Partnerships to improve Patient Safety

PRIMIS Partnerships For Progress March 2004

Partnerships to improve Patient Safety

Dr Maureen Baker, Professor Tony Avery and Rosie Medlicott


Improving the safety features of GP computer systems

Report on an NPSA-funded project

Professor Tony Avery

University of Nottingham


Background

• There are concerns about patient safety in primary care in terms of: Prescribing errors Failure to complete intended actions such as patient

referrals and medication monitoring Failure to respond to abnormal results or advice from

other professionals Safe and effective communication of information

between GPs and patients and professionals in secondary care and community pharmacy


Potential role of computer systems

• Computers have considerable potential to help GPs to practise safely in terms of providing:

– Accurate information on patients and drugs at the point of decision-making

– Effective decision support– Intelligent hazard alerts for cautions,

contraindications, drug interactions and allergies– Help with timely and appropriate monitoring – Help with error trapping – Reporting on patients at risk


Why the need for a project?

• While computer systems have considerable potential some problems have been highlighted:– GPs and practice staff may not know how to

make best use of their systems and may not use important safety features

– GPs may override hazard alerts– Computer systems may not contain all the

safety features that are desirable


Objectives of the project• To identify the most important safety issues

regarding GP computer systems• To assess GP computer systems in terms of

these safety features• To determine GPs’ knowledge, use and training

needs in relation to computerised safety features• To work with stakeholders to produce

specifications for GP computer suppliers and for training practice staff


Identifying the most important safety issues

• Methods used:– Stakeholder interviews– Two-round Delphi


Stakeholder interviews• GPs• Computer system

suppliers• Drug database

suppliers• SCHIN• RCGP

• DoH• NHSIA• Design Authority• MDU and MPS• Patients’

representative• Experts in health

informatics


Key themes from stakeholder interviews (1)

• The need for a drug dictionary for NHS primary care to improve communication between systems

• The need for drug ontologies that provide sensible alerts and decision support

• The need to ensure that users record data so that functionality is available when required


Key themes from stakeholder interviews (2)

• The need to ensure that users have access to accurate and safe information on which to guide decision making

• The need to ensure that account is taken of human ergonomics in the ways in which safety information is presented to users and in how they are encouraged to respond

• The need for practitioners to make best use of computerised systems for ensuring that intended actions such as patient referrals and medication monitoring are completed

• The need for audit trails

• The need for training in the effective use of systems


The Delphi exercise

• 21 participants

• Presented with 55 statements

• 33 statements ranked as important or very important by over 90% of respondents


Key issues from Delphi

• Importance of computerised alerts• Avoiding spurious alerts• Making it difficult to override critical alerts and to

have audit trails• Support for safe repeat prescribing• Effective computer-user interface• Importance of call and recall• Need to be able to run “safety reports”


Assessing GP computer systems

• From the results of the Delphi we have developed a series of vignettes/test cases

• These have been used on the main GP computer systems with dummy patients

• Suppliers have been asked to comment on the results

• Results will be presented in anonymised form


Key points from assessment of GP computer systems

• There are a lot of good features, but we have detected some problems:– Lack of alerts in relation to contraindications– Spurious alerts– Failures of drug allergy warnings– Risks of prescribing drugs with similar names– Lack of warning for methotrexate– “Hidden” alerts– It is easy to override most alerts– Lack of audit trials


Determining GPs’ knowledge, use and training needs

• We have undertaken interviews with GPs: – There was a strong sense that they have

come to rely on their computers to provide alerts

• We have developed a questionnaire that has been sent to GPs in two sites in England (387 responses; 64% response rate)


Key findings from the GP questionnaire (1)

• The following are regarded as important by >90% of GPs– computerised alerts

• Allergy alerts (99%)• Interaction alerts (99%)• Contraindication alerts (99%)

– Need to make it more difficult to override critical alerts

– Systems for recall for patient monitoring


Key findings from GP questionnaire (2)

• GPs are not fully aware of the safety features on their computer systems, e.g. a third of users of a system that doesn’t have contraindication alerts thought that the system did have these alerts!

• Only a minority have had training on the use of safety features on their computers

• The preferred method for learning more about the use of safety features is “hands-on” learning with tuition (either one-to-one or in a group setting)


Stakeholders’ views on how to make improvements to systems

• System suppliers are willing to make changes provided these are sensible and in keeping with GP opinion

• Suppliers acknowledge that change is more likely to take place if this is made mandatory rather than voluntary

• Working through the National Programme for IT in the NHS seems to be the best way of ensuring change


Suggestions for improvement in the short-term

• Act to close the loophole in the recording of allergy alerts• Define the most important hazard alerts, ensure these

are available on all systems and that they cannot easily be overridden

• Ensure that system suppliers make full use of ontologies available to them, e.g. for contraindication alerts

• Develop a computerised “query set” for interrogating GP computer systems to identify hazards

• Develop a training package to help practices make best use of the safety features of their clinical computer systems


Suggestions for improvement in the longer-term

• Introduce a drug dictionary for the NHS• Evaluate existing ontologies to determine whether these

are fit-for-purpose or whether alternatives need to be developed

• Ensure that systems are designed to “make it easy to do the right thing”

• Ensure that the design of alert messages take account of research indicating best practice

• Ensure that health professionals are properly trained to make best use their systems

• Work to develop safety culture in primary care


Summary

• GP computer systems already have a number of important safety features

• There are problems in that– GPs have come to rely on hazard alerts when they

are not full-proof– GPs do not know how to make best use of safety

features on their systems• There are a number of solutions that could either

– Help to improve the safety features of GP computer systems

– Help to improve the abilities of healthcare professionals to use these safety features


Rosie Medlicott

PRIMIS Senior Learning Consultant


“We had a system that for 12 to 15 years we never really used effectively and that was because we failed to train people.”

Why PRIMIS?

Dr Mark CullenSouth Hams and West Devon PCT


In The Beginning

CHDGP - Original objective• Devise and test educational methodologies

for improving data quality and information management


PRIMISAim:• Improve patient care using information technology

Objectives:• Optimise use of clinical systems• Improve data quality • Improve information management• Impact at practice level based on national and local

clinical priorities


PRIMIS Training Agenda

• Training Needs Analysis & Scheme Management

• Recording for Data Quality• Clinical Coding• MIQUEST• Data Analysis, Interpretation &

Feedback• Action Planning & Supporting

Change in Practice


PRIMIS Training Agenda• Facilitation Skills• Information Governance• Rush for Practices

New for 2003• Primary Care Data: Uses and

Abuses• Path to Paperless• Supporting Quality Outcomes• Patient Safety


How Does It All Start?

• Facilitators• PRIMIS Learning Consultants• PRIMIS evaluation• Other PRIMIS team member


Training Module Development

• Approval• Work group established• Expert advice


Coming up with a plan

• Scope the subject• Specification

– Learning objectives– Learning activities– Success criteria • Timetable

• Resources


Links to other PRIMIS training

• Quality Data Quality Outcomes

• Action Planning for Change

• Facilitation Skills

• Information Governance


Training Specification

• Learning Objectives– Awareness of NPSA role– Understanding of the potential impact of data

quality on patient safety– Awareness of the functionality of safety

features inherent in GP Clinical systems– Provide tools to identify risks to patient safety– Be able to support practices to implement

change


Learning activities

• Presentation by NPSA• Review of University of Nottingham’s

research• Data quality scenarios• Identify and use a range of tools• Presentation and workbook• Discussion• Group work


Researching The Topic


Developing The Training Materials

• Presentation• Workbook• Exercises• Scenarios• Other training tools


Ready To Go?

• Pilot with Learning Consultants• Senior Learning Consultant• Service Director• Expert advisor• PRIMIS project board• Pilot with small group of Facilitators• Roll out to all PRIMIS Facilitators


But That’s Not All

• Training manual Editor• All LCs shadow workgroup• Feedback from Facilitators • Training materials reviewed annually


“Scenarios helped make the subject real”“Recognising the importance of data quality and patient safety”

“NPSA Presentation and linking data quality to the GMS contract”

“Practical sessions brought home the seriousness”

Partnerships to improve Patient Safety

Documents

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