Housekeeping The is no fire alarm test planned for today Toilets are located to the left of the main hall Presentation will be available from the Healthcare Improvement Scotland website E-pass accreditation – not available due to re-launch of the system Royal Pharmaceutical Society accreditation is available – details can be found at the registration desk In case of Fire Alarm: Leave your work task and switch off any hazardous appliances Evacuate the building using the nearest exit Close doors as you leave the building Assist guests you meet en route but do not put yourself at risk Follow the directional signs to the fire assembly point (located: Health club car park ) Report to your supervisor for the roll call Report any concerns, suspicious people or missing colleagues to your supervisor immediately Do not re enter the building until told to by the fire coordinator

Developing and Implementing a Patient Safety Programme in Primary Care Dr Neil Houston GP and Clinical Lead Healthcare Improvement Scotland

Aims of The Day Why is Safety in Primary Care Important? Raise Awareness of Scottish Patient Safety Programme in Primary Care (SPSP-PC) To provide more information about the work streams, approaches and tools Highlight the resources available Encourage you to start thinking about how you will implement the programme.

Your Aims For The Day

Today’s Agenda Welcome and Introductions Mike Winter, Chair of SPSP:PC Action Group, Medical Director, NSD Neil Houston, Clinical Lead, Patient Safety in Primary Care Introduction to Harm in Primary Care Learning from Development Work and Overview of Programme Tools Gordon Black, GP and Clinical Champion, NHS Lothian Learning from Development Work and Overview of Programme Tools including an update on current work within NHS Greater Glasgow and Clyde Simon Randfield, GP and Clinical Champion, NHS Forth Valley Paul Ryan, Clinical Director, NHS Greater Glasgow and Clyde Overview of the National Programme and Next Steps Jill Gillies, Programme Manager

Patient Safety Preventing patients being harmed by the care they receive If harm does occur identify and analyse it and learn from it to prevent it recurring

World First

Why Bother High Volume Increasingly complex Multi morbidity

Q What proportion of NHS Hospital patients is estimated to suffer some form of unintentional harm as a result of their care? A One in 3 B One in 10 B One in 10 C One in 7 D One in 18 £5,000

Q Of those patients harmed, which percentage is judged to be preventable? A 10% B 99% 50% 50% D Not known C £15,000

Q What percentage of NHS acute hospital admissions are thought to be related to sub-optimal primary health care? A 2.6% B 12% B 12% C 50% D Unknown £32,000

Q What percentage of NHS acute hospital admissions are thought to be related to adverse effects of medication ? A 2.6% B 15% C 6.5% C 6.5% D Unknown% £64,000

Q In UK General Medical Practice, what percentage of prescriptions is estimated to contain an error? A 5% A 5% B 0.6% C 1.9% D 25% £1,000,000

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

How Safe are we? Consultations 98% safe Adverse Event rate 1- 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

A Story from the front line…..

A Story from the front line….. Mrs J.U’s Flu Jag

At your tables now take 15 minutes to discuss: What is your experience of where things go wrong in Primary care?

Causes of harm Literature Drug adverse events Clinical error Systems Issues Medication errors Administration errors Results Systems Communication Delayed diagnosis

6048 prescriptions 5% Prescriptions have an error 1 in 550 serious 9 out of 11 from Warfarin Processing errors not knowledge

NHS Scotland 89 million prescriptions 2011 4,450,000 errors 161,800 prescriptions with serious errors

Why? Human Factors Time pressures Frequent distractions and interruptions Little training Team communication IT Issues Interface communication

Statistics- Comission In a care home - 50% chance of ADE High risk prescribing Insulin Administration errors common

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

(un)Reliable Heart Failure Care ACE inhibitor 88% Correct B Blocker 70% B blocker at target dose 45% Pneumococcal 71% NYHA status 71% All 5 - 23%

Reliable Care?? 38% of patients with Type 1 Diabetes receive 9 key interventions NICE 2008/9

A patient on Warfarin…….

Medication Reconciliation

Med Rec Unreliable at admission Inaccurate and delayed at discharge, Unreliable systems in place in primary care for updating Causes harm/ admissions

Impact Lack of med rec causes 20% of all adverse drug events( varkey 2007) 72% adverse events post discharge due to medication (Foster2004)

“WHO identified poor test follow up as a major cause of harm to patients resulting in serious lapses in patient care”

Evidence Practices do not track requests for tests, Lack protocols on how to inform patients of results. 400 Clinical Risk Self Assessments 84% of practices had risks associated with test results. Cause of delayed diagnosis complaints and claims

Scottish Patient Safety Programme Acute Focus

VAP rate – one SPSP pilot ward (per thousand ventilator days) 62% reduction 9.11 3.49

Central line infection rate – one SPSP pilot ward (per thousand line days) 92% reduction 2.34 0.18

At your tables, discuss: What do we currently do to make care safer in Primary Care ?

Not a new agenda……. Significant Event Analysis Complaints reviews IT systems Prescribing Systems Managing Results Culture

NHS Scotland Quality Strategy 2010 No avoidable harm Evidence based consistent care

NHS Scotland Quality Strategy “Design and implement a Patient Safety Programme in Primary Care” Roll out March 2013 Similar programmes for Paediatrics and Mental Health 50

Questions/ Comments