Developing Patient Safety in Primary Care in Scotland

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Developing Patient Safety in Primary Care in
Scotland

• Neil Houston, Arlene Napier

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Historically Acute Focused

• IHI 100,000 lives
• Scottish Patient Safety Programme
• NPSA Reporting

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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

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Collaborative

• 32 Volunteer Practices
• Patients
• Clinical Effectiveness / Governance Staff

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Project Aims7 Steps to Patient Safety

• Lead, teach and support staff
• Integrate risk management activity
• Promote reporting
• Involve patients
• Learn and share lessons
• Implement solutions
• Develop safety culture

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Training

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

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Homework
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Follow Up 6 MonthsShare the learning

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

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Year 2

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

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Evaluation

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

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Project Aims7 Steps to Patient Safety

• Lead, teach and support staff
• Integrate risk management activity
• Promote reporting
• Involve patients
• Learn and share lessons
• Implement solutions
• Develop safety culture

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Wider Impact?

• On Health Boards
• On NHS Scotland

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Lead, Teach and Support Staff

• Training valued
• Confidence and skills Protected learning and
  facilitation valued
• Involving all staff
• Need GP leadership

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Risk Register
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Integrating Activity

• All identified an area of risk in prescribing
• All worked to reduce risk in this area
• Shared risk and solutions with others

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Promote Reporting - National Context

• NPSA
• IR1s
• Datex
• SEAs
• Enhanced Services Warfarin and Near patient
  testing

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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.

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Say that again

• Report what?
• To Whom?
• By When?
• Analyse?
• Hands Up?

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Ideal reporting systems

• IT based
• lt 2 mins
• Trusted
• Feedback
• Action
• Used by all
• How does the IR1 and NPSA match up?

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NHS ScotlandCurrent reporting systems- IR1s

• Paper based
• Too slow
• ? feedback/ action
• ? trusted
• ?used
• Slips and trips

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Project IR1s

• Training
• Encouraged
• eIR1 pilot
• Incident logs

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Feedback

• We found it absolutely awful
• Its a huge form to fill in its ridiculous
  actually
• It doesnt work in a small organisation.. and
  it doesnt work well in the hospital either..!

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Significant Event AnalysisFamiliar territory

• Almost all practices do it QOF
• 12 in last 3 years
• 3 per year
• GP Appraisal
• External peer review

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Promoting Reporting

• Incident Reporting Forms (IR1s) - not useful or
  used
• SEAs More skills
• Positive and negative SEAs
• More inclusive
• More structured
• More detailed in reporting

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Sharing Significant Events

• Most Practices submitted SEAs
• Fulfilled QOF criteria but
• No standardised format for submission
• Variable Quality
• Change/ impact often unclear
• No wider learning

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Learning and Sharing Lessons

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

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Incident Reporting SEAs
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Issues

• Lack of trust ?? anonymity
• Negative impact on practice
• I think there was a feeling that youd be
  washing your dirty linen in public and the
  partners were not prepared to do that
• GPs more negative than others

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More Issues

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

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SEA and Risk Issues

• Medication reconciliation at interface

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SEA and Risk Issues

• Medication reconciliation at interface
• Drugs that look alike sound alike

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Looks Can Be Deceptive
Spot the Difference?
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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

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Low Tech Solutions

• Sticky Tape
• Wipe Boards
• Talking over coffee at 11 am!

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IT Solutions

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

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Involving Patients

• Limited success
• Workshops input valued
• Leaflets 20 - found it useful
• Labour intensive
• Patient groups
• How to do it without raising alarm?

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Culture
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Patient Safety Culture

• Scoring Highly gt75 most criteria
• Could be developed in areas of
• Shared Decision making
• Communication
• Informing staff when errors occur

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Progress.

• Its not about blame, its about it not happening
  again
• Awareness
• Involvement
• Non clinical staff

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Benefits to Health Board

• Increased Capacity Collaboration
• Common Risks Identified
• Action on interface issues
• System wide approach now adopted
• Culture change ??

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For NHS Scotland

• Generating interest
• National Patient Safety Programme should involve
  Primary care
• ?Enhanced service
• Clinical Governance guidance for contract
• SEAs - systems for wider learning

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What role do you think IT has

• As a source of Risk?

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What role do you think IT has

• As a method of risk reduction?

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IT Solutions

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

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IT

• Email
• Results downloaded to GP Notes
• Protocols Accessible on web /via patient records
• Incident Reporting

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Any Questions?