1. Improving Safety Culture and Safety
Practice
In Primary Care

2. Scottish Patient Safety Programme
Acute Focus

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

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:
1. 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 fortnight
All or nothing measure

31. Warfarin Bundle Compliance
Overall Warfarin Bundle Compliance (Wave 1)
100%
80%
60%
40%
20%
0%
28th 14th 28th 11th 25th 9th 23rd 6th 20th 4th 18th 1st 15th 29th 12th 26th 10th 24th 7th 21st 5th 19th 2nd
Feb Mar Mar Apr April May May June June July July Aug Aug Aug Sept Sept Oct Oct Nov Nov Dec Dec Jan

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
Tests per Patient
2.5
2
1.5
1
0.5
0
May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11

40. The Trigger Tool and GP
Detecting Harm in Primary Care
Where is all this harm?
What are we going to do about it?
Dr Gordon Cameron
GP / 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
Interruptio
Email ns
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 Tool
Where is all this harm?

48. Trigger Tool Data Proforma
General information Classification of severity Number of consultations
Date of review E Temporary harm to the patient - required Telephone
intervention
Time to review F Temporary harm to the patient - required GP - surgery
record minutes hospitalization
CHI no G Permanent patient harm GP - home visit
H Required intervention to sustain life Practice nurse
I Death of patient Other
Is Trigger Did harm occur? Harm origin? Preventable?
Triggers Severity?
present? Prev* ?=unsure ?=unsure
≥3 consultations in 7 Yes Yes
Yes No No Prim ? Sec Yes ? No
days new prev
New ‘high’ priority read Yes Yes
Yes No No Prim ? Sec Yes ? No
code added new prev
New allergy read code Yes Yes
Yes No No Prim ? Sec Yes ? No
added new prev
‘Repeat’ medication Yes Yes
Yes No No Prim ? Sec Yes ? No
item discontinued new prev
OOH / A&E attendance Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
Hospital admission Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
INR >5, < 1.8 Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
Hb < 10 Yes Yes
Yes No No Prim ? Sec Yes ? No
New prev
eGFR reduction ≤5 Yes Yes
Yes No No Prim ? Sec Yes ? No
New prev
*Prev=tick this box if the harm incident has been recorded before.
Brief description of harm event(s) Incidental findings
1.
2.
3.
© 2010 NHS Education for Scotland Measuring harm in primary care http://www.nes.scot.nhs.uk/initiatives/patient-safety

53. Trigger Tool Data Proforma
General information Classification of severity Number of consultations
Date of review E Temporary harm to the patient - required Telephone
intervention
Time to review F Temporary harm to the patient - required GP - surgery
record minutes hospitalization
CHI no G Permanent patient harm GP - home visit
H Required intervention to sustain life Practice nurse
I Death of patient Other
Is Trigger Did harm occur? Harm origin? Preventable?
Triggers Severity?
present? Prev* ?=unsure ?=unsure
≥3 consultations in 7 Yes Yes
Yes No No Prim ? Sec Yes ? No
days new prev
New ‘high’ priority read Yes Yes
Yes No No Prim ? Sec Yes ? No
code added new prev
New allergy read code Yes Yes
Yes No No Prim ? Sec Yes ? No
added new prev
‘Repeat’ medication Yes Yes
Yes No No Prim ? Sec Yes ? No
item discontinued new prev
OOH / A&E attendance Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
Hospital admission Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
INR >5, < 1.8 Yes Yes
Yes No No Prim ? Sec Yes ? No
new prev
Hb < 10 Yes Yes
Yes No No Prim ? Sec Yes ? No
New prev
eGFR reduction ≤5 Yes Yes
Yes No No Prim ? Sec Yes ? No
New prev
*Prev=tick this box if the harm incident has been recorded before.
Brief description of harm event(s) Incidental findings
1.
2.
3.
© 2010 NHS Education for Scotland Measuring harm in primary care http://www.nes.scot.nhs.uk/initiatives/patient-safety

55. Experience so far…
Generally received positively
• “It has been overall very positive, it
has been a fantastic tool”

56. “Seemed a bit intimidating when we first had it
presented to a large group … much easier to use in
practice … it’s a remarkably effective tool for
reflective analysis on patient safety and other clinical
issues …has created a lot of interest from other
doctors in the practice as a tool for professional
development and for appraisals”

57. Experience
• Quick – about 90mins to review 20 sets of notes
• Finding harm not previously indentified – and that
would not have been otherwise identified
• Focus for Improvement
• Cultural change
• Need training and support
• Not for measurement

58. Frequent Themes
• Missing Read codes
• Huge variation in what doctors thought the
“allergy” or “adverse reaction” codes were
for
• Often the most valuable safety lessons
were in patients who had no triggers found
in their notes
• It’s led to big changes in my practice

59. Trigger Tool or SEA
• SEA • Trigger tool
– Can only be used in – Can pick up near miss
cases where harm has cases where no harm
already occurred actually occurred
– Needs a lot of writing – No formal writing up
up needed
– Very reliant on the – Less threatening
clinician feeling able – A more powerful tool
to share for changing individual
– Can be threatening ways of working

60. That’s the good news
• We know harm exists
• We know what it looks like
• We know how to find it
• We’ve got a strategy to deal with it

61. But now for the bad news …

62. Culture Eats Strategy For
Breakfast
Safety Culture
Safety Climate

63. Safety Climate Survey
• On line
• Practice report
• Measurement
• Diagnosis
• Catalyst for
change

66. Safety Climate Results
• My own practice
• Two years of
results

67.  Workload
 Average this year 4.5 Last year 5.0
Other practices average = 4.7
 Leadership
 Average this year 5.8 Last year 5.8
Other practices average = 5.8
 Teamwork
 Average this year 5.5 Last year 5.6
Other practices average = 5.4
 Safety Systems and Learning
 Average this year 5.2 Last year 5.5
Other practices average = 5.6

68. Communication Category:
Our average 2010 = 4.4 out of a possible
7.0
Our average 2011 = 4.2 out of a possible
7.0
Average for all other practices 2011 = 4.8

69.  Doctors and managers
 Scored the communication category questions
at
5.7

70.  Doctors and managers
 Scored the communication category questions
at
5.7
 Non managers
 Scored the communication category questions
at
3.5

71.  Team members feel free to question the decisions of those with
more authority
Our score 0.6 less than the average
 Team members are comfortable expressing concerns to
leadership about how things
are done
Our score 0.7 less than the average
 There is open communication between team members across all
areas in the practice
Our score 0.5 less than the average
 Team members are kept up to date about practice developments
Our score 0.4 less than the average
 The practice leadership communicates its vision for practice
development
Our score 0.2 less than the average

72. Progress in Aviation

77. Team Resource Training
 Team members feel free to question the decisions of those with more authority
Assertiveness
 Team members are comfortable expressing concerns to leadership about how things
are done
Assertiveness
 There is open communication between team members across all areas in the practice
Communication
 Team members are kept up to date about practice developments
Awareness
 The practice leadership communicates its vision for practice development
Leadership

80. Development and Testing
Safety Improvement in Primary Care 1

81. Overall Challenges
• Understanding
• Time Pressures
• Competing priorities
• Staff and IT changes
• Team Involvement
• Resources and remuneration
• Practice environment - culture

82. Overall Successes
• Increased Knowledge and skills
• Improved Patient Care
• Safer Systems
• Improved Team-working
• Real Patient Involvement
• Less stress
• Greater Efficiency and confidence

83. Overall
• 82% say the programme has benefited
their practice
• 75% say the Programme has improved the
safety culture of their practice
• 81% say they plan to continue using SIPC
tools/procedures

84. Safety Improvement in
Primary Care 2

85. “Look at areas of major clinical risk to patients as they
move across the health system.”
• Medication Reconciliation
• Results handling
• Communication after outpatients

86. Experience so far…
• Literature review
• Process mapping
• Areas of risk
• (un)Reliable processes
• Measures
• Improvement in practices and interface

87. What Next?

89. Current Activity
Spread
SIPC
• Greater Glasgow &C
• Lothian- LES
• Dumfries and
• Forth Valley- LES Galloway - LES
• Tayside • Ayrshire and Arran
• Grampian • Lanarkshire - LES
• Borders • GP training
• Highland • Appraisal
• Pharmacy – Climate
Survey

90. Innovation Adoption Curve
.

91. “Design and implement a Patient
Safety Programme in Primary
Care”
Start with GP Practices, Community Nurses
and Pharmacy

92. Patient Safety in Primary Care
Programme - 3 Workstreams
• Safer Medicines
• Safe and reliable patient care across the interface and at
home
• Safety Culture and Leadership

93. Safer medicines
• Safe and reliable prescribing, monitoring and
administration of high alert medications
e.g.DMARDs Warfarin Insulin Lithium
• Reducing high risk prescribing – data/alerts
• Reliable Medication Reconciliation

94. Safe and Reliable Patient Care across the
Interface and at home
Reliable:
• Medication Reconciliation
• Management of test results
• Communication at point of referral
• Handling written communication

95. Identify risk and reduce harm for vulnerable frail
adults in the home care setting
Reducing harm from:
• Falls
• Pressure ulcers
• Catheter associated UTIs

96. 3. Safety Culture and leadership
Ensuring:
A culture of safety and learning
e.g. Trigger tools, climate surveys safety walk rounds
Organisational learning from SEAs
Capacity and capability to support the programme
Patients become partners in making care safer

97. Patient Safety in Primary Care
Programme - 3 Workstreams
• Not all at once
• Menu
• Build over time
• Boards and practices prioritise

98. Implementation Plan
• Communication
• Engagement
• Capacity Building
• Measurement
• Method ??
• Central support
• Linkage – Prescribing - RTC
• System changes – IT – Pharmacy
• Reporting and Evaluation

99. Successful implementation needs..
• To Build on the professionalism of front line staff
• Prioritised within existing and adapted GMS contract
• Alignment with GP Appraisal and Revalidation
• Commitment of boards

100. Boards need…
• Executive buy in and championing
• To Prioritise this programme
• Dedicated clinical leadership, QI and pharmacy support
• Build knowledge and skills
• PLT

101. In Return …
• Fewer adverse events
• Fewer Admissions
• Fewer Falls/ UTIs/Pressure ulcers
• Improved Interface working – SPSP
• Engage with Primary care

102. How can we make sure the Boards are
facing the right way …?

103. How might the current GP Contract support
patient safety?
Patient safety is a core responsibility of all staff
BUT
Ensure key high risk processes are done safe and reliably
Highlight these within the GMS contract.

104. GP Appraisal and Revalidation
• The Trigger Tool (structured case review)
• Safety Climate Survey
• Care bundles
• Reliability Data - test results and medication
reconciliation
• High risk prescribing

105. Why Bother?
• “Houston we have a problem”
• By Improving safety we will have :
• Safer care
• Confidence in systems – less waste
• Fewer things going wrong
• Less stress
• Improved interface working
• Greater Capacity

107. Get training……!