Developing a Patient Safety Programme for Primary Care

Aims To Focus on Safer Medicine To review research To scope out what’s happening/ is planned To consider what might go into the PSPC programme To consider measures, levers and timescales.

Harm in Primary Care Context Little research - variable findings - quality 2% adverse event rate Majority do not impact significantly on the patient More with elderly and medication 300 million consultations in UK pa “Absolute number of those harmed may be just as large or greater than secondary care”

Source of harm Human factors – teamwork/communication Structural processes and environment Clinical factors medication Clinical complexity Polypharmacy, Conditions, Frailty

Key Areas Communication Interface Tests Medicines management

System issues Communication Inadequate systems for learning Lack of coordination Excessive task demand and fragmentation of work Test ordering reporting acting on telling patients Climate - lack of focus on quality Better outcomes if better systems to address and identify harm Defiicits at interface delayed or inadequate discharge summaries

Medication Interface prescribing Adherence by patients 21% pts receive optimum benefit Errors – Hypo-glycaemics, Cardiovascular Anticoagulants, Diuretics / NSAIDs Care Homes Lack of teamwork with pharmacy Co - Prescribing High Risk medicines Drugs that look sound alike

Patient Safety in Primary Care Programme (PSPC) 4 Workstreams: Safety Culture and Leadership Safer Medicines Improving Safety across the Interface Healthcare Acquired Infection

Safer Medicines Prescribing and monitoring of high risk medications Warfarin / DMARDS Insulin/Lithium? Avoiding harmful co-prescribing Medication Reconciliation

Safe and Reliable Patient Care across the Interface focussing on: Medication Reconciliation at discharge from hospital Improving shared care of patients attending outpatient clinic Safe management of test results Chronic diseases/leg ulcers/falls Developing reliable systems for Medication Reconciliation in the community when a patient has been discharge from hospital Improving shared care of patients attending outpatient clinic by reliably implementing recommendations made after clinic attendance The reliable and safe management of test results Implementing care bundles to ensure reliable care for patients with Long Term Conditions such as Congestive Heart Failure (CHF), and leg ulcers, falls and catheter care Managing Patient expectations by Involving and informing patients of the processes and their roles within them.

Reduce healthcare acquired infections: Improve anti microbial prescribing Promote hand hygiene Catheter care Reduce healthcare acquired infections in the community, for example develop/align with existing community based interventions to improve anti microbial prescribing and promote hand hygiene.

Developing Practice Teams Safety Culture Patient Involvement Identify and reduce harm via Structured case review (Trigger Tools) Safety Climate Surveys Learning from SEAs

Patient Safety in Primary Care Programme (PSPC) Process: Consultation on themes Scoping Develop aims/measures/tools Implementation strategy Phased roll out by 2013 3 Month consultation on themes April, May, June 2011 Scoping currently underway – looking at current activities in PSPC in Scotland and beyond and scanning literature identifying current harm, etc. Established subject matter expert groups and developing aims, measures and tools Develop implementation strategy aligned to contractual levers for roll out by 2013

Patient Safety in Primary Care Programme (PSPC) Who and When? October 2011 to April 2012 Focus on activities that involve General Practitioners, District Nurses, Health Visitors and Community Pharmacy From Summer 2012 Expand to include Dentistry and Optometry

Improving safety 83 studies mainly USA Little evidence Awareness raising Campaigns Incident reporting Audit and feedback Safety culture surveys

Staffing Changing roles Involving pharmacists Nurses Patients Electronic records and prescribing Hospital discharge planning Training in teamwork and communication

Most Promising Clinical Complexity computerised prescribing and alerts Human factors – pharmacists integrating pharmacists roles Systems issues- collaboratives, audit and feedback and discharge planning

“Little effect on outcomes” Interventions Alerts -reduced errors 23 out of 27 studies Improved px behaviour and reduced error rates – mostly hospital But Overriding - 40 % of docs always – clinical value of alert crucial Incident reporting good at identifying areas but not improving Education and support improve knowledge but outcomes? Feedback on performance quarterly ? Impact Identify issues - RCA FMEA culture survey – identify areas/ transition “Little effect on outcomes”

Human factors Pharmacist key to detecting errors and potential harm Pharmacy calling GP practices reduced errors Quality circles with GPs and pharmacists 42 reduction in cost more generic Patient engagement – leaflets little effect Safety bulletins to practices Education – improved attitude to safety Interface education of acute staff improved quality of dx letter

Aims To Focus on Safer Medicine To review research To scope out what’s happening/ is planned To consider what might go into the PSPC programme To consider measures, levers and timescales.

Topic Intervention Testing Timeframe for roll out Who Lever Aim / Outcome Warfarin Bundle SIPC1 March 2012 GP teams CP Local Enhanced Service Admission INR <1.5 >5 DMARDs Methotrexate and Azathioprine Local Enhanced Service/ Community Pharmacy Contract 95% compliance with bundle No co prescribing strengths a or daily px MTX Insulin NHS GGC TBC DN’s Nurse Directors Co-prescribing DQIP and Effips NHS Tayside GPs and CP Local Enhanced Service/Community Pharmacy Contract 60% reduction in dangerous co-prescribing in specific combinations Medication Reconciliation Testing Bundle SIPC2 March 2013 GP CP Acute QOFQIP Org Indicator HEAT Target Readmission rates Error rates in med list Lithium and Methotrexate Checklist tool ? Comm. Pharms Jan 2012 Check patient's concordance, adverse reactions, interactions and monitoring for these drugs

Today Community Pharmacy contract DMARDs Warfarin Co – prescribing Medication Reconciliation Lithium? Others alerts - Closer working etc

Safer Medicines Current Contract Recording of drug allergies and adverse reactions in the notes An indication for the drug can be identified in the records Minimum Standard 80% A system to identify and follow up patients who do not attend for injectable neuroleptic medication A system for checking the expiry dates of emergency drugs on at least an annual basis A medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines.

Current Contract Maintain a register Reliable call and recall system, Provide education Management plan diagnosis, target INR,duration Adequate record keeping Use recognised guidance Review patients annually Notify Board of any admission

An Early Opportunity Adapt the current enhanced services Prescribing and monitoring of high-risk medications for the contractual year 2012/13. More reliable and safe systems Cost Effectiveness

Improvements - Be specific? Patients on Warfarin should have in their notes clearly highlighted: Patients Contact phone number Diagnosis Planned duration of treatment (and whether any patients are being treated beyond planned duration, including an SEA if so) Target INR Patients Warfarin dosing and advice on the interval for blood testing given to patient follows current local guidance The patients INR should be maintained within 0.5 of target INR. Practices should clearly inform patients of the advised dose and date of follow up blood and record it in the patients notes The INR is taken within 7 days of planned repeat INR The practice provides the patient with written education about their warfarin and records it in the notes

Specifics - Methotrexate Prescribe patients on methotrexate only 2.5mg tablets or 10mg Prescribing Methotrexate to be taken weekly Should not be on the repeat prescription system Detail on each prescription the number of tablets to be taken and the dosage i.e. 4 tablets weekly (10mg ) Practices should have systems for reviewing the blood results prior to issuing a prescription Patients on these drugs should have in their notes clearly highlighted Patients Contact phone number/Diagnosis/Duration Patients interval for blood testing follows current local guidance The blood test is taken within 7 days of planned repeat bloods Practices should clearly inform patients of the advised dose and date of follow up blood and record it in the patient’s notes The practice provides the patient with written education and records it in the notes Patients should be offered pneumococcal and annual flu vaccines

Care Bundles 4 or 5 elements of care Evidence based Across Patients Journey Creates teamwork Done reliably All or nothing Small frequent samples – 5 per fortnight

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?

Warfarin 5 patients per fortnight The last advice re warfarin dosing followed current local guidance? The interval for blood testing followed current Guidance Has 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 3 months? Bundle Have all measures been met for each patient

Developed and tested in Scotland …..

SIPC work Seeing Improvement “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”

DMARDS Composite Key ____ Practice Data ____ Board Data

Tayside

Lothian

METHOTREXATE 2.5MG TABLET PRESCRIPTIONS AS A % OF ALL METHOTREXATE TABLET PRESCRIPTIONS BY HEALTH BOARD (MAY ’06 TO MAY ’11) NHS GGC

Board Data Boards data: % INR’s <1.5 or >5 or > 8 per practice % patients not receiving monitoring % methotrexate 2.5mgs % not monitored Feed this back to practices.

Measurement Initial measures – systems Regular measures Quarterly – 25% sample? Bundles? One topic regular measurement What’s possible / negotiable

Looking Forward Engage Creating will Educate PLT x 2 Boards Engage clinical leads and QI experts ehealth IT systems ESCRO SCIMP Alerts

Key Issues/Next Steps Alignment eHealth Productivity and Efficiency Polypharmacy IT systems Alerts, EMIS sharing searches ECS – planned care, educate PC on use Data Pharm. access to results, ECS and prescribing history Aggregated board /practice data

Key Issues/Next Steps Prioritisation Proportionality Suite of interventions Measurement What How Using it Communication and relationship building Patient engagement Resources, patient information leaflet Sharing and professional trust