developing patient safety in primary care in scotland neil houston, arlene napier
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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?