1. Patient Safety in Primary Care The Linneaus Collaboration www. linneaus-pc.eu Aneez Esmail Professor of General Practice University of Manchester (UK)

2. What I am going to cover The epidemiology of error in primary care The challenges that we face Three things that you can do when you leave here –Understand your safety culture –Set up a reporting system –Undertake a root cause analysis

3. My typical Monday morning! Imagine that it is always a busy day…..

4. Why is patient safety important in primary care?

5. 1. It’s where most episodes of care take place 95% of all NHS contacts take place in primary care 300 million general practice appointments per year 750,000 people consulting GPs every day Primacy of primary care in most European countries

6. 2. Mistakes happen…. 5-80 safety incidents per 100 000 consultations Between 37 – 600 incidents per day 4 main categories Diagnosis Prescribing Communication Organisational Sandars and Esmail, 2001

7. Why is primary care different? 1. The environment Lower profile than acute sector Low technology environment Different organisational structures Mode and site of care delivery – telephone, home visits Interfaces important Increasing complexity Consultation skills and interpersonal skills critical

8. Practice Organization and its relationships

9. Why is primary care different? 2. The processes Less obvious implications 50% no consequences 20% non-clinically important delay in diagnosis 10% upset patients Up to 20% could have serious implications Less litigatious Different professional dynamics

10. Frequency of errors (Primary Care) CodeError descriptionFrequency% 14Failure/delay in diagnosis49450% 48Medication inappropriately prescribed565.6% 23Failure/refusal/delay in referral515.17% 46Failure to warn/recognise side effects of drugs 505.07% 22Failure to monitor condition464.66% 41Unsatisfactory performance of procedure 424.26% 50Failure to diagnose complications in pregnancy 242.43%

11. Frequency of outcomes (Primary Care) CodeOutcomeFrequencyPercent 33Death17820.7% 35Deterioration in clinical condition505.81% 86Unnecessary pain343.95% 3Amputation of limb313.60% 88Appendicectomy232.67% 10Brain damage202.33%

12. Why is primary care different? 3. The underlying philosophy Variation more acceptable Different approach to risk and uncertainty

13. Primary care…. Accept uncertainty Explore probability Marginalise danger Marshall Marinker

14. So what are we going to do? My mistake! Yes it happens to all of us!!!

15. The problem Much can go wrong in general practice, so it is important to have a system to learn from your mistakes. After a number of close-calls you agreed to make improving patient safety a priority a year ago, but nothing has changed. How can you establish a new system to manage risk?

16. Starting Put someone in charge and agree a timetable of key activities and deadlines. Their first task should be to carry out an audit to assess your practices’ safety culture.

17. Safety culture Your practice must have a culture where staff are encouraged to evaluate risk, mistakes are acknowledged and there is a system to take action when things need putting right. It requires a good understanding of your practice’s approach to risk management and a broad discussion about the ‘safety culture’ in your practice

18. How to assess safety culture Put someone in charge and agree a timetable of key activities and deadlines Carry out an audit to assess your practices’ safety culture. Build a safety culture http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61598 http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61598 MaPSaF (http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59796)http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59796

19. MaPSaF (Manchester Patient Safety Framework) Set aside about two hours as a practice team to do this. It is a worthwhile exercise to stimulate discussion about the strengths, weaknesses and differences of the patient safety culture in your practice. At the end of the process, you will have a shared understanding of where the main problems are, the barriers to improving things and also some of the strengths of the practice.

20. Lack of formal procedures We are a small practice and have rather an ad- hoc way of recording events that impact on patient safety. How can we formalise this process?

21. Reporting For a four-week period you will report on adverse events that take place within the practice. Give all staff the ability to anonymously report incidents that disrupt the delivery of best quality care in the practice Defining safety –‘something that should not happen in my practice, and I don't want it to happen again’

22. Incident reporting form National Patient Safety Agency. Incident Report Form. https://www.eforms.npsa.nhs.uk/gpreport/ https://www.eforms.npsa.nhs.uk/gpreport/ –In a typical group practice of 5,000 patients, over a four-week period, you will expect to collect about 15 patient safety incidents. should read the reports and present them to the practice. At this point you should not analyse the incidents, but get an agreement on which of them should be studied in more depth

23. Too much information We are drowning in information, with a series of reports of significant events and our incident reporting system, but how can we learn from them?

24. Significant Event Audit SEA –Dilemmas in significant event auditing, Pulse 2010. http://www.pulsetoday.co.uk/story.asp?sectioncode =24&storycode=4127376&c=4 http://www.pulsetoday.co.uk/story.asp?sectioncode =24&storycode=4127376&c=4 –Have a formal process and keep a record

25. Root cause analysis Root cause analysis shows where systems need to be developed to prevent future harm, by identifying the chain of events and the contributory factors which caused the incident. It works best when the whole practice team is involved in agreeing to the investigation and learning lessons from it. Used for more serious outcomes (serious harm or death).

26. Five Whys? Root Cause Analysis: Five whys tool - http://www.nrls.npsa.nhs.uk/resources/?entryid45=75605Root Cause Analysis: Five whys tool http://www.nrls.npsa.nhs.uk/resources/?entryid45=75605 –to consider what control measures can be implemented to prevent the incident happening again. You may have to revisit your protocols and checklists to see if they need to be modified or if new ones need to be developed –For example: If the problem identified is a delay in diagnosis, identify which systems could be improved to ensure that abnormal results are appropriately dealt with. It is important that any changes that are made are piloted and then reviewed

27. Finally Keep a record of what you have done. People leave and things get forgotten. Having an organisational memory is a critical part of learning from things that go wrong.

28. A charter for action (with a little help from Atul Gawande) Count something Change something Write about it Keep the conversation going