Nearly 7 million patients might have been subject to a general practice error in the past year. With new models of care proposed, Sukhmeet Panesar and colleagues urge GPs to have a greater awareness of patient safet

Ahluwalia, S

Carson-Stevens, A

Diaper, M

Forsyth, D

Marshall, MN

Panesar, S

Rees, S

Vincent, C

UCL Discovery

Page 1 of 4http://www.hsj.co.uk/home/commissioning/dont-let-primary-care-patients-slip-through-the-nets/5078203.article#.VNUYncY3S68Don't let primary care patients slip through the nets4 February, 2015 | By Sukhmeet Panesar, Martyn Diaper, Donna Forsyth, Andrew Carson-Stevens, Sanjiv Ahluwalia,Siân Rees, Martin Marshall, Charles VincentNearly 7 million patients might have been subject to a general practice error in the past year. With new models of careproposed, Sukhmeet Panesar and colleagues urge GPs to have a greater awareness of patient safetyGeneral practice has evolved slowly since theinception of the NHS in 1948, but a consensus isgrowing around the need for radical change toaddress issues of morale, recruitment andretention.The traditional small scale of practices isperceived to be a particular problem. Yet,although new network models of practice areemerging, the implications for patient safety ofchanges in structure and governance havereceived scant attention.‘Errors in primary care occur in about 1 to2 per cent of all consultations’Perhaps this is because little is known aboutpatient safety in primary care. But at a timewhen GPs face ever greater complexity, morerisk and an ageing population’s multimorbidity – all of which make errors more likely – the lack of focus on safetyinitiatives is worrying. It has been estimated that errors in primary care occur in about 1 to 2 per cent of all consultations, although somestudies put this figure higher.This is lower than the 10 per cent error rate in hospitals, reflecting the nature of risk in the two sectors.There were an estimated 340 million GP consultations, in absolute terms, in 2013-14. So 6.8 million patients mighthave experienced an error over the last year.The National Reporting and Learning System is the largest repository of patient safety incidents in England and Wales.06/02/2015 19:40Don't let primary care patients slip through the nets | Resource centre | Health Service JournalPage 2 of 4http://www.hsj.co.uk/home/commissioning/dont-let-primary-care-patients-slip-through-the-nets/5078203.article#.VNUYncY3S68Since 2003, 11 million incidents have been reported.However, only 5,706 incidents were reported from general practice over the last year. It is likely that this reflectsunderreporting by GPs, and the reasons for this are complex.New patient safety incentives revealedSharing errors data can reduce medical negligencePatient safety bill to legislate for zero NHS harmDefinitions of harmThere are two main problems with the promotion of patient safety in primary care. First, there is a lack of consensusabout the patient safety terms in common use, which can cause problems for those attempting to engage primary carepractitioners.Definitions of patient safety termsPatientsafetytermDefinitionHarm Any physical or psychological injury or damage to the health of a person, either temporary or permanent.Harm is usually classified as no harm, low harm, moderate harm, severe harm or death.Near miss Any patient safety incident that had the potential to cause harm but was prevented, resulting in “noharm”.AdverseeventAny event involving unintended harm to a patient that resulted from medical care.PreventableadverseeventAn event involving patient harm as a result of wrong or inappropriate action (“error of commission”) orfailing to do the right thing (“error of omission”).Adversedrug eventAny incident in which the use of medication results in harm to a patient, including adverse drug reactions– as in the case of known side effects that occur even when the medication is used as intended – as wellas events in which the drug has been used erroneously.PatientsafetyincidentAny unintended or unexpected incident that could have harmed or did harm the patient, including “nearmisses”. The term “patient safety incident” is preferred to “error”, as the latter has a more negativeconnotation.Criticalincident*A term first coined in the 1950s and made famous by a classic human factors study by Cooper of“anaesthetic mishaps”. They defined critical incidents as occurrences that are “significant or pivotal, ineither a desirable or undesirable way”. This means that there was significant potential for harm – oractual harm – but also that the event has the potential to reveal important hazards in the organisation,and provide valuable opportunities to learn about individual and organisational factors that can beremedied to prevent future incidents.Source: Cooper et al 1978 (reproduced with permission of Wolters Kluwer Health)In general practice, it is less common for patients to come to serious harm than in acute settings (examples of thediffering nature of risk in primary care settings are shown in the table, below).Examples of patient safety incidents with corresponding levels of harm*Categoryof harmDefinition ExampleNo harm(impactprevented)Any unexpected orunintended incidentwhich was noticed andhalted or reversedbefore it was able tocause harm to apatient.A GP prescribes an inappropriate dose of a drug, which the local communitypharmacist picks up when dispensing the prescription.No harm (impactnotprevented)Any unexpected orunintended incidentwhich did not lead toharm on this occasion.A patient is on medication that requires blood pressure monitoring. The hospitaldischarge letter does not mention this to the GP, which results in the patient notbeing followed up appropriately. However, it is noted when the patient visits the GPfor a further prescription. The patient’s observations are then found to be normal.06/02/2015 19:40Don't let primary care patients slip through the nets | Resource centre | Health Service JournalPage 3 of 4http://www.hsj.co.uk/home/commissioning/dont-let-primary-care-patients-slip-through-the-nets/5078203.article#.VNUYncY3S68Low Any unexpected orunintended incidentwhich required extraobservation or minortreatment and causedminimal harm, to oneor more persons.A patient’s home visit is missed. The terminally ill patient required a painassessment. This was picked up the following day, resulting in the patientcontinuing to be in pain until the medication was altered.Moderate Any unexpected orunintended incidentwhich resulted infurther treatment,possible surgicalintervention, cancellingof treatment, ortransfer to anotherarea and which causedshort term harm, toone or more persons..Continuing treatment with warfarin without monitoring clotting levels for a lengthof time which results in an overdose and bleeding problems that require closemonitoring and follow-up.Severe Any unexpected orunintended incidentthat caused permanentor long term harm toone or more persons.A patient, who is a heavy smoker, visits the GP with a cough. The patient’s name isMr Jones. He has a chest X-ray and the report suggests a suspicious lesion withthe advice to refer for further investigations. The GP writes on the report that anurgent appointment is needed and the receptionist files the report in Mr Jones’sfile. Mr Jones rings the surgery for his results and the receptionist looks in his fileand says that no report has been received yet and that the practice will ring him ifthere is any news in the next week. Mr Jones does not hear so assumes everythingis OK. Two months later Mr Jones visits the GP on a routine appointment and MrJones’s urgent request is found. Mr J Jones is referred and it is found that he haslung cancer.Death Any unexpected orunintended incidentwhich caused thedeath of one or morepersons.A patient suffering from chest pain is asked to wait for a free slot in the GPsurgery. As he feels difficulty in getting his breath, he goes for a walk, collapsesand dies in the GP surgery’s car park.*Examples of incidents from Seven steps to patient safety for primary care.Patchwork reportingA second problem in promoting patient safety in primary care is that, in addition to the NRLS, there are severalchannels for reporting and learning from errors.Given these disparate and disconnected reporting systems, it is hardly surprising that practices are confused and havefailed to engage with the safety agenda in a systematic way.‘It’s hardly surprising that practices have failed to engage with the safety agenda in a systematic way’Change cannot be expected overnight – it has taken a decade for the patient safety movement to make significantgains in the acute setting.However, we need to explore the benefits of a unified mechanism of reporting and learning from errors.Big data has a role to play but a mechanism to capture errors from routine datasets without relying on self-reporting isneeded. The Primary Care Trigger Tool, developed by the former NHS Institute for Innovation and Improvement,attempted to reduce this burden using a targeted case note review.However, despite being considered the gold standard, case note reviews can be resource intensive and have neverreally been used in a “before and after” scenario to assess the efficacy of safety initiatives.We need to develop a better understanding of safety in primary care and what this means to GPs and others. Arenewed effort is needed to encourage patient safety experts, policy makers and GPs to enshrine patient safety withinthe newer service models for primary care.‘Patient safety needs to be a priority in the creation of multispecialty community providers’06/02/2015 19:40Don't let primary care patients slip through the nets | Resource centre | Health Service JournalPage 4 of 411General practice needs to define the meaning of safety in line with its core principles of first contact, andcomprehensiveness, continuous, coordinated and patient centred care.Safety and quality improvement training needs to be provided in both undergraduate and postgraduate curricula.GPs must be equipped with the knowledge and tools on how to design, test, implement and evaluate safetyimprovement initiatives, both at practice and population health levels.New modelsDuring this period of promoting various models of care, it is possible to imagine federations or networks havingdedicated patient safety officers, risk managers and the infrastructure to promote reporting and learning from errorsakin to those found in hospitals.Patient safety needs to be a priority in the creation of multispecialty community providers, one of the new models ofcare suggested by the NHS Five Year Forward View.Similarly, primary and acute care systems need hospitals to assess how their patient safety infrastructure can betranslated into primary care.‘Hospitals need to assess how their patient safety infrastructure can be translated into primary care’The long term vision should answer two very important questions.First, how can the newer models of care incorporate routine surveillance mechanisms to assess the burden of unsafecare, perhaps through the use of standardised safety indicators?Second, how can an open culture of reporting and learning from errors be promoted locally within newer models ofcare and shared nationally?Significant strides have been made in improving safety in hospitals and the time is now ripe for similar progress to bemade in the primary care sector.We should not wait for a patient’s primary care horror story to make the tabloids before we focus on delivering saferprimary care.Sukhmeet Panesar is honorary fellow at the Centre for Population Health Sciences, University ofEdinburgh; Martyn Diaper is medical director (quality) of Southern Health Foundation Trust and head ofpatient safety (primary care) at NHS England; Donna Forsyth is senior head of patient safety(investigation) for NHS England; Andrew Carson-Stevens is clinical lecturer in healthcare improvementat the Cochrane Institute of Primary Care and Public Health; Sanjiv Ahluwalia is deputy head of GPSchool for London Deanery; Siân Rees is director of University of Oxford Health Experiences Institute;Martin Marshall is professor of healthcare improvement at UCL; and Charles Vincent is professor ofpsychology for the University of OxfordShare thisPrint

Don't Let Primary Care Patients Slip through the Nets

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Don't Let Primary Care Patients Slip through the Nets

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