alexa Abstract | Assessing risk by analysing signiŽcant events in primary care

Quality in Primary Care
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Clinical Governance in Action Open Access


Risk assessment in one local healthcare cooperative (LHCC) was conducted by applying a national incident grading matrix (CNORIS) to 56 signiŽ cant event analyses (SEAs) undertaken by 32/39 (82%) general practitioners (GPs) as a voluntary and educational activity.Analysis demonstrated a ratio of ‘near miss’ to actual adverse event of 1:6 and a wide range and combination of categories. In 40% of incidents reported, the severity was assessed to be ‘major’ or ‘catastrophic’. In 78% of incidents, the risk of recurrence was considered ‘possible’, ‘likely’ or ‘almost certain’. Risk assessment for recurrence of incidents was described as ‘high’ in 25%, ‘moderate’ in 31% and ‘low’ in 44% of cases.The study demonstrates that GPs can work within a national framework for risk assessment.However, the process identiŽ ed a need for consistency in terms of deŽ nitions and coding, dedicated software, a managed reporting system, practical guidance and possibly incentives for GPs

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Author(s): Jill Murie


Innovative primary care, Primary care medicines, Advanced concepts in primary care

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