluate incidents in primary health care, types of incidents, contributing factors and solutions to make primary care safer	– Highlighted the need for expanding safety culture in chief care in order to gear up patients and health professionals to place and manage agin events
Condom climate measures just
Curran et al. [24]	2018	17	To place the origins, psychometric properties, quality and safety climate domains measured past survey instruments used to assess prophylactic climate in primary care settings	– Consideration should be given to selecting an instrument that has safety climate domains relevant to primary care – Need to focus on further establishing the criterion-related validity of existing surveys, rather than creating new surveys – Questionnaire with the most evidence of validity and reliability: PC SafeQuest, Frankfurt Patient Safety Climate Questionnaire and SCOPE
Desmedt et al. [26]	2018	14	To requite an overview of empirical studies using self-reported instruments to assess patient safety culture in main intendance and to synthesize psychometric properties of these instruments	– A standard and widely validated survey is needed to increase generalizability and comparability – The SCOPE-PC survey is the nigh appropriate instrument to assess patient safe civilisation in master care – There is a demand to consider the triangulation of qualitative and quantitative methods to achieve an in-depth assessment of culture
Madden et al. [27]	2020	44 (10) a	To identify patient-reported condom climate measures described in the literature and make recommendations for best practise	– Few measures reported satisfactory levels of validity, reliability or usability measurement – Few measures are specifically designed for measuring the attitudes of primary care patients – There is value in using a mixed-methods approach to measuring patient safety
Vasconcelos et al. [25]	2018	18	To carry an investigation of the tools used to assess safe civilisation in primary care	– In improver to reliability, other measures of validity are needed to establish the credibility of an instrument. Research addressing other types of psychometric tests is needed – The domains of communication, direction perception and teamwork were present in all instruments. Future enquiry on patient safety should incorporate these attributes
Reporting systems only
King et al. [22]	2010	17 (v) a	To place the state of the art in patient reporting systems used in research studies	– When designing a reporting tool, it should be evaluated in the local setting to ensure appropriate terminology is used. International terminology standards should be adopted. Reports from patients should be actively solicited
Ricci-Cabello et al. [23]	2015	28	To identify and characterize available patient-reported instruments to measure patient condom in primary intendance	– Taxonomies for classifying errors and damage were not consistently used for developing the instruments, impairing the ability to make comparisons – At that place was a lack of valid and reliable instruments specifically designed to provide a comprehensive measurement of the safety of care provided in primary intendance practices
Patient record review only
Davis et al. [17]	2018	fifteen	To understand the ability of trigger tools to discover preventable adverse events in the primary care outpatient setting	– Outcome measures were heterogenous, precluding the ability to quantitatively compare the studies
Madden et al. [20]	2018	xv	This review aimed to synthesize the literature describing the apply of patient record review to measure out and better patient safety in primary care	– Studies using trigger tool methodologies tended to detect higher incidences of PSIs, suggesting greater empirical support than other methods – Need to refine and standardize the methods used in patient record review to better consistency and validity and facilitate ease of comparison across studies – Stiff rationale for combining more than than 1 method of studying patient prophylactic
Tsang et al. [21]	2012	xv	To make up one's mind the types of agin events that are routinely recorded in primary care	– Measurement of master care adverse events was often based on secondary intendance data in conjunction with other clinical and not-clinical information. This employ of multiple information sources will enhance the accurateness of measurements and compensate weaknesses inherent to private data types – Greater attention required on developing indicators and other measures that have advantage of the available Information technology resources to meliorate quality and prophylactic

a

Number in brackets is the number of included studies focused on chief care.

Tabular array 3

Summary of included systematic reviews

Authors	Year	# articles	Aim of review	Summary of findings
All condom measures
Hatoun et al. [18]	2017	21	To identify published articles detailing condom measures applicative to adult primary intendance	– Although numerous measures of patient safety be, many are non validated and pertain but to a particular research written report or quality improvement project
Lawati et al. [19]	2018	28	To review the literature on the safety culture and patient safety measures used globally	– The most common theme emerging from 2011 onwards was the assessment of safety culture – The nearly normally used condom culture assessment tool was the Hospital Survey on Patient Safety Civilisation
Lydon et al. [15]	2017	56	To identify and review articles that presented or described the use of measures of patient safe suitable for use in general practice settings	– At that place is a need to improve the psychometric properties of existing tools as opposed to developing new tools – At that place is a need to accept a multi-methods approach to assessing patient safety
Marchon and Mendes [16]	2014	33	To identify methodologies to evaluate incidents in master health care, types of incidents, contributing factors and solutions to make primary care safer	– Highlighted the demand for expanding safety culture in primary intendance in order to set up patients and wellness professionals to identify and manage adverse events
Safety climate measures only
Curran et al. [24]	2018	17	To place the origins, psychometric backdrop, quality and safety climate domains measured by survey instruments used to assess safety climate in primary intendance settings	– Consideration should be given to selecting an instrument that has safe climate domains relevant to primary intendance – Need to focus on further establishing the criterion-related validity of existing surveys, rather than creating new surveys – Questionnaire with the most evidence of validity and reliability: PC SafeQuest, Frankfurt Patient Safety Climate Questionnaire and Telescopic
Desmedt et al. [26]	2018	xiv	To give an overview of empirical studies using self-reported instruments to appraise patient rubber culture in main care and to synthesize psychometric properties of these instruments	– A standard and widely validated survey is needed to increase generalizability and comparability – The SCOPE-PC survey is the most appropriate instrument to assess patient safety culture in master care – There is a need to consider the triangulation of qualitative and quantitative methods to attain an in-depth assessment of culture
Madden et al. [27]	2020	44 (10) a	To identify patient-reported safety climate measures described in the literature and make recommendations for best do	– Few measures reported satisfactory levels of validity, reliability or usability measurement – Few measures are specifically designed for measuring the attitudes of primary intendance patients – There is value in using a mixed-methods approach to measuring patient safety
Vasconcelos et al. [25]	2018	18	To conduct an investigation of the tools used to assess condom culture in primary care	– In addition to reliability, other measures of validity are needed to establish the credibility of an instrument. Enquiry addressing other types of psychometric tests is needed – The domains of communication, management perception and teamwork were present in all instruments. Future research on patient safety should contain these attributes
Reporting systems only
Male monarch et al. [22]	2010	17 (v) a	To identify the state of the art in patient reporting systems used in research studies	– When designing a reporting tool, it should be evaluated in the local setting to ensure appropriate terminology is used. International terminology standards should be adopted. Reports from patients should be actively solicited
Ricci-Cabello et al. [23]	2015	28	To identify and narrate available patient-reported instruments to measure patient safety in primary care	– Taxonomies for classifying errors and damage were not consistently used for developing the instruments, impairing the ability to make comparisons – There was a lack of valid and reliable instruments specifically designed to provide a comprehensive measurement of the rubber of care provided in principal intendance practices
Patient record review only
Davis et al. [17]	2018	15	To understand the ability of trigger tools to detect preventable adverse events in the principal care outpatient setting	– Outcome measures were heterogenous, precluding the ability to quantitatively compare the studies
Madden et al. [xx]	2018	15	This review aimed to synthesize the literature describing the apply of patient record review to measure and improve patient condom in principal care	– Studies using trigger tool methodologies tended to notice higher incidences of PSIs, suggesting greater empirical support than other methods – Need to refine and standardize the methods used in patient record review to improve consistency and validity and facilitate ease of comparison beyond studies – Strong rationale for combining more i method of studying patient safety
Tsang et al. [21]	2012	xv	To decide the types of adverse events that are routinely recorded in primary care	– Measurement of primary care adverse events was often based on secondary care data in conjunction with other clinical and non-clinical information. This use of multiple data sources will enhance the accuracy of measurements and recoup weaknesses inherent to private data types – Greater attention required on developing indicators and other measures that have advantage of the available IT resources to improve quality and safety

Authors	Year	# articles	Aim of review	Summary of findings
All condom measures
Hatoun et al. [eighteen]	2017	21	To place published articles detailing safety measures applicable to adult chief care	– Although numerous measures of patient safe exist, many are non validated and pertain simply to a item enquiry study or quality improvement project
Lawati et al. [19]	2018	28	To review the literature on the safe culture and patient safety measures used globally	– The most mutual theme emerging from 2011 onwards was the assessment of prophylactic civilization – The most ordinarily used safe culture assessment tool was the Hospital Survey on Patient Rubber Culture
Lydon et al. [xv]	2017	56	To place and review articles that presented or described the utilize of measures of patient safety suitable for utilise in full general practise settings	– There is a need to ameliorate the psychometric properties of existing tools equally opposed to developing new tools – There is a need to take a multi-methods approach to assessing patient rubber
Marchon and Mendes [16]	2014	33	To identify methodologies to evaluate incidents in primary health intendance, types of incidents, contributing factors and solutions to brand chief care safer	– Highlighted the need for expanding safety culture in main care in order to set patients and health professionals to identify and manage adverse events
Safety climate measures simply
Curran et al. [24]	2018	17	To place the origins, psychometric properties, quality and safety climate domains measured by survey instruments used to assess rubber climate in chief care settings	– Consideration should exist given to selecting an instrument that has safety climate domains relevant to principal intendance – Demand to focus on further establishing the criterion-related validity of existing surveys, rather than creating new surveys – Questionnaire with the most evidence of validity and reliability: PC SafeQuest, Frankfurt Patient Safety Climate Questionnaire and SCOPE
Desmedt et al. [26]	2018	14	To give an overview of empirical studies using cocky-reported instruments to assess patient rubber culture in primary care and to synthesize psychometric properties of these instruments	– A standard and widely validated survey is needed to increase generalizability and comparability – The SCOPE-PC survey is the almost advisable instrument to assess patient rubber civilization in master care – There is a demand to consider the triangulation of qualitative and quantitative methods to attain an in-depth cess of culture
Madden et al. [27]	2020	44 (10) a	To identify patient-reported safety climate measures described in the literature and make recommendations for best practice	– Few measures reported satisfactory levels of validity, reliability or usability measurement – Few measures are specifically designed for measuring the attitudes of primary care patients – At that place is value in using a mixed-methods approach to measuring patient safety
Vasconcelos et al. [25]	2018	xviii	To conduct an investigation of the tools used to assess prophylactic culture in primary intendance	– In addition to reliability, other measures of validity are needed to constitute the brownie of an instrument. Research addressing other types of psychometric tests is needed – The domains of communication, management perception and teamwork were present in all instruments. Future enquiry on patient safety should incorporate these attributes
Reporting systems only
King et al. [22]	2010	17 (5) a	To identify the state of the fine art in patient reporting systems used in inquiry studies	– When designing a reporting tool, information technology should be evaluated in the local setting to ensure appropriate terminology is used. International terminology standards should exist adopted. Reports from patients should be actively solicited
Ricci-Cabello et al. [23]	2015	28	To identify and narrate available patient-reported instruments to measure patient safe in primary intendance	– Taxonomies for classifying errors and harm were non consistently used for developing the instruments, impairing the ability to make comparisons – There was a lack of valid and reliable instruments specifically designed to provide a comprehensive measurement of the safety of care provided in master care practices
Patient tape review just
Davis et al. [17]	2018	fifteen	To sympathize the ability of trigger tools to detect preventable adverse events in the primary care outpatient setting	– Outcome measures were heterogenous, precluding the ability to quantitatively compare the studies
Madden et al. [20]	2018	15	This review aimed to synthesize the literature describing the utilize of patient record review to measure and meliorate patient safety in main intendance	– Studies using trigger tool methodologies tended to detect higher incidences of PSIs, suggesting greater empirical support than other methods – Demand to refine and standardize the methods used in patient tape review to improve consistency and validity and facilitate ease of comparison across studies – Strong rationale for combining more than one method of studying patient safety
Tsang et al. [21]	2012	15	To make up one's mind the types of adverse events that are routinely recorded in primary care	– Measurement of primary care adverse events was frequently based on secondary care information in conjunction with other clinical and non-clinical information. This utilise of multiple information sources will raise the accuracy of measurements and compensate weaknesses inherent to private information types – Greater attention required on developing indicators and other measures that have reward of the bachelor IT resources to ameliorate quality and safety

a

Number in brackets is the number of included studies focused on chief care.

Figure i

PRISMA menstruation diagram.

Effigy i

PRISMA menses diagram.

Past damage

The almost commonly reported method of measuring by harm was through patient record review. Papers using patient tape review methodologies were included in seven reviews [xv–31], with three reviews specifically focused on studies using patient record review methodologies [17, twenty, 21]. Issues identified with the use of patient record review methodology were the potential for false positives, lack of tools and poor quality of studies [17, 20]. It was suggested that a trigger tool approach to record review may offering a reliable approach to reviewing patient records [17, twenty]. However, at that place is a need to refine and standardize the methods used to improve consistency and validity and facilitate ease of comparison beyond studies [20].

Papers describing incident reporting systems or agin effect reports were included in four reviews [two, 16, nineteen, 22], with 2 of these reviews specifically focused on reports generated by patients [22, 23]. It was recognized that in that location is a need for further evolution and refinements of patient reporting systems [22, 23].

Other examples of methods of assessing past harm from papers included in the systematic reviews were as follows: the use of chemist's shop and administrative data (described in one review [16]); interviews, surveys and focus groups with patients about their experiences of damage (included in two reviews [13, 14]) and staff surveys or interviews (included in i review [16]).

Reliability of prophylactic clinical processes

Papers describing methods of measuring and monitoring the reliability of safe critical processes were included in four systematic reviews [fifteen, 16, 18, nineteen]. The nearly commonly reported methods were checklists, observations and surveys of staff (included in four reviews [15, 16, eighteen, 19]). Studies utilizing patient surveys (e.g. assessing for medication discrepancies) were included in ii reviews [18, nineteen]. It was suggested that checklists should be accompanied by structured guidelines for use that volition increase the ease of employment, allowing them to be implemented at a relatively low toll [fifteen].

Sensitivity to operations

Two systematic reviews included papers that were concerned with sensitivity to operations [fifteen, 16]. These reviews included papers that used observation, staff surveys, interviews or focus groups (included in [16]) and active monitoring in which principal care providers completed an cess immediately after a consultation to identify whatever potential harm (included in [15]). Studies in which simulated patients presented specific cases to assess the care provided past the primary care provider were included in two reviews [15, 16]. It was suggested that the reason why agile-monitoring and faux patients were infrequently used is because of the resources intensive nature of these approaches [xv].

Anticipation and preparedness

Seven reviews included papers reporting the use of safety climate surveys [15, xvi, 19, 24–27], with three reviews completely devoted to staff surveys [24–26] and one on patient assessments of prophylactic climate [27]. At that place are a big number of different safety climate surveys that have been used in primary care setting (e.thou. Curran et al. [24], included 17 unlike surveys in their review). A number of the reviews concluded that the psychometric backdrop of these surveys are variable [xv, 25–27]. Item staff safety climate survey with the most evidence of validity and reliability were the PC SafeQuest, Frankfurt Patient Prophylactic Climate Questionnaire (FraSiK) and Scope. It was suggested that rather than developing new surveys, researchers should focus on improving the psychometric properties of existing tools [15, 24, 26].

Other less frequently used methods of assessing apprehension and preparedness included the following: staff surveys of patient prophylactic (e.1000. medical role survey on patient prophylactic; included in one review [xvi]), staff interviews or focus groups (included in ii reviews [sixteen, 19]) and Failure Modes and Effects Analysis (included in 1 review [xix]). It was suggested that the advantage of interview methodologies was that the interviewer's proximity to the person they are interviewing allows an analysis of the impact of a straight or indirect result or experience [sixteen]. However, bug such as geographical separation, sampling and resource were recognized equally a barrier to interview approaches.

Integration and learning

Two reviews included studies that addressed the integration and learning dimension of safety [16, xix]. One review [16] included a study concerned with identifying lessons learned from mistake, and another review included studies on the use of safety civilisation data to inform risk management and feedback in gild to inform comeback efforts [19]. A number of the reviews too concluded that safety data should be used to inform patient prophylactic improvement [xvi, 19], and there was a need to triangulate safety data from multiple sources [15, 20, 21, 26, 27]. However, information technology was suggested that the recruitment of patients to consummate patient report measures may add another layer of difficulty that may reduce the use of such measures [15].

Quality assessment

The mean CASP score was vii.three/viii (SD = 1.0; range = 5–8). CASP scores for individual studies are presented in Supplemental Fabric 2. The reviews generally addressed whether the results of the review were valid and were judged to take included the relevant papers. However, 3 of the reviews [16, 23, 25] could have had more than specific inquiry questions, and four of the reviews [18, 21, 23, 25] could have carried out a more than rigorous quality assessment. All of the reviews clearly presented the findings of the review, the findings were relevant to safety improvement in primary intendance and all of the outcomes have been adequately considered.

Give-and-take

Statement of principal findings

A total of xiii systematic reviews of methods of MMS in chief care were included in this meta-review. Many of the methods for MMS in primary care are readily available, quick to administer, do not require external interest and are cheap [15]. However, there is even so a need to improve the psychometric properties of many of these methods for MMS [15, 18, xx, 23–26]. Therefore, with the exception of the sensitivity to operations dimension of safety, rather than developing new methods of MMS, there should instead exist a focus on using and adapting existing methods of MMS in order to increase generalizability and comparability [15, 18, 24, 26]. There is besides a need for multi-methods approach to measuring safety to assess safety beyond each of the five dimensions of safety described by Vincent et al. [2, three].

Strengths and limitations

The strengths of this meta-review are the broad coverage of methods of MMS in principal intendance, the prospective registration of the review protocol, the use of a comprehensive search strategy across multiple databases (including the gray literature) and a rigorous review procedure. The main limitation of the meta-review was that it was of systematic reviews only. Therefore, it does not include any methods of MMS that have non been included in a systematic review, nor is there a discussion of the specific measures described in individual papers. Rather, the focus is upon the conclusions drawn by the systematic review authors. This is consistent with the goal of a meta-review to provide an overview of the enquiry prove on a particular issue [10].

Interpretation inside the context of the wider literature

A trigger tool approach to patient record review may offer a reliable and usable approach to evaluating past harm in primary care [17, 20]. A trigger tool is a checklist of a selected number of clinical 'triggers' (e.g. frequency of consultation) that a reviewer seeks to place when screening medical records [28]. If a 'trigger' is identified in the tape, and then the reviewer scrutinizes information technology in more item to appraise whether an undetected PSI had occurred [29]. Information technology is possible to review up to 20 records in 2–3 h, with near patient records taking <5 minutes to review [9]. Moreover, patient record review data are useful in helping primary care providers to identify where safety improvements are required [8, nine]. Therefore, it is recommended that a trigger tool chart review methodology has great potential as a mensurate of past harm, and the awarding of this approach merits further refinement and investigation in principal care settings.

The included systematic reviews summarized a number of methods of assessing the reliability of disquisitional processes. It is suggested that prophylactic checklists may provide a applied method for identifying safety problems that can be readily completed by one member of the practice staff. For example, Bowie et al. [30] adult a 22-detail checklist that addresses medicine management, housekeeping, information systems, registration checks, patient admission and identification, and health and safety. It is recommended that checklists such as this could be used periodically past a practice manager to support the identification of workplace hazards that touch on patient rubber and quality of intendance.

Methods of measuring and monitoring sensitivity to operations are arguably less well developed than those designed to appraise the other dimensions of safety. In secondary intendance, methods of measuring and monitoring sensitivity to operations include safe walk rounds, ward rounds, briefings and debriefings [two, three]. However, these approaches are not applicable to principal intendance. The methods used in main care were somewhat unstructured (eastward.k. focus groups), time consuming (e.g. primary care providers completed an assessment immediately after a consultation) or unlikely to be broadly adequate (patients as 'underground shoppers'). Therefore, it is recommended sensitivity to operations is a particular dimension of safety that would do good from the evolution of structured approaches to assessment.

Safe climate surveys were the dominant approach for MMS in the anticipation and preparedness safety dimension. Safety climate is regarded as the measurable component of the underlying safety culture at a given bespeak in fourth dimension [31]. Prophylactic culture refers to the values, attitudes, norms, beliefs, practices, policies and behaviours effectually safety in an system [32]. Condom climate surveys provide a viable method to assess the condom of primary care practices. It is recommended that to assess safety over fourth dimension and to make (inter)national comparisons, information technology is important that a survey has sound psychometric backdrop [24]. It is further recommended that any staff-completed rubber climate survey is carried out in parallel with 1 completed past patients who may have a different perspective on safety than practice staff [27].

A mutual conclusion amidst the systematic review authors was the need to integrate prophylactic data from multiple sources in order to inform learning [xv, xx, 21, 26, 27]. There are examples of such approaches in the literature. For example, the Scottish Patient Safety Program in Primary Care includes a trigger tool chart review (past harm) and a prophylactic climate survey (apprehension and preparedness) [33]. Madden et al.'s [8] feasibility study of this plan added feedback during practice meeting (integration and learning) and could be further extended with a safety checklist (reliability of safety critical processes). Therefore, information technology is recommended that researchers give consideration as to how data from measures across all of the other 4 dimensions of rubber tin be integrated in gild to inform learning.

Implications for policy, practice and enquiry

Any constructive safety surveillance organisation must consider methods of MMS that address each of the 5 dimensions of safety identified by Vincent et al. [2, 3]. It has been suggested that healthcare stakeholders could go the data they need with 25% of what is currently beingness spent on measurement [34]. Therefore, a healthcare safety surveillance system should exist efficient and measure only what matters [34]. This is particularly truthful for main care where in that location are generally non defended risk and safety personnel.

Lack of time has been identified past master intendance providers every bit a bulwark to implementing condom interventions [8]. Therefore, an approach to MMS that is considered too burdensome or lacks brownie will not be implemented [35]. There is also a demand to consider how to encourage the implementation of a robust safety monitoring system in master care practices. Implementation could be encouraged through allowing the MMS activities to exist counted towards standing medical educational activity, allowing the prophylactic information to be used for mandatory annual audits, or reductions in indemnity insurance for practices that accept a robust rubber direction system in identify. How to back up and encourage practices to collect safety information is an of import consideration for policymakers and researchers.

Conclusions

This meta-review has provided an overview of approaches to MMS in primary care in order to identify considerations that demand to be addressed in order to develop a safety monitoring system for chief care practices. Main intendance doctors accept highlighted that a lack of information is a barrier to improving patient safety. Therefore, researchers must support the evolution of psychometrically sound measures that practice non overburden primary care practitioners. Policymakers must consider how primary intendance practitioners tin can be supported to implement these measures.

Supplementary textile

Supplementary textile is available at International Journal for Quality in Health Care online.

Acknowledgement

None declared.

Funding

None alleged.

Contributorship

All authors were involved in the design and planning of the review. POC and SL developed the search strategy. CM and EOD conducted the searches and completed the information extraction. POC and EOD conducted the quality assessment, and POC conducted the data analysis. POC, SL and DB drafted the initial manuscript with all other authors assisting with redrafting it. All authors reviewed and approved the manuscript prior to submission.

Ethics and other permissions

This was a meta-review review, so ethical approval was not required.

Data availability statement

All data are either presented in the article or included in the supplemental fabric.

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