Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Opioid dependence is a chronic relapsing condition resulting in significant individual and community harms, for which the most effective treatment is long term opioid pharmacotherapy (OP). In contrast to other Australian states and territories, in Victoria, 80-85 % of OP prescribing is undertaken by GPs, and while demand for this treatment is difficult to estimate, all evidence indicates that the current and future GP workforce is inadequate to meet projected need. / GPs have shown a reluctance to become actively involved in the treatment of patients with drug dependence, especially where illicit drugs are involved. In order to prescribe OP, Australian medical practitioners are required to complete a specific training program. Little is known of the reasons why GPs decline to undertake this training, and why the majority who complete training, subsequently prescribe to very few or no patients. / Using in-depth interviews and an analysis of existing data from the Victorian Department of Human Services, this thesis not only explores why GPs are unwilling to complete OP training, and why many subsequently fail to prescribe, but also identifies both barriers and facilitators which influence GPs in their decisions regarding these issues. The results have not only provided new information on the reasons GPs decline the offer of training but also supported existing research.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Background: Many Australians do not meet recommended levels of physical activity and GPs can play an important role in addressing this. Objectives: To evaluate the effectiveness of an exercise referral scheme, in patients referred by their general practitioner (GP). Design: A pre post evaluation with measurement of outcomes immediately post intervention (five weeks) and again at six months. Intervention: The 42 patients that agreed to participate in the study took part in an initial fitness and lifestyle assessment with an exercise physiologist. They then undertook ten exercise sessions over a period of five weeks, following an individually prescribed exercise program. At the completion of the ten exercise sessions, participants were reassessed (fitness and lifestyle) by the exercise physiologist. This was repeated again six months after they completed the intervention. Main outcomes measured: The primary outcomes measured were changes in self reported physical activity and associated markers including cardiovascular fitness. Secondary outcomes measured include changes in physiological and anthropometric measures, behavioural risk factors (dietary behaviour, alcohol consumption and smoking) and quality of life. Patient well-being (using SF12), patient satisfaction and GP satisfaction with the program was also assessed. Results: There was a large withdrawal of participants. Results have been presented in terms of outcome frequency at each assessment point. There was an 18% increase (from baseline) in the proportion of participants achieving the Australian physical activity guidelines and a 31% increase between baseline and the six month follow-up assessment in those that completed the program. There were statistically significant improvements in cardiovascular fitness measures and small improvements in some physiological, anthropometric, dietary behaviours and general well being measures. Conclusions: The results of this study suggest that referral to a community based leisure centre for supervised exercise, supported by a written exercise prescription by an exercise physiologist, may be effective in increasing physical activity levels short and long term in those that complete the program. Exercise referrals can form part of national strategies to increase physical activity, particularly for primary care.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Thesis (Ph. D.)--University of Adelaide, Dept. of Public Health, 1988. / Includes bibliographical references (p. 379-394).

Thesis (M.D.) -- University of Adelaide, Dept. of Psychiatry, 2000. / Bibliography: leaves 554-636.

Thesis (Ph.D.) - University of Queensland, 2005. / Includes bibliography.

Thesis (M.P.H.) - University of Queensland, 2003. / Includes bibliography.

Thesis (Ph.D.) - University of Queensland, 2005. / Includes bibliography.