Table 4

Patient suggestions as to how the potentially harmful preventable problem might have been prevented

How could it be prevented?All reported problems n=132Clinician ranked ‘possibly or higher’ (lower threshold) n=71
1. More resources—all14 (11%)3 (4%)
 1.1 Quicker access to primary care7 (5%)2 (3%)
 1.2 More thorough and quicker investigations2 (2%)1 (1%)
 1.3 Fewer demands on primary care—more staff or fewer patients1 (1%)0
 1.4 More time with clinicians for treatment and diagnosis2 (2%)0
 1.9 Provision of resources to manage long-term conditions1 (1%)0
 1.10 Provision of patient travel service for routine appointments1 (1%)0
2. Improved communication and involvement of patients26 (20%)18 (25%)
 2.1 Listen to the patient and trust their judgement more21 (16%)15 (21%)
 2.2 Tell patients about their diagnosis, test results, changes in medication or loss of results3 (2%)1 (1%)
 2.3 Improve communication between staff (within or outside primary care)2 (2%)2 (3%)
3. Better organisation and administration17 (13%)10 (14%)
 3.1 Follow-up referrals and appointments to ensure they happen, be consistent in sending routine reminders10 (8%)3 (4%)
 3.2 Log in or process results as soon as received to avoid loss1 (1%)1 (1%)
 3.3 Keep the notes up to date, well-organised, safe and ensure information is transcribed accurately5 (4%)5 (7%)
 3.4 Keep a record of the location of equipment1 (1%)1 (1%)
4. Improved prescribing systems18 (14%)17 (24%)
 4.1 More checks on prescribing and dispensing8 (6%)8 (11%)
 4.2 Check repeat prescriptions carefully, especially for transcribing errors8 (6%)7 (10%)
 4.3 Use medication reviews and computerised clinical decision support systems2 (2%)2 (3%)
5. Better clinical practice19 (14%)10 (14%)
 5.1 Take in to account all the patient’s information—their medical history and results and letters13 (10%)7 (10%)
 5.2 Address the patient’s problem in some way—patients can feel their problem is being ignored5 (4%)2 (3%)
 5.3 Act on advice from other clinicians and test results1 (1%)1 (1%)
6. Staff training11 (8%)7 (10%)
 6.1 More informed and better trained staff11 (8%)7 (10%)
Other responses27 (20%)6 (8%)
  Do not know/missing21 (16%)3 (4%)
  Problem was due to an individual member of staff2 (2%)1 (1%)
  Prescribe right, better, different, more, less medicine1 (1%)0
  Better organisation1 (1%)0
  Laboratory procedures were the problem2 (2%)2 (3%)