Patient Safety

in Primary Care

The Linneaus Collaboration

www. linneaus-pc.eu

Aneez Esmail

Professor of General Practice

University of Manchester (UK)

What I am going to cover

• The epidemiology of error in primary care

• The challenges that we face

• Three things that you can do when you leave here– Understand your safety culture– Set up a reporting system– Undertake a root cause analysis

My typical Monday morning!

Imagine that it is always a busy day…..

Why is patient safety important in primary care?

1. It’s where most episodes of care take place

• 95% of all NHS contacts take place in primary care• 300 million general practice appointments per year• 750,000 people consulting GPs every day• Primacy of primary care in most • European countries

2. Mistakes happen….

• 5-80 safety incidents per 100 000 consultations• Between 37 – 600 incidents per day • 4 main categories

• Diagnosis

• Prescribing

• Communication

• Organisational

Sandars and Esmail, 2001

Why is primary care different?

1. The environment

• Lower profile than acute sector• Low technology environment• Different organisational structures

• Mode and site of care delivery – telephone, home visits• Interfaces important• Increasing complexity

• Consultation skills and interpersonal skills critical

Practice Organization and its relationships

Why is primary care different?

2. The processes

• Less obvious implications• 50% no consequences• 20% non-clinically important delay in diagnosis• 10% upset patients• Up to 20% could have serious implications

• Less litigatious• Different professional dynamics

Frequency of errors (Primary Care)Code Error description Frequency %

14 Failure/delay in diagnosis 494 50%

48 Medication inappropriately prescribed 56 5.6%

23 Failure/refusal/delay in referral 51 5.17%

46 Failure to warn/recognise side effects of drugs

50 5.07%

22 Failure to monitor condition 46 4.66%

41 Unsatisfactory performance of procedure

42 4.26%

50 Failure to diagnose complications in pregnancy

24 2.43%

Frequency of outcomes (Primary Care)Code Outcome Frequency Percent

33 Death 178 20.7%

35 Deterioration in clinical condition 50 5.81%

86 Unnecessary pain 34 3.95%

3 Amputation of limb 31 3.60%

88 Appendicectomy 23 2.67%

10 Brain damage 20 2.33%

Why is primary care different?

3. The underlying philosophy

• Variation more acceptable• Different approach to risk and uncertainty

Primary care….Primary care….

Accept uncertaintyAccept uncertainty

Explore probabilityExplore probability

Marginalise dangerMarginalise danger

Marshall MarinkerMarshall Marinker

So what are we going to do?

My mistake!

Yes it happens to all of us!!!

The problem• Much can go wrong in general practice, so it is

important to have a system to learn from your mistakes.

• After a number of close-calls you agreed to make improving patient safety a priority a year ago, but nothing has changed. How can you establish a new system to manage risk?

Starting

• Put someone in charge and agree a timetable of key activities and deadlines. Their first task should be to carry out an audit to assess your practices’ safety culture.

Safety culture

• Your practice must have a culture where staff are encouraged to evaluate risk, mistakes are acknowledged and there is a system to take action when things need putting right.

• It requires a good understanding of your practice’s approach to risk management and a broad discussion about the ‘safety culture’ in your practice

How to assess safety culture

• Put someone in charge and agree a timetable of key activities and deadlines

• Carry out an audit to assess your practices’ safety culture. • Build a safety culture http://www.nrls.npsa.nhs.uk/resources/?

EntryId45=61598• MaPSaF (http://www.nrls.npsa.nhs.uk/resources/?

EntryId45=59796)

MaPSaF(Manchester Patient Safety Framework)

• Set aside about two hours as a practice team to do this. It is a worthwhile exercise to stimulate discussion about the strengths, weaknesses and differences of the patient safety culture in your practice.

• At the end of the process, you will have a shared understanding of where the main problems are, the barriers to improving things and also some of the strengths of the practice.

Lack of formal procedures

• We are a small practice and have rather an ad-hoc way of recording events that impact on patient safety. How can we formalise this process?

Reporting

• For a four-week period you will report on adverse events that take place within the practice. Give all staff the ability to anonymously report incidents that disrupt the delivery of best quality care in the practice

• Defining safety– ‘something that should not happen in my practice,

and I don't want it to happen again’

Incident reporting form

• National Patient Safety Agency. Incident Report Form. https://www.eforms.npsa.nhs.uk/gpreport/

– In a typical group practice of 5,000 patients, over a four-week period, you will expect to collect about 15 patient safety incidents.

• should read the reports and present them to the practice. At this point you should not analyse the incidents, but get an agreement on which of them should be studied in more depth

Too much information

• We are drowning in information, with a series of reports of significant events and our incident reporting system, but how can we learn from them?

Significant Event Audit

• SEA– Dilemmas in significant event auditing, Pulse 2010.

http://www.pulsetoday.co.uk/story.asp?sectioncode=24&storycode=4127376&c=4

– Have a formal process and keep a record

Root cause analysis

• Root cause analysis shows where systems need to be developed to prevent future harm, by identifying the chain of events and the contributory factors which caused the incident.

• It works best when the whole practice team is involved in agreeing to the investigation and learning lessons from it.

• Used for more serious outcomes (serious harm or death).

Five Whys?

• Root Cause Analysis: Five whys tool -http://www.nrls.npsa.nhs.uk/resources/?entryid45=75605

– to consider what control measures can be implemented to prevent the incident happening again. You may have to revisit your protocols and checklists to see if they need to be modified or if new ones need to be developed

– For example: If the problem identified is a delay in diagnosis, identify which systems could be improved to ensure that abnormal results are appropriately dealt with. It is important that any changes that are made are piloted and then reviewed

Finally

• Keep a record of what you have done. People leave and things get forgotten.

• Having an organisational memory is a critical part of learning from things that go wrong.

A charter for action(with a little help from Atul Gawande)

• Count something

• Change something

• Write about it

• Keep the conversation going