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Learning from International Networks about Errors and Understanding Safety in Primary Care

Final Report Summary - LINNEAUS EURO -PC (Learning from International Networks about Errors and Understanding Safety in Primary Care)

Executive Summary:
Learning from International Networks about Errors and Understanding Safety in Primary Care (LINNEAUS EURO-PC)

The importance of primary care in health care systems and why we have to study patient safety in primary care
There is an increasing understanding of the importance of patient safety in the delivery of health care. Landmark studies (in the USA, Australia, the UK, Denmark and the Netherlands) assessing the contribution of adverse events causing harm to patients, have resulted in major initiatives for improving patient safety in many countries. However, initiatives related to patient safety are still primarily focused on hospital and specialist care with little activity in primary/generalist care.
Although there is a focus of patient safety initiatives concentrated on hospital and specialist care, in many EU countries, access to health care occurs through primary or generalist care. For example, in the UK, 85% of contacts with the National Health Service take place in primary care and there are 300 million general practice (GP) appointments each year, which means that nearly 750,000 patients consult their GP each day. In Germany the rates are even higher – approximately 1.5 million visits per day to primary care physicians, with GPs and general internists issuing 550 million prescriptions per year. It is estimated that in the Netherlands, every citizen has 2.6 GP consultations per year.
Primary care is therefore a vast organised sector for health care with millions of interactions occurring every day throughout the EU. A literature review of the nature and frequency of error in primary care suggested that there are 5 to 80 safety incidents per 100,000 consultations which in the UK would translate to between 37 and 600 incidents per day. The vast majority of incidents can be categorised into four main areas covering diagnosis, prescribing, communication between health care providers and patients, and organisational or administrative problems. International estimates suggest that nearly 2.5% of interactions in primary care result in a patient safety incident, which in the context of millions of visits to primary care physicians every day, represent a significant potential for error. Many of these patient safety incidents can result in significant harm to patients. For example, analysis of medico-legal databases suggests that when errors do occur in primary care, 50% are of no consequence, 20% result in non-clinically relevant delays in diagnosis and 10% result in upset patients. However, 20% of errors could have serious consequences for the patients, sometimes resulting in death.
Linneaus Euro PC (Learning from InterNational Networks about Errors And Understanding Safety in Primary Care) was a co-ordination action programme, financially supported (2.46m Euros) by the EC under the Framework 7 Programme for four years (2009-13). It involved 11 research groups in 8 EU countries (UK, The Netherlands, Germany, Austria, Denmark, Poland, Greece and Spain). It was involved in addressing issues specifically related to improving patient safety,

Project Context and Objectives:
The Linneaus-Euro-PC collaboration co- ordination action encouraged collaboration and supported the development of research in patient safety through:
- The development of a taxonomy of adverse events and errors and the development of a reporting tool for primary care. This will enable the development of tools for reporting and categorising errors which are already being used at a national level for bench marking and which can be modified for comparative analysis at the European level.
- Identifying best clinical practice and the way that this can improve patient safety through an understanding of decision making and medication errors in primary care. This has already been identified as a major area contributing to adverse events and errors.
- Achieving consensus on the measurement of safety culture and leadership in the primary care context . A series of indicators have been developed which can be used to assess improvements in safety culture.
- Enhancing existing knowledge from quality improvement techniques which are widely used in the primary care setting (in which members of the collaboration had extensive experience)and applying these to learning cycles for improvements in patient safety.
- Building up an existing network into a pan European network which extended the current knowledge and experience from countries where the importance of patient safety is nationally recognised to countries where it was less developed; by sharing information through workshops and seminars the collaboration ensured that there was an appropriate focus on primary care, and encouraged co-operation and collaboration for future interventions through large scale trials.
Aa a result of the collaboration, partners successfully accessed funding from national research funders in the UK to extend the work of the Linneaus collaboration and have also been successful in obtaining funding from the Framework 7 programme to carry out a large multi-centre randomised control trial to reduce polypharmacy.

Project Results:
Development of the network and how it has been implemented throughout the project

Prior to the inception of the Linneaus project, work on patient safety in primary care was mainly carried out by a few academic institutions in European countries where health administrations had recognised the importance of patient safety as an important component of quality in health care. In these countries (UK, Denmark, Netherlands and Spain), although there was an increased focus on patient safety, there was little activity in relation to primary care. The Linneaus project brought together for the first time, researchers and practitioners from Europe who recognised the importance of patient safety in the context of primary care. The task of the consortium was to establish a collaborative partnership, use the experience of researchers from countries where knowledge and activity on patient safety in primary care was more developed (chiefly the UK and Netherlands) and use the collaboration to disseminate that knowledge and experience to a wider audience. From the beginning we worked closely with the consortium members to establish a mechanism for exchange of information and knowledge, shared expertise through collaboration between the different work packages and gave support to members where the development of activity in patient safety in primary care was embryonic. We also pursued an agenda to disseminate knowledge on the importance of patient safety in primary care and to provide primary care practitioners with information on how to set up structures and activities which would help them to improve patient safety in their clinical practice.

The successful Manchester Conference held in October 2010 was the first attempt to bring together practitioners (as opposed to researchers) from across Europe and give practical advice and support in order to develop local strategies for improving patient safety. The Warsaw Conference held in September 2011 with a follow up workshop in Lodz 17th & 18th April 2012 extended this approach to practitioners from Central and Eastern Europe who were under-represented in Manchester. Our final conference held in Frankfurt in September 2012 brought together the outputs of the Linneaus network with participation from policy makers, clinicians and researchers and established us as the premier research network on patient safety in primary care in Europe.

We successfully incorporated partners from Spain, Greece and Scotland and developed important working relationships with independent rural practitioners who are an important constituency in many European countries.

In addition to these activities, consortium members have played an important role in highlighting the importance of patient safety in their own countries, through engagement with professional organisations, researchers and their national health services. In parallel with this we have also sought to bring patient safety in primary care to the forefront of the agenda on health services through speaking at international conferences, engagement with policy makers and national research organisations. Our website provides a useful resource for downloading material developed through the project and as a means of disseminating the products of the Manchester conference and the Frankfurt conference. Clinicians and researchers can now easily have access to and download materials on reporting, safety culture, patient involvement, laboratory standards, diagnostic and medication error. The information can help both individual practitioners and researchers who want to develop work on patient safety in primary care.

Our success in obtaining substantial grant funding for further research in the UK, the involvement and engagement of the World Health Organisation in this agenda and the success of obtaining further EU funding for research on improving medication safety serves as a testament to the success of this approach. Similarly, the addition of new partners to the consortium and our close working relationship with key organisations such as EURIPA, WHO, WONCA and the various national organisations bodes well for the future sustainability of the network.

As the period of funding for the consortium draws to an end we have been turning our attention to creating a sustainable platform for the continuation of the consortium. We are confident that the network that we have created which extends well beyond the immediate consortium partners will continue beyond the end of the project through participation in research projects. Our aim is that Linneaus through its website and established network will continue to grow and will become the primary destination for resources, expertise and knowledge used by policy makers, researchers and practitioners who are seeking to improve patient safety in primary care in Europe.

The success of the co-ordination and support action will be determined on the effectiveness of dissemination of the findings – the ultimate aim being to place patient safety in primary care at the centre of discussions on policy and research in future Europe wide deliberation on quality and safety.

In the first reporting period, we developed the web portal and have now undertaken a major upgrade to ensure that the website can be used as the portal for downloading the different outputs from the project.

In the second reporting period held we the first international conference in Manchester (October 2010). The outputs of this conference have been placed on the website. We worked with WP7 to replicate aspects of the conference for future partners in Central and Eastern Europe. These were held in September 2011 in Warsaw and April 2012 in Lodz. We successfully held the final conference of the collaboration in Frankfurt in September 2012. The Manchester and Frankfurt conference proceeding’s have been placed on the Linneaus website, allowing visitors to the website to see the conference speeches and obtain a download of the relevant conference outputs.

Through our dissemination activities we have brought on board partners from Greece, Spain and Scotland. Their contributions extended and enhanced the objectives of the collaboration. All three new partners successfully completed their objectives despite a very short time frame. We also made important links with physicians and researchers in Sweden and supported the developments in relation to improving safety in primary care. We also worked with colleagues from WHO to develop a programme of action which will see many of the developments that we are piloting in Europe, extended to developing countries. We have also established links with the European forum for rural and independent practitioners (EURIPA) and worked with them to extend the work of the collaboration so that it remains relevant to isolated practitioners working in rural areas of the European Union (an important constituent). We organised a workshop in Manchester on xxx where key members of the EURIPA executive together with rural practicing clinicians from Greece, Croatia, Wales and Norway modified the safety culture instruments and reporting systems for use in rural practices. These versions including the commissioned literature review have been uploaded onto the Linneaus website.

B. Summary of progress during the second reporting period (01/09/10 - 29/02/12)

Linneaus website:

The Linneaus website was launched in July 2009. It has been designed so that it can be expanded as the collaboration gains new members and as outputs from the work packages, conferences and other initiatives are developed. It remains the main source of information for new members, researchers and other stakeholders and has recently undergone a major upgrade to reflect the increasing number of outputs from the collaboration which can be downloaded from the site. All the conference material has been placed on the site, together with an up to date bibliography of research studies and reports on patient safety in primary care. Outputs of work packages are also being placed on the website. We have incorporated a content management system which will enable us to maintain the site ourselves.

Contacts with relevant organisations in the UK and internationally

The collaboration between the partners has resulted in significant benefit in terms of advancing the research agenda. Through a better understanding of the issues involved in patient safety gained through discussions and sharing of information, the UK group has been successful in obtaining several grants for extending the work on patient safety in primary care. The success of these grants will enable the extension of the work of the Linneaus collaboration and will ensure the sustainability of the collaboration beyond the end of the project. Many of the partners will join the scientific advisory group of the research initiatives and some of the collaborating members will takes part in the research programme through the sharing of knowledge and expertise. Many of the outputs of these research collaborations will be directly relevant to further the research agenda. The outputs will be directly relevant to improving patient safety in primary care within the European Union through the sharing of research outputs and the future possibility of being involved in trials.

We have successfully bid for a grant totalling €4.9 million on ‘Polypharmacy in chronic diseases: Reduction of Inappropriate Medication and Adverse drug events in elderly populations by electronic Decision Support’ to the Framework 7 program. It is a further example of the fruitful collaboration within the Linneaus collaboration with Austria and Manchester taking the lead on the application.

Contacts with International organisations

We have developed a working relationship with WHO Patient Safety Program and are using the expertise of Linneaus partners to support WHO in its plan to raise the profile of patient safety in primary care. We have already begun helping partners in South Africa in helping them develop a research program to support the development of initiatives on patient safety in primary care.

We are developing links with EURIPA (European Union Rural and Independent Practitioners Association) and will be hosting a workshop in September 2012 to address the specific problem of supporting initiatives relevant to rural and independent practitioners in Europe. Through this relationship we are also developing a close working relationship with WONCA and EQUIP (European Quality Improvement Program). We submitted an unsuccessful grant funding proposal for extending the development of a patient safety toolkit in Europe to WONCA.

Frankfurt Conference 18th & 19th September 2012
The purpose of this conference was to disseminate the findings from the LINNEAUS collaboration, plan the future research programme and strengthen the network. We aimed to bring together policy makers and researchers from EU countries where patient safety in primary care has been given a national priority to share and exchange information with policy makers and, researchers from countries where patient safety in primary care has not been given the national priority it deserves. Our aim was to encourage the development of national health policy which recognises the importance of improving patient safety in primary care. We will use our experience to plan the future research agenda for patient safety in primary care, discussing future challenges and funding opportunities, building on the experience of the LINNEAUS collaboration. Our aim is to develop further opportunities for collaboration to enhance our ability to access national and EU funds for future research in this area.

Special Supplement

We have completed the writing and editing of 18 articles which have been submitted to the EJGP which has agreed to create a special supplement of all the Linneaus contributions. This is going to be an important dissemination vehicle for the outputs of the collaboration. The articles will be peer reviewed and the expected date of publication is September/October 2013. This is the summary of the supplement.

This supplement brings together a body of research focusing on the issue of patient safety in relation to primary care. It represents the outputs of the Linneaus Collaboration which was a four year (2009-2013) co-ordination and support action funded under the Framework 7 programme by the European Union. Being a co-ordination and support action its aim was not to undertake new research but to build capacity through engaging primary care researchers and practitioners in identifying some of the key challenges in this area and developing consensus statements which will be an essential part in developing a future research agenda. We were also cognisant of the need to involve new members from countries where there may be little understanding of patient safety, let alone its contribution to problems in primary care.

The programme of work was unique primarily because of its exclusive focus on primary care. It is therefore appropriate that its outputs are disseminated in the European Journal of General Practice. We have written the outputs in a way that will make them accessible to clinicians working in primary care, whether they are general practitioners, nurse practitioners, practice nurses or pharmacists. The outputs will also be relevant to primary care researchers who want to identify the current gaps in the research and understand the current state of the art. Our aim has been to provide an overview as well as practical guides and tools for practitioners who need to understand why the focus on primary care is important, understand the contribution of diagnostic error, laboratory testing, medication safety, culture and time to safety. We also consider the development of a classification and reporting system that will help researchers and practitioners categorise errors so that they can begin the process of learning from incidents identified in their practice. The development of a web based reporting system based on extensive experience from the UK and Germany provides a mechanism for clinicians to record and analyse patient safety incidents in their practice. Building on the classification and reporting system, we summarise the current evidence on learning from patient safety incidents and set out a process where physicians can use prospective risk analysis to learn from patient safety incidents. Recognising that a large component of primary care requires working across interfaces, we have provided a template for patient involvement that seeks to minimize patient safety incidents. Finally, we show that engagement with the patient safety agenda is not dependent on commitment from national authorities or from additional resources. Using examples from our experience in Greece and Poland, countries where there is virtually no infrastructure to support patient safety initiatives, we show how physicians can use the resources we have provided to start the process of reporting, understanding their culture related to safety and even begin the process of developing a minimum accreditation system for patient safety. In the final contribution we reflect on our experience gained over the last 4 years to set out an agenda for future research.

It is our view that patient safety in primary care is going to be an area where policy makers, clinicians and researchers will have to devote increasing attention partly because it remains relatively under researched but also because it will be increasingly important as healthcare shifts towards primary care and we become more aware of the potential for harm to patients in the primary care setting. The Linneaus collaboration represents an important contribution to this developing agenda through the creation of sustainable network of researchers in Europe and achieving consensus on a range of issues relevant to this area. It is important that researchers build on this work by using these outputs to develop and test evidence based interventions, working collaboratively across Europe. There are significant opportunities for obtaining grants both from the European Union and in some cases from national governments. The key to success will be collaboration, building on existing consensus and working closely with clinicians working in primary care. We have also shown that even in countries where there is little support from national governments for this agenda, it is possible to address issues related to patient safety, using existing knowledge and research outputs from the Linneaus collaboration.

This introductory paper introduces the Linneaus collaboration to readers, sets out the case for why primary care is important in relation to patient safety and provides the policy context for current developments.

Potential Impact:
1. The development of Europe-wide systems for classification of adverse events in patient safety that occur at the primary care level. This will allow comparisons of adverse events across Europe and will be critical in addressing possible interventions.
2. Agreement on the development and use of reporting systems in primary care. This has addressed a significant deficiency in knowledge about patient safety at the primary care level and will form the basis of developing interventions.
3. Development and agreement on the use of instruments to assess patient safety culture in primary care across Europe. Addressing safety culture is likely to be critical for improvement strategies and will also allow transnational comparisons.
Grant Agreement 223424 Final Report – 31st July 2013 6
4. A better understanding of diagnostic errors in primary care and the development of recommendations for future research. Diagnostic error remains the least studied and understood contributor to adverse events in primary care.
5. The development of strategies for learning which can be used to improve patient safety in primary care. Learning for patient safety is critical to underpining strategies to improve patient safety across the EU.
6. The development of strategies to ensure that patients are involved at all stages in addressing issues related to patient safety in primary care and are an integral part of improvement strategies.
7. Building on the work to develop patient safety initiatives in countries where the development of patient safety is still nascent and to improve initiatives in reporting, measuring culture and improving medication safety. The collaboration developed a preliminary framework for the accreditation of health centres in rural and isolated areas focusing on patient safety. This was done by achieving consensus through participant workshops and engagement with the wider collaboration.
8. Identifying safety issues related to communication problems focussing on the exchange of results at the primary secondary interface and by using consensus methods amongst consortium members and wider experts. The consortium developed standards for the exchange of information across the primary secondary interface.
9. Building on the work to identify indicators to identify patient safety outcomes, the consortium developed through a range of consensus statements and participant workshops, the key characteristics of patient safety indicators for primary care.
10. The development of a sustainable Europe-wide network linking healthcare professionals, researchers and patient safety groups, to share best practice internationally.
11. Developing consensus and recognition by governmental and professional bodies that patient safety in primary care is a major problem which needs to be addressed by policy makers, researchers and health care practitioners.

List of Websites:
Project public website

The project’s public website was launched in January 2010. It gives background to the project, lists the objectives, and describes how these will be achieved through the various work-packages (WPs). The beneficiary organizations (with their web-sites) are listed, together with photographs and contact details of the WP leaders. The website underwent a major upgrade in February 2012 to reflect the completed outputs and to provide the framework for the continuation of the website at the end of the project. The addition of a content management system will enable us to make additions to the website and to maintain it beyond the end of the project.

The website is updated regularly and currently provides information about the first international conference hosted in Manchester by Linneaus; this conference, aimed at primary healthcare workers across the EU, is primarily to provide help and guidance setting-up an integrated safety culture, together with reporting networks using harmonized taxonomy, throughout the EU member-countries.

Current members of the collaboration:

1. Prof Aneez Esmail (coordinator), Primary Care, School of Community-based Medicine, University of Manchester, UK (
2. Kerstin Klemp, Institute for General Practice at Johann Wolfgang Goethe University, Frankfurt am Main, GERMANY (
3. Prof Andreas C. Soennichsen, Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, AUSTRIA (
4. Prof Dianne Parker, Safety Culture Associates Ltd., UK (
5. Dr Michel Wensing, Radboud University Nijmegen Medical Centre, Nijmegen, THE NETHERLANDS (
6. Dr Maciek Godycki-Cwirko, Medical University of Lodz, POLAND (
7. Jonas Egebart, Danish Society for Patient Safety, Hvidovre, DENMARK (
8. Dr Olga Kostopoulou, Medical Decision Making & Informatics research group, Division of Health & Social Care Research, Kings College London, UK (
9. Dr. Paul Bowie, NHS Education for Scotland, UK (
10. Dr Yannis Skalkidis, Athens University Medical School, GREECE (
11. Ms. Eva Frigola, The Catalan Health Institute Public Health Division, Catalan Health Department, SPAIN (

Senior Project Administrator: Annette Barber
Health Sciences Group - Primary Care
School of Community Based Medicine
5th Floor, Williamson Building,
University of Manchester, Oxford Road, Manchester M13 9PL
(T) 0161 275 7636 (F) 0161 275 7600