Table 3

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

How could it be prevented?Problems in last 12 months, n=300All problems analysed,* n=564
More resources—total100 (33%)157 (28%)
 Quicker access to primary care43 (14%)62 (11%)
 More thorough and quicker investigations35 (12%)59 (10%)
 Fewer demands on primary care—more staff or fewer patients7 (2%)12 (2%)
 More time with clinicians for treatment and diagnosis8 (3%)12 (2%)
 Improved access to social care3 (1%)3 (1%)
 More follow-up by primary care2 (1%)3 (1%)
 Improved continuity of care1 (<1%)2 (<1%)
 Access to a second opinion1 (<1%)2 (<1%)
 Provision of resources to manage long-term conditions02 (<1%)
Improved communication and involvement of patients—total53 (18%)92 (16%)
 Listen to the patient and trust their judgement more36 (12%)68 (12%)
 Tell patients about their diagnosis, test results, changes in medication or loss of results10 (3%)15 (3%)
 Improve communication between staff (within or outside primary care)7 (2%)9 (2%)
Better organisation and administration—total27 (9%)48 (9%)
 Follow-up referrals and appointments to ensure they happen, be consistent in sending routine reminders12 (4%)23 (4%)
 Log in or process results as soon as received to avoid loss5 (2%)7 (1%)
 Keep the notes up to date, well-organised, safe and ensure information is transcribed accurately9 (3%)15 (3%)
 Keep a record of the location of equipment01 (<1%)
 Improve the method of appointment allocation01 (<1%)
 Fine patients for not attending appointments1 (<1%)1 (<1%)
Improved prescribing systems—total21 (7%)45 (8%)
 More when checks on prescribing and dispensing19 (6%)32 (6%)
 Check repeat prescriptions carefully, especially for transcribing errors2 (1%)10 (2%)
 Use medication reviews and IT clinical decision support systems03 (1%)
Better clinical practice—total17 (6%)47 (8%)
 Take in to account all the patient’s information - their medical history and results and letters7 (2%)27 (5%)
 Address the patient’s problem in some way—patients can feel their problem is being ignored9 (3%)18 (3%)
 Act on advice from other clinicians and test results1 (<1%)2 (<1%)
Staff training—total22 (7%)53 (9%)
 More informed and better trained staff22 (7%)53 (9%)
Other responses—total60 (20%)122 (22%)
 Do not know/missing28 (9%)64 (11%)
 Problem was due to an individual member of staff6 (2%)11 (2%)
 Do not make wrong, late, delayed diagnosis7 (2%)15 (3%)
 Prescribe right, better, different, more, less medicine8 (3%)15 (3%)
 Should have been referred6 (2%)9 (2%)
 Better organisation3 (1%)4 (1%)
 Patient recognised their own responsibility2 (1%)2 (<1%)
 Laboratory procedures were the problem02 (<1%)
  • *All problems analysed includes scenarios arising from Ipsos MORI survey in the last 3 years and the pilot survey (24) within the last 12 months.