Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

Diabet. Med. 27, 1322–1326 (2010) Abstract Aims  Key elements of a patient safety system include mechanisms for identifying errors or safety events, methods for investigating the events and processes for acting on the findings of the investigations. A patient safety system for management of diabetes in primary care might help to reduce adverse outcomes. The aims of this study were to review the current state of research into patient safety systems for people with diabetes in primary care. Methods  MEDLINE, EMBASE and nine other biomedical and health management databases were searched for articles published up to April 2009. Selection and review of abstracts were carried out independently by two authors. Results  Abstracts of 1659 articles were identified, of which only three fulfilled the selection criteria, and these did not appear in mainstream primary care journals. These papers covered the applications of root cause analysis, videoconferencing and automated telephone support to patient safety systems for managing diabetes in primary care. Conclusions  There is very little evidence on how patient safety systems for the management of primary care diabetes can be implemented, or on how the effectiveness of such systems can be maximized. If patient safety systems do have potential to improve the processes and outcomes of care, the lack of relevant research may be regarded as a missed opportunity—investigation into the reasons for the situation is needed, with the aim of motivating and enabling further research on a range of problems identified here.