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Most patient safety studies in primary care settings have been descriptive, and those studies have led to a better understanding of the types of errors occurring in those setting, their consequences, and potential remedies. 1 - 13 However, little research in primary care has focused on activities that occur during an error event chain to prevent or minimise harm, which is called mitigation. 7 13 14
The use of the term "mitigation" is not consistent in the patient safety literature; consequently, it is necessary for us to further specify our use of the term. We see mitigation taking place in what Van der Schaaf 15 describes as the "dangerous situation"-the temporary state that follows the occurrence of a human error or system failure, before it resolves into its outcome. We distinguish it from "recovery," which is the action of people or systems that takes place after the chain of events has played out. Nolan specifies three strategies for the design of safe healthcare systems: preventing errors, making errors visible, and mitigating the effects of errors. 16 His "mitigation" closely resembles our term "recovery," whereas his "making errors visible"-which he refers to as "procedures or attributes that make errors visible to those working in the system so that they can be corrected before causing harm"-is part of our mitigation process. Our "mitigation" takes place when an error becomes visible (in our terminology, "discovered") and an intentional action is undertaken to avoid or reduce harm. Helmreich's three-tiered pyramid model of error management 17 distinguishes between avoiding errors, trapping those errors that are not avoided (our "mitigation"), and mitigating those errors that are not trapped (our "recovery"). If we draw an analogy to prevention, stopping an error from occurring is primary prevention, mitigation is secondary prevention, and recovery is tertiary prevention.
While some errors result in harm (preventable adverse events), others do not (close calls or near misses). Some errors do not cause harm by chance or because the errors are remote from patients, but others do not cause harm because humans or systems catch the errors and prevent or mitigate patient harm. A few researchers have investigated near misses, recovery from near misses, and mitigating behaviour in disciplines other than primary care. 15 18 - 22...