Risk management in general practice

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Transcript Risk management in general practice

Risk management in general practice

Eric Bater 6 th November 2013

Aim of programme

 to apply the principles of risk management to practical situations and relate these to personal experiences  to improve the quality of care by implementing initiatives to remedy deficiencies in the service provided.


 To help reduce the risk of harm to patients, staff and visitors by improving safety and the quality of care in practice

Harvard Medical Practice Study New England Journal of Medicine 1991 

3.7% patients suffered an adverse event

Of these 13%


58% events related to system errors

Summary of New Complaints Procedure ( 1998, 9/12 period) MDU experience  Failure or delay in diagnosis most common reason (28%)  24% of complaints made after bereavement  Non-clinical issues accounted for 34% of complaints  10% of complaints related to attitude  93% settled at local resolution

MDU Settled Claims Against UK GPs

 Failure to diagnose - 51%  Medication error - 26%  Pregnancy including labour - 13%  Minor surgical procedure - 7%  Other - 3%

MDU Claims Settled

 Quality of medical care  Medical record issues  System failures 7% 60% 33%

Clinical Governance

 Clinical risk management  Complaints procedures  Adverse incident reporting  Clinical audit  Evidence- based practice  Whistle blowing  Performance review


“The possibility of incurring misfortune or loss”

Living with risks

Risk is part of everyday life  At home   When travelling With patients

You can minimise your risks by improving your systems

In general practice…

   Average GP will provide about 200,000 consultations during their career 25% of adverse events occur in primary care And, it is estimated that 1% of GP consultations (one a week) are associated with a significant adverse outcome

Making amends DH 2003

Incident reports to the National Patient Safety Agency

 2600 reports from October 2006 to September 2007 from general practice:  29% Medication errors   14% Documentation 11% Access/admission/transfer/discharge  10% Consent/communication/ confidentiality 0.33% of all reports received NPSA National Reporting and Learning Data Summary Issue 7 December 2007

Top key risks in UK general practice

      95% Confidentiality 92% Prescribing 90% Health and safety 85%Communication 84% Record keeping 84% Test results MPS Risk Consulting August 2006


Common issues:  Breaches of confidentiality in waiting rooms and reception areas  Staff contracts do not include a clause covering confidentiality post-employment    Not all patient-identifiable information is shredded Patient medical records are not securely stored Computers may be left on and unattended

Breach of confidentiality

Can lead to:  Breakdown of practitioner/patient relationship  Lack of trust/confidence in other healthcare professionals   Failure to seek further treatment Disciplinary action by GMC and employers


Common issues:  No repeat prescribing protocol    No designated receptionist to record or generate repeat prescriptions Reception staff are allowed to add medication to the computer Medication reviews are undertaken on an ad hoc basis.   No system for recalling patients on long-term medication Uncollected prescriptions are destroyed

Record keeping

Common issues:  Illegible writing in the records  Letters scanned into wrong record    Telephone advice not always recorded Medical records go missing Home visits not always recorded on the computer

Test results

Common issues:     No tracker system to ensure that patients are followed up No system of knowing when all a patient’s test results have been returned Test results not recorded onto the computer Non-clinical staff allowed to inform patients of their result and treatment required

Infection control

Common issues:    No infection control policy Specimen handling Hand washing issues

Hand washing

For effective hand washing consider the following :  Liquid hand dispenser   Paper towels Elbow/foot operated mixer taps     Alcohol based hand rub No sink plug Remove jewellery Designated hand wash basin

What is clinical risk management?

■ Common sense ■ Identification, measurement and control of risk to avoid harm to patients and staff ■ Involves everyone ■ Relates to the whole package of care ■ Equates to good practice


A careful examination of what 1. could cause harm 2. its significance and 3. what precautions are needed to eliminate the risk or reduce it to an acceptable level

Risk Management Benefits

 for patients – improved quality of care and service – – enhanced patient safety confidence in the service  for health care professionals – – – protection of confidence and reputation quality procedures and staff involvement decreased numbers of complaints and claims

The four principles of risk management


Identify the risks

what’s likely to go wrong?


Assess the risk

what are the chances of it going

wrong, what could happen, does it matter?


Reduce/eliminate the risk

what can you do about it


Cost the risk

what are the costs of getting it right v.

the cost of getting it wrong?

Risk Management Techniques

 Complaint handling  Risk assessment  Staff awareness/training  Protocol and guidelines monitoring  Good medical records  Adverse incident reporting

Risk Areas

     Staff - especially locums Organisation  adequate staffing  regular guideline review Communication Consent Record keeping

Clip 2 – Morning Surgery

Identified Risks

 Breaches of confidentiality – front desk/reception area etc.

 Health and safety issue.

 Lack of systems.

 Phone call interruptions.

 Verbal requirements regarding nurse visit.

 Inappropriate roll/responsibilities of receptionist.

What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

Clip 3 – Test Result / Minor Surgery

Identified Risks

 Dealing with smear results.

 Aseptic techniques.

 Lack of chaperones.

 Unreasonable patient request.

 Lack of informed consent.

 Disposal of clinical waste/needles.

What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

Clip 4 – Home Visit

Identified Risks

 Examination.

 Response to collapsed patient.

 Communication regarding hospital admission.

 Communication with mother.

 Dealing with request for repeat prescription.

 Dealing with aggressive patient.

What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

Aims of Assessment

     Improve patient care Ensure safe standards of practice Ensure patient/staff safety and well being Decrease the number of complaints and claims Lessen the stress associated with litigation

The ‘three bucket’ model for assessing risky situations (Reason, 2004)

3 2 1 SELF CONTEXT TASK The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

Self Bucket

Level of knowledge Level of skill Level of experience Current capacity to do the task newly qualified competence and experience involuntary automaticity, under/over confidence fatigue, time of day, negative life events

Context Bucket

Equipment and devices Physical environment Workspace Team and support Organisation and management usability, not available lighting, noise, temperature working environment, writing space, leadership, stability and familiarity, trust safety culture, culture, targets and workload

Task Bucket

Errors Task complexity Novel task Process omission errors, primary goal achieved before all steps complete, lack of cues from previous steps calculations unfamiliar or rare events task overlap, multi-tasking

Reason’s Swiss cheese model

Department of Consumer

and Employment Protection

Resources Safety