Transcript EVOLVING BY INVOLVING” - SCIMP | Scottish Clinical

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
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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 Practices
Patients
Clinical Effectiveness /
Governance Staff
Project Aims
7 Steps to Patient Safety
1.
Lead, teach and support staff
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Integrate risk management activity
3.
Promote reporting
4.
Involve patients
5.
Learn and share lessons
6.
Implement solutions
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Develop safety culture
Training
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Clinician / Administrator
What is Patient Safety
Developing Risk Registers
Reporting
SEAs
Involving Patients
Medication errors
Homework
Follow Up – 6 Months
Share the learning
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Sharing risks and SEAs
Finding Solutions
Projects
Developing Team Culture
Next Steps
Year 2
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16 more practices
Updated training
Ongoing support
Build local capacity
Sharing Sharing Sharing
Evaluation
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Culture survey x2
Training
Outputs
Involving patients
SEAs wider learning
External evaluation
Project Aims
7 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
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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…
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Report what?
To Whom?
By When?
Analyse?
 Hands Up?
Ideal reporting systems
IT based
< 2 mins
Trusted
Feedback
Action
Used by all
How does the IR1 and
NPSA match up?
NHS Scotland
Current reporting systems- IR1s
Paper 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 Analysis
Familiar territory
Almost all practices do it QOF
 12 in last 3 years
 3 per year
GP Appraisal
External peer review
Promoting Reporting
 Incident Reporting Forms (IR1s) - not useful or
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used
SEA’s More skills
Positive and negative SEA’s
More inclusive
More structured
More detailed in reporting
Sharing Significant
Events
Most Practices submitted SEAs
Fulfilled QOF criteria but:
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No standardised format for submission
Variable Quality
Change/ impact often unclear
No wider learning
Learning and Sharing Lessons
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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
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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
Involving Patients
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Limited success
Workshops – input valued
Leaflets 20% - found it useful
Labour intensive
Patient groups
 How to do it without raising
alarm?
Culture
Patient Safety Culture
Scoring Highly >75% most criteria
Could 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”
Awareness
Involvement
Non clinical staff
Benefits to Health Board
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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
Engage
Culture
Measure
Involve
Sustain
Spread
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
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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?