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PLoS Med. 2017 Jan 17;14(1):e1002217. doi: 10.1371/journal.pmed.1002217. eCollection 2017 Jan.

Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis.

Author information

Division of Population Medicine, Cardiff University, Cardiff, United Kingdom.
Institute of Child Health, University College London, London, United Kingdom.
Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia.
Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, United States of America.
Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts, United States of America.
Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America.
Institute for Healthcare Improvement, Cambridge, Massachusetts, United States of America.
Division of General Practice, University of Nottingham, Nottingham, United Kingdom.
Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom.
Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.



The UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.


We undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.


This study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.

[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: ACS and AE are co-chief investigators of a National Institute for Health Services and Delivery Research Program grant to characterize patient safety incident reports in primary care. AS is a member of the Editorial Board of PLOS Medicine.

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