Improving Safety Culture and Safety Practice In Primary Care

1. Improving Safety Culture and Safety PracticeIn Primary Care

2. Scottish Patient Safety Programme Acute Focus

3. Central line infection rate (per thousand line days 92% reduction

4. Why ? Who? What ? How? Delivering Quality in Primary Care“Design and implement a Patient Safety Programme in Primary Care”

11. 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)

12. How Safe are we? • Consultations 98% safe • Adverse Event rate1- 2% Consultations • More with frail elderly • 300 million consultations in UK pa “Absolute number of those harmed may be just as large or greater than secondary care” Health Foundation 2011

13. Statistics- Commission • 11% prescriptions contain errors • In a care home - 50% chance of ADE • High risk prescribing

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

16. Causes of harm • Drug adverse events • Medication errors • Delayed diagnosis • Clinical error • Administration errors – Results – Med rec • Communication

18. 6048 prescriptions 95% Prescriptions are safe 1 in 20 have an error 1 in 550 serious error 9 out of 11 from Warfarin Processing errors not knowledge Human factors

19. Why?- Human Factors Time pressures Frequent distractions and interruptions Blood monitoring errors Little training Team communication IT Issues Interface communication

20. Not a new agenda…….

21. Development and Testing Safety Improvement in Primary Care 1

22. Aims • To enable 50 Primary Care teams to: • Identify and reduce harm to patients 2. Improve reliability of care for patients On High Risk Medications With Heart Failure 3.Develop safety Culture 4.Involve Patients in QI

23. The Tools • Collaborative • Bundles • Patient Involvement • Trigger Tools • Safety Climate

24. Knowledge • Topics • Tools • What to spread? • How to spread?

25. Measurement

26. Reliable Care - Care Bundles 4 or 5 elements of care Evidence based Across Patients Journey Creates teamwork Done reliably All or nothing Small frequent samples

27. DMARDS Full blood count in the past 6 weeks? Abnormal results acted on? Review of blood tests prior to issue of last prescription? Had pneumococcal vaccine? Asked re side effects last time blood was taken?

29. Methotrexate data

30. Warfarin - Bundle Warfarin dosing followed current local guidance?Patient informed of the warfarin dose and date of next test Patient been taking the advised dose since last blood test?INR is taken within 7 days of planned repeat INR?Face to face education recorded every 12 months? 5 patients per fortnightAll or nothing measure

31. Warfarin Bundle Compliance

32. Heart Failure Bundle

33. “The care bundle was useful because it identified gaps” “You can see week by week, month by month, whether or not you are showing any improvement, we seem to be improving and that’s good”

34. Improvements • Optimised care • Guidance/ Templates • Blood monitoring /Recalls • Reduced variation • Patient Education and Self management • More efficient • Less Stress!

35. Greater efficiency & confidence in practice procedures “shortly after starting there seemed to be these patients in my messaging system all the time and that now seems much more manageable”

36. Less Stress for some staff in their job • “Staff member X who manages the register and the recall for these patients, it caused her an enormous amount of stress prior to the programme” “ Now that the programme is much more streamlined and she feels more confident and has taken much more clinical responsibility”

37. Staff time-saving - patients being more proactive “staff member X doesn’t have to continually phone people up every month, that is quite a time saver for her, patients are now more coming in cause they understand the consequences potentially of the side effects of the potential toxic drugs”.

38. Reduction in tests per patient

40. The Trigger Tool and GPDetecting Harm in Primary CareWhere is all this harm?What are we going to do about it?Dr Gordon CameronGP / Patient Safety Advisor

41. Not In My Back Yard? • 11% of maintenance logs show significant errors which could jeopardize safety • Around 2% of worker shifts end with the potential for a significant adverse event • In the satellite workshop setting there is a 50% chance of a safety log containing a significant deviation from protocol • More than 60,000 visitors a year spend time in the “high risk zone” of this facility

42. But This IS Our Back Yard … • 5% of UK GP prescriptions contain the potential to harm the patient • Around 2% of consultations end with the potential for a significant adverse event • In the care home setting there is a 50% chance of a Kardex containing a significant drug interaction • More than 60,000 patients in Scotland each year receive a “high risk prescription” – methotrexate, warfarin etc

44. Prescribing targets Interruptions Email Emergencies Meetings Personal Stress Phone calls Personal Health Fatigue

45. If pilots had the same working day as GP’s … …….. Would you get on a plane ?

46. The Trigger ToolWhere is all this harm?