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
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 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 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: 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
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
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 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