Developing Patient Safety in Primary Care in Scotland

Neil Houston, Arlene Napier

Historically– Acute Focused

IHI 100,000 lives

Scottish Patient Safety Programme

NPSA Reporting

Patient Safety in Primary Care - Why Bother?

High Volume 95% of patient contact Increasing complexity

Adverse Events in the community cause: 12% of Admissions to hospital

5.5% of Deaths in hospital

Under reporting 0.4% NPSA

Collaborative

32 Volunteer PracticesPatientsClinical Effectiveness / Governance Staff

Project Aims7 Steps to Patient Safety

1. Lead, teach and support staff

2. Integrate risk management activity

3. Promote reporting

4. Involve patients

5. Learn and share lessons

6. Implement solutions

7. Develop safety culture

Training

Clinician / Administrator What is Patient Safety Developing Risk Registers Reporting SEAs Involving Patients Medication errors

Homework

Follow Up – 6 MonthsShare the learning

Sharing risks and SEAs Finding Solutions Projects Developing Team Culture Next Steps

Year 2

16 more practices Updated training Ongoing support Build local capacity Sharing Sharing Sharing

Evaluation

Culture survey x2 Training Outputs Involving patients SEAs wider learning External evaluation

Project Aims7 Steps to Patient Safety

1. Lead, teach and support staff

2. Integrate risk management activity

3. Promote reporting

4. Involve patients

5. Learn and share lessons

6. Implement solutions

7. Develop safety culture

Wider Impact?

On Health Boards

On NHS Scotland

Lead, Teach and Support Staff

Training valued Confidence and skills Protected learning

and facilitation valued Involving all staff Need GP leadership

Risk Register

Integrating Activity

All identified an area of risk in prescribing

All worked to reduce risk in this area

Shared risk and solutions with others

Promote Reporting - National Context

NPSA IR1s Datex SEAs Enhanced Services – Warfarin and Near

patient testing

DES

“Practices are required to audit adverse incidents and to notify clinical

governance leads all emergency admissions or deaths of any patient

where the adverse event is due to the usage of the anticoagulant.”

Say that again…

Report what? To Whom? By When? Analyse?

Hands Up?

Ideal reporting systemsIT based< 2 minsTrustedFeedbackAction Used by allHow does the IR1 and NPSA match up?

NHS ScotlandCurrent reporting systems- IR1sPaper based Too slow? feedback/ action? trusted?used Slips and trips

Project – IR1s

Training

Encouraged

eIR1 pilot Incident logs

Feedback

“We found it absolutely awful” “It’s a huge form to fill in – its ridiculous

actually” “It doesn’t work in a small organisation..

and it doesn’t work well in the hospital either..!”

Significant Event AnalysisFamiliar territory

Almost all practices do it QOF 12 in last 3 years 3 per yearGP AppraisalExternal peer review

Promoting Reporting

Incident Reporting Forms (IR1s) - not useful or used

SEA’s More skills Positive and negative SEA’s More inclusive More structured More detailed in reporting

Sharing Significant Events

Most Practices submitted SEAsFulfilled QOF criteria but:

No standardised format for submission Variable Quality Change/ impact often unclear No wider learning

Learning and Sharing Lessons

Practices submitted SEA’s for wider learning Newsletter Extended to all practices in FV Volunteering SEAs Common Interface Themes emerging

Incident Reporting – SEA’s

Issues Lack of trust ?? anonymity Negative impact on practice

“ I think there was a feeling that you’d be washing your dirty linen in public and the partners were not prepared to do that”

GPs more negative than others

More Issues

Did practices receive it? Did they send it round staff? How best to disseminate? How relevant? Does it change behaviour?

SEA and Risk Issues

Medication reconciliation at interface

SEA and Risk Issues

Medication reconciliation at interface Drugs that look alike sound alike

Looks Can Be Deceptive

Spot the Difference?

SEA and Risk Issues

High Risk Medication Patient misidentification Patients lost to follow up especially

across care settings Communication within and between

teams and settings

Low Tech Solutions

Sticky Tape

Wipe Boards Talking over coffee at 11 am!

IT Solutions

Patient Identification Warning messages Searches under CHI Confidentiality Telephone Headsets Paper light records Results - Docman

Limited success Workshops – input valued Leaflets 20% - found it useful Labour intensive Patient groups

How to do it without raising alarm?

Involving Patients

Culture

Patient Safety Culture

Scoring Highly >75% most criteriaCould be developed in areas of:

Shared Decision making Communication Informing staff when errors occur

Progress….

“ Its not about blame, its about it not happening again”

AwarenessInvolvement

Non clinical staff

Benefits to Health Board

Increased Capacity Collaboration Common Risks Identified Action on interface issues System wide approach now adopted

Culture change ??

For NHS Scotland

Generating interest National Patient Safety Programme

should involve Primary care ?Enhanced service Clinical Governance guidance for contract SEA’s - systems for wider learning

SpreadSpread

EngageEngage

SustainSustain

CultureCulture

InvolveInvolve

MeasureMeasure

What role do you think IT has …

As a source of Risk?

What role do you think IT has …

As a method of risk reduction?

IT Solutions

Medication Reconciliation Computer Prescriptions Alerts eWard discharge letters OOH Anticipatory care Single Electronic Record

IT

Email Results downloaded to GP Notes Protocols Accessible on web /via patient

records Incident Reporting

Any Questions?