Establishing a comprehensive incident reporting system in...
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Michael Robinson Associate Director of Integrated Governance Establishing a comprehensive incident reporting system in Primary Care
Transcript of Establishing a comprehensive incident reporting system in...
Michael RobinsonAssociate Director of Integrated Governance
Establishing a comprehensive incident
reporting system in Primary Care
Declaration of Interest
Bolton CCG are the sole funders of the scheme
Bolton CCG have supported my attendance at the conference
There are no additional funding sources
Michael Robinson
Associate Director of Integrated Governance
Why?
CCG’s role in patient safety and quality
My role within the CCG
Berwick; Francis; Keogh reports
Limitations of conventional data sources
Needed a solution!
Most QI safety initiatives in secondary care
Options
What makes a hospital safer?
Incident reporting system
Required a change in primary care culture
Significant challenge with limited resources
50 independent practices
GP’s role as referrers and commissioners
Develop
GPs significant event analysis in isolation
Health economy GP sharing of learning
Opportunity to share patient experiences
Not used in an adversarial sense by the CCG
Opportunity to develop services & learn
Implement primary care web reporting system
Upload on to Safeguard database
Results
14 12 914
8
42 46 43
58
126
137
7639 39
81 85
46
61 64 6571
90
247
109
0
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April May June July August September October November December January February March
Incidents reported in Financial Year
2013/14 2014/15
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Results
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140
10
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2 2 3 3
132
114
103
55
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22
7 6 5 3 3 3 10
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Scheme Incidents by Cause Group
2013-14 2014-15
Results
153163
25
219
4 1 1 4 1 3 1 3 1
346
73
28 2717 14
6 6 4 3 1 1 10
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Scheme Incidents by Incident Type2013-14 2014-15
Outcomes Safer primary care?
Increasing willingness to discuss errors and report no harm incidents
Improved primary care systems; prescribing; clinical pathways; audit; referrals etc…
Improved commissioned services e.g. CAMHS;
rheumatology; GP out of hours etc…
Established clinical standards principles -agreed across primary and secondary care
How we achieved it Clinical transformational leadership and a
committed team as no additional resource
Developed GP patient safety champions
Visited practices to describe the vision
CCG Executive supported the scheme
Act on the intelligence received and provide feedback to those who report
Newsletters, meetings, education events
Next steps This was never just about incident reporting!
Further develop the emerging patient safety culture in primary care and care homes
Implement additional schemes e.g. care bundles; audits; de-prescribing; thermometers
Develop a health economy patient safety blog on CCG website
Maintain/develop the incident reporting system and improve measurement and effectiveness
“Doctors do not do mistakes”: Developing a
patient safety collaborative manual
Paresh Dawda1, Amr Abou Elnour1 , Dale Ford1, 2,
Mark Morgan1 and James Dunbar1
Affiliation: 1 APHCRI Centre of Research Excellence, GGT UDRH Flinders University2 Improvement Foundation Australia (IFA)
The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant
from the Commonwealth of Australia as represented by the Department of Health and Ageing. The information and opinions contained in
it do not necessarily reflect the views or policy of the Australian Primary Health Care Research Institute or the Commonwealth of
Australia (or the Department of Health and Ageing).
Partnership
• Our Centre for Research
Excellence (CRE) in
partnership with
Improvement Foundation
(Australia) used a
systematic approach to
develop a Patient Safety
Manual for the Australian
Primary Care
Collaboratives Program.
http://www.greaterhealth.org/resources/p
atient-safety-collaborative-manual
Does Your Practice Have a Process for Identifying Adverse Events and Taking Follow-up
Action?
Primary Care Practices
Percent of primary care doctors
Sources: The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries; C. Schoen et al., "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009." Health Affairs Web Exclusive, Nov. 5, 2009, w1171–
w1183 Data collection: Harris Interactive, Inc.
18Source: 2009 and 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percent
Doctors’ Use of Electronic Medical Records
in Their Practice, 2009 and 2012
Practice Use of IT on a Routine Basis for Core Tasks
Primary Care Practices
Percent of primary care doctors
Notes: Percent reporting ROUTINE:
Sources: The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries; C. Schoen et al., "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009." Health Affairs Web Exclusive, Nov. 5, 2009, w1171–
w1183 Data collection: Harris Interactive, Inc.
20
Percent
Doctor Can Electronically Exchange Patient Summaries
and Test Results with Doctors Outside their Practice
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Patient safety 32% of patient errors in Australian General practices resulted in patient
harm. (Makeham, Dovey et al. 2002)
Internationally, the level of harm in primary care:
• England: 8% (Rubin, George et al. 2003)
• The US: 24% (Elder, Vonder Meulen et al. 2004)
• Scotland: 2% (de Wet and Bowie 2009)
One of proposed actions in Australian Safety and Quality Framework for
Health Care is “Areas for action: 3.2 Health professionals take action for
safety, and 3.8 Take action to prevent or minimise harm from healthcare
errors”. (ACSQHC, 2010)
One of the submissions to ACSQHC proposed the urgent need for
“development of a nationally coordinated, systematic and effective means of
reporting errors and near misses within primary health care”. (ACSQHC, 2011)
Process errors (79%) Knowledge and skills errors (21%)
Errors in office administration (20%) Errors in the execution of a clinical task (5%)
Investigation errors (13%) Errors in diagnosis (14%)
Treatment errors (29%)Wrong treatment decision with right diagnosis (2%)
Communication errors (15%)
Payment errors (1%)
Errors in healthcare workforce management (2%)
32% of these errors resulted in patient harm and 9% of these harms were very serious or extremely serious. (Makeham, Dovey et al. 2002)
Australian general practice
Reflection and discussion
Does this resonate within your health
system context?
What do you think is the one single
most intervention that is necessary to
improve patient safety in general
practice
General practice accreditation
Standards for general practices
Criterion 3.1.2
Clinical risk management systemsOur practice has clinical risk management
systems to enhance the quality and safety of our
patient care.
A. Our GP(s) and clinical staff can describe the process for identifying and reporting a slip, lapse or mistake in clinical care
B. Our GP(s) and clinical staff can describe an improvement we have made to prevent slips lapses and mistakes in clinical care from reoccurring
► A. Our practice team can demonstrate how we:
regularly monitor, identify and report near misses and mistakes
in clinical care
identify deviations from standard clinical practice that may
result in patient harm.
► B. Our practice has documented systems for dealing with near
misses and mistakes.
► C. Our practice team can describe improvements made to our
systems to prevent near misses and mistakes in clinical care.
► D. Our practice monitors system improvements to ensure
successful implementation of changes made to our clinical risk
management systems.
► E. Our practice has a contingency plan for adverse and
unexpected events such as natural disasters, pandemic diseases
or the sudden, unexpected absence of clinical staff.
4th edition
3rd edition
I think this was a really important standard introduced
into general practice without anywhere near enough
education for practices to understand. So most
practices I go into, when I talk about slips, lapses and
mistakes they look at me blankly; that would be
70%–80% of practices that I go to. GP surveyor
Clinical risk management systems
Patient safety in primary care: more data
and more action needed
“Australia’s lack of system-wide
reporting on patient safety is a black
hole that means there are no data and
no contextual information for patient
safety improvements” Med J Aust. 2015;202(2):72-3.
AimThe main aim of this manual is to support those general practices
engaged in the patient safety collaborative to provide safer care.
Literature review: errors and harms in primary care, common errors,
trigger tool and patient safety guideline.
Consultations with national and international experts on patient safety
Interviews with highly experienced surveyors who are involved in accreditation of Australian general practices
Interviews with high performing general practices in safety and quality to identify their characteristics and activities
Developing a patient safety collaborative
manual
Patient safety: lesson from a novice
I thought
The problem is errors
Rules create safety
Reporting is necessary to track problems and progress
Technology is the mainstay of safety
Health care is mostly the same as other high hazard industries
What's important happens before the injury
I learned
The problem is harm
Rules and breaking the rules create safety
Stories are necessary to gain knowledge.
Conversation is the mainstay of safety.
Health care differs a lot from other high hazard industries
What happens after the injury is equally important.
Berwick, D. M. Patient safety: lessons from a novice: Adv Neonatal Care. 2002 Jun;2(3):121-2.
Change Concepts
Engaging the team
Improving data
quality
Reducing Harm
•Finding harm
•Understanding harm
•Preventing harm
Aims:
To generate a culture of patient safety in participating practices
Change Ideas:
Use Medical Office Survey of patient safety culture annually to measure the
culture and use to create a practice wide discussion.
Measures:
Survey scores in each component
Engaging the team
Improving Data quality• Aims: To create systems for improving medical records continuously in general practices
• Change Ideas:
I. Develop system for continuous updating of past medical history
II. Involve patients in the process of keeping records up to date
III. Make verified records available on e-Health
• Measures:
I. Monthly report of PCS CAT ‘clinical data self-assessment tool’
II. Monthly data extraction tool to assess concordance of medication list and diagnosis list as an extension to PCS CAT
III. Record the number of e-Health uploads.
HarmFinding
Trigger tool
Event log
UnderstandingEvent analysis
PreventingMedication safety in multimorbidity
• Aims: To improve medication safety in patients with multi-morbidity by conducting an annual medication review in conjunction with community pharmacist.
• Change Ideas:
I. Develop a registry of patients 75 years or over on 10 or more regular medicines per day.
II. Arrange with community pharmacist for MedsCheck or Home Medication Review, for residential aged care
patients Residential Medication Management Review (RMMR).
III. Identifying opportunities for safely deprescribing.
IV. Add annual recall.
• Measures:
I. Proportion of eligible patients who have had a medication review in the last 12 months
II. The number and percentage of those 75 and over who are on high risk medications: benzodiazepines, tricyclic
antidepressant, aspirin AND warfarin, non-steroidal anti-inflammatory drugs AND ACE inhibitors AND diuretics.
Preventing harm: B) Improving medication safety in patients with multi-morbidity
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Thank you
Questions
