An extensive literature review of tools for patient safety in general practice was used to source indicators. Two independent reviewers followed Cochrane guidelines for systematic reviews21 (for a full description of the search strategy see Appendix 1). Search terms in three stems (setting, topic, and output) were performed on the following databases: Embase, CINAHL, Pubmed, MEDLINE (Ovid 1996 onward), Health Management Information Consortium, and Web of Science on 1 November 2011. The output was too heterogeneous to apply meta-analysis techniques, so the study considered individual indicators using the following process. First, potential indicators that described a pattern of prescribing that could be hazardous and may put patients at risk of harm were identified and then the exclusion criteria shown in Box 1 were applied. New indicators found in the systematic review process were added to an existing set of 34 indicators published by the authors.15 The literature was re-reviewed particularly to identify new indicators published since 2009.
How this fits in
GPs have a very important role in improving patient safety by carefully prescribing and monitoring patients’ medicines. Nevertheless, many patients are put at risk, and some are harmed, as a result of hazardous prescribing in general practice. Assessing the safety of prescribing by GPs is an important feature of patient safety measures. This study updates the prescribing-safety indicators developed by the authors in 2009 for the Royal College of General Practitioners, and identifies which of these indicators are most likely to lead to harm to patients.
The indicators developed in this project were derived mostly from existing sources because of the considerable amount of work that has been done on prescribing-safety indicators in other countries and other settings. In addition to the sources for the Royal College of General Practitioners (RCGP) indicators,3–5 a number of new key papers were found that were previously unknown to the authors (Table 1).6–11,17 Over 600 prescribing indicators were reviewed against the inclusion and exclusion criteria, and against attributes of good indicators, including importance, validity, and feasibility of data collection using electronic health records. After removing duplicates, 34 original RCGP indicators and 37 new indicators were considered suitable for inclusion in round 1 of the subsequent consensus technique.
There are various reasons why few candidate indicators were chosen from some of the sources. For example, many indicators from the Screening Tool of Older Person’s Prescriptions5 relate more to the appropriateness of prescribing than to safety. The Beers criteria3 relate more to US prescribing during the 1990s than they do to the current UK situation. Reasons for not selecting more indicators from new sources are listed in Table 1. Grey literature from patient safety organisations, such as the National Patient Safety Agency and the Agency for Healthcare Research and Quality, and targets from sources, such as the QOF and the National Service Framework for Older People, were also examined for potential indicators.
