1. Primary care safety- Why bother?
National Learning Event
29th March 2012
Dr Brian Robson,
Executive Clinical Director

2. What is quality healthcare?
Now I come from the healthcare world – so let us look at what ‘quality’ actually is in my world. When I say my world – it is YOUR world – your care and the care of your family, friends and neighbours
So .... I would like you to spend the next 2-3 minutes at your tables and i would like to discuss what ‘quality’ healthcare means to you – what does this look like?
.... Ok so that means noise ( usually gets a laugh ! And they always start talking )
After a few minutes then walk around the tables – picking on 3-4 tables until they get a picture of ‘quality’
Walking back to stage ... Well I am glad to hear you call out these features because NHS Scotland has also called these out ....as part of our 6 dimensions of quality ....

3. The Only Show in Town
This is our overarching strategy in NHs Scotland – and this has bold ambitions !
Scottish Government, May 2010

4. The Healthcare Quality Strategy for Scotland
Person-Centred - Mutually beneficial partnerships between patients, their families, and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication, and shared decision making.
Clinically Effective - The most appropriate treatments, interventions, support, and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.
Safe - There will be no avoidable injury or harm to patients from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.
These are our 3 central ambitions ..

5. We have a long way to go ... 7 UK NHS organisations
Failures are common (13-19%)
Real risk to patients
1 in 7 Rx records contained an error. 20% of which could have serious harm
1 in 7 outpatient appointment proceeded with incomplete medical record. 1.5% with no record at all.
Wide variation in reliability
1 in 5 operations involved wrong, faulty or missing equipment or staff didn’t know where it was or how to use it.
However just in case you thought that we had it all sorted in healthcare – we know that we don’t
This recent study from the think tank, The Health Foundation, which involved studying defects in care in 7 NHS organisations across the UK, including NHs Lothian, set out just were some of the failures in our system occur.
And, in case you think this is a new feature of complex healthcare
May 2010

6. 1200
The audit commission reported that in 2001, in England and Wales, every year we killed up to 1200 patients as a result of medication errors – which in Scotland might translate as 120 patients – however just think of the impact of these deaths have on the individual and family hundred lives
Number of patients who die every year as a result of medication errors in hospital
Audit Commission, E&W, 2001

7. Doctors protesting
And if are wondering why these errors might occur then just think about one of the oldest sources of humour visited on the medical profession – their hand writing ...

8. This is a real example of the drug chart in a Scottish hospital – our sickest patients, with the most toxic of medications – and not a computer in sight !
There is currently only one hospital in Scotland with an electronic prescribing system and so transcription errors are common.

9. £500m Audit Commission, E&W, 2001
These errors alone , in 2001, were estimated to cost the NHS in England and Wales and staggering £500m per annum
Cost per year of medication errors in hospital
Audit Commission, E&W, 2001

10. 98,000 To Err Is Human, Institute of Medicine,2000
Number of patients who die every year in US hospitals as a result of medical errors
To Err Is Human, Institute of Medicine,2000
And this is a global issue – in the United States, the IOM reported more than 10 years ago that up to 98,000 people a year were dying as a result of medical ( not limited to medication error) error per year

11. To Err Is Human, Institute of Medicine,2000
Their report showed that medical error accounted for more deaths per year than either of RTAs, Breast cancer or AIDs

12. Patient Safety in Primary Care - Why Bother?
High Volume
Increasingly complex
Real harm – adverse events in primary care cause:
12% of Admissions to hospital Quality and Safety in Healthcare April 2007
5.5% of Deaths in hospital To Err is Human, 1999
76% of incidents in primary care are preventable Med Journal Australia ; 169 ; 73-6)

13. Common safety issues Prescribing Warfarin Methotrexate
Patients with complex conditions
Patient misidentification
Results lost to follow up
Interface Interface Interface…

14. Harm in Primary Care Context
Adverse Event rate 2% Consultations
More with frail elderly
300 million consultations in UK pa
Patient reports 8x harm
WHO expert group Feb 2012
“Absolute number of those harmed may be just as large or greater than secondary care” Health Foundation 2011

15. Causes of harm Drug adverse events Medication errors Delayed diagnosis
Clinical error
Administration errors
Results Systems
Communication …

16. Omission - Lack of reliable care
Methotrexate – 12% not monitored
Mix of strengths 30%
Prescribed daily

17. (un)Reliable Heart Failure Care
ACE inhibitor 88%
Correct B Blocker 70%
B blocker at target dose 45%
Pneumococcal 71%
NYHA status 71%
All %

18. (un)Reliable diabetic Care?
38% of patients with Type 1 Diabetes receive 9 key interventions
NICE 2008/9

19. Nearly 60% of patients are not told about the potential side-effects of their prescribed medications

20. “Every system is perfectly designed to get the results it gets.”
Paul Batalden

21. System issues Inadequate systems for learning
Excessive task demand and fragmentation of work
Results - reporting acting on telling patients
Climate - lack of focus on quality
Need tools to identify and address harm
Deficits at interface -discharge summaries

22. System design
Cash card
Methotrexate
Penicillin vs Penicillamine

23. Information overload …
But every time I learn something new, it pushes something old out of my brain ....
Jenny – evidence into practice  overwhelmed

24. Heroes or teamwork ?

25. Systems that depend on perfect human performance are fatally flawed.
Everyone makes mistakes
We try to be perfect but its not possible
Systems that depend on perfect human performance are fatally flawed.
Health care professionals schooled to be perfect ---
Taught that individual performance is what yields good results.
Individual performance is only one factor in good results. 25 25

26. Adverse Event Causation
Technical
Factors
(30-20%)
Accident
Causation
Human
Factors
Safety
Culture
Operator
Behaviour
(70-80%) = +

27. All improvement is local
Clinicians working in partnership with patients
Doesn’t occur in isolation

28. Clinicians working in partnership with patients
Societal context
Political and policy context
Organisational context
Team context
Clinicians working in partnership with patients

29. Culture eats strategy for breakfast
Anon

30. Positive Safety Culture
Safety a Priority
Eliminate “shame and blame” mentality
Accept staff will make errors
Build systems to support their work
Foster a culture where people can speak up
Team training
Organizational learning from errors and near- misses

31. Our Practice Safety Climate

32. Much of the value of these types of surveys lies in raising the profile of patient safety and promoting conversations, that’s when the improvements come through
The Health Foundation, 2011

33. Not a new agenda……. Significant Event Analysis Complaints reviews
IT systems
Prescribing Systems
Managing Results
Culture
Practices are already doing elements of this – its not a new agenda

34. This is not an easy road
If improvement of patient safety was easy, it would have been done by now. No one wants a single person to be harmed by medical care. Eliminating patient injuries is difficult, even with the best of intentions. Solutions such as "wash your hands,“ "give the antibiotic on time," and "use the checklist" seem so simple that many ask, "How could they not do that?" In fact putting these solutions into action is elusive, requiring culture changes, new forms of teamwork, uncomfortable levels of transparency, disclosure, dialogue, changes in patterns of workflow, and constant vigilance at all levels.
Are you up for that ?
Berwick D, McCannon J : JAMA, June 1, 2011 —Vol 305, No. 21

35. We are not alone

36. Ventilator Associated Pneumonia: 0 or 300 days between
Outcome Aims
Mortality: 15% reduction
Adverse Events: 30% reduction
Ventilator Associated Pneumonia: 0 or 300 days between
Central Line Bloodstream Infection: 0 or 300 days between
Blood Sugars w/in Range (ITU/HDU): 80% or > w/in range
MRSA Bloodstream Infection: 30% reduction
Crash Calls: 30% reduction

37. Scotland – 8.4% reduction in HSMR

38. Central line infection rate (per thousand line days)
March 2011:
zero central line infections
in whole country

39. VAP rate (per thousand ventilator days)
62% reduction
9.11
3.49

40. % ICU mortality
14% improvement
18.2%
15.7%

41. General ward C.Difficile rate (per thousand patient days)
88% reduction
1.18
0.14

42. Courtesy of Malcolm Daniels
This is why it matters
Courtesy of Malcolm Daniels

43. “Each of you ... All of us”
“ The key is collective impact !” “ working together means that you should never worry alone.”

44. Thank You