Enhanced Significant Event Analysis in General Practice S E A Adam Hay Thursday 2nd October 2014

Why do an Enhanced SEA? Necessary part of GPST training SEA has developed from high risk organisation We make mistakes every day – why not learn from them? 9 out of 10 medical consultation are based in primary care 1-2% of these are estimated to have some level of error occurring Submitting and SEA during GPST training is a requirement in the West of Scotland Deanery Medicine is a high risk profession like aviation and petro-chemical/nuclear industry and we can learn from systems and research that they heavily invest in Turn making mistakes into a positive event. Most mistake are small but we will all encounter the potential and actual consequences of a large scale mistake/significant event

Why change to the Enhanced SEA? SEA submitted during GPST training should now be in the format of Enhanced SEA which I will go on to describe

Why change to the Enhanced SEA? Criticisms of the old SEA Lead to a superficial description of the process No active action often taken SEA were often discussed informally SEA choice often “selective” Enhanced SEA aims to avoid all this and Encourage professional learning Improve patient care Discourage blame culture Lead to a simple description of an event with little learning gained No active action often taken – group agrees “not to do it again” or “to watch out for it happening again” Informal discussion are unlikely to involved the whole practice team and therefore limit whole practice learning If planning to discuss an SEA the primary person may have chosen one which did not paint them in too bad a light – you would not want everyone to think you were an idiot especially when quite junior Encourage professional learning from an event Improve patient quality of care through individual and system changes The process of SEA is design to look at the evidence and allow analysis to avoid simply blaming an individual

Blame Culture & Traditional SEA A feeling of blame post-SEA could occur due to: Hindsight bias The illusion of free will Fundamental attribution bias Just world hypothesis Hindsight bias – the ability to look back post event and say “I knew that would happen” or “how could they not have imagined that happening” The illusion of free will – as we are felt to determine our own futures this includes both good and bad events and therefore the bad events are our own doing Fundamental attribution bias – linking negative traits of a persons character to negative events happening to them e.g. “he is often rude to other members of staff that’s why this happened to him” Just world hypothesis – bad things happen to people when they deserve them

Benefits of doing Enhanced SEA Enhanced SEA during GPST training is intended to aid Understanding reasons for error occurring Improve the safety culture Enhance teamwork and communication Improve the healthcare system Attempt to aid predicting what might go wrong in the future Understanding reasons for error occurring through in-depth analysis of an event and reflection Improve the safety culture of your place of work Enhance teamwork and improve communication by bring people together to discuss events Improve the healthcare system which may involve improvements equipment as well as processes Attempting to aid to predicting what might go wrong in the future to allow pre-emptive steps to avoid this

How to choose a significant event

How to choose a significant event What makes an event significant? “Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice” Pringle et al 1995 What type of events are often seen? Near miss Adverse event Error A “near miss” – e.g. printing a prescription for Amoxicillin for a patient with a Penicillin allergy but not giving it to the patient An “adverse event” – e.g. the patient actually receiving Amoxicillin and taking the medication with a subsequent reaction An “error” – e.g. recording a consultation in the wrong patient’s records when two patients have the same name

Types of Error Active error or passive error Can be: Slip Lapse Mistake Violation Active errors involve doing something which has a direct consequence to error. Passive errors are also known as system errors that can lead to the potential for error to occur. Errors types can also be seen in four categories Slips e.g. misreading the BNF resulting in prescribing the wrong dosage of a medication Lapses e.g. forgetting to do a routine hospital referral for a patient you saw last week Mistake e.g. mistakingly identifying a patient with dyspnoea as having LRTI instead of really a PE Violation e.g. choosing to deviate from a protocol such as the surgeries protocol for methadone prescribing

How to record your Enhanced SEA Useful to complete the short e-learning module from NES http://www.nes.scot.nhs.uk/media/2408590/enhanced_significant_event_analysis_module_-_updated.pdf Or search “Enhanced SEA” on NES website You are advised to use the template available from NES website http://www.nes.scot.nhs.uk/ Navigate: >Education and training >>By theme / initiative >>>Patient Safety and Clinical Skills >>>>Enhanced Significant Event Analysis >>>>>The Guide Tools & Report Format

How the form looks

Steps in the Enhanced SEA Report Section One Title page Describe what happened The impact or potential impact Title page to fill in your details and the name of the SEA. You can also choose to receive feedback as to whether or not your ESEA was satisfactory or not Describe what happened In chronological order the sequences of events, who was involved and where Keep in short and clear The impact or potential impact On patients/relatives, yourself, other members of staff Impact may be clinical, professional, organisational Explain the impact

Steps in the Enhanced SEA Report Section Two Human and System factors How these factors combined to make the event happen Did you identify these factors by yourself or with the help of others Human factors are dealt with on the next few slides as they are new concepts to many The interactions between the different Human and System Factors The last part helps to demonstrate teamwork and group reflection

Human Factors “concerns understanding interactions among humans and other elements of a system…” “also concerns applying theory, principles, data and methods..in order to optimise human well-being and overall system performance” (International Ergonomics Association) Enhanced SEA uses a process called human factors (sometimes also called ergonomics) with the following description

Types of Human Factors to consider People Factors E.g. patients, interactions between staff Directly and possibly indirectly involved Activity Factors E.g. task complexity, lack of protocol or guidance Environment Factors E.g. physical environment, practice culture, time/work load pressure, lighting, noise etc

Case Example for Human Factors A Receptionist asked the duty GP to sign a repeat prescription for Amitriptyline for a patient waiting at the desk. The GP noticed the dose of Amitriptyline appeared incorrect and checked the patient’s medical record. The GP discovered that Amisulpride, rather than Amitryptiline, should have been prescribed. She amended the prescription, explained the error to the patient, and apologised. Fortunately, the patient had not suffered any complications from the wrong drug (and dose) and had not suffered a psychotic exacerbation. Read out to group if people cannot see it properly

Possible Human and System Factors PEOPLE An administrative team member had entered the prescription incorrectly a few months before. Amitriptyline is prescribed often, and has several indications, including chronic pain and irritable bowel syndrome. Amisulpride is an antipsychotic drug and is very rarely prescribed. Assumed from experience and deciphering of written note that is must be Amitriptyline. Lacked sufficient clinical knowledge to realise a potential patient safety issue A GP had signed the initial, wrong prescription. Patient expectation of quick service. ACTIVTY The initial request for Amisulpride was a handwritten note and mostly illegible. GPs often sign batches of prescriptions, without always checking for accuracy. Flexible working to attempt satisfy patient need on the day. ENVIRONMENT Time and workload pressures Distractions and noisy environment Possible staff training on awareness of high risk medications Availability of handwritten prescriptions Safety system design issue with repeat prescribing signing by GPs

Steps in the Enhanced SEA Report Section Three What lessons have been learned? What learning needs have you identified? Once the Human & System factors are identified the reflect on learning: Again you may wish to relate these to the Human and Systems factors identified Learning needs can be individual, just the doctors in the surgery or the whole practice

Steps in the Enhanced SEA Report Section Four How have you minimised the chances of this event happening again? Who is responsible for ensuring this? Outline an action plan Who will be involved? Over what time period? Has it already happened? If not, why not? If no action plan is required explain why Who is responsible to prevent it and how this will be monitored and sustained May further demonstrate teamwork

Steps in the Enhanced SEA Report Step Five Submit your Enhanced SEA for peer review June.morrison@nes.scot.nhs.uk

Short Exercise on Human Factors Work in groups Consider What was the impact? Why did it happen? Consider in terms of Human Factors and System Factors i.e. People, Activity, Environment What could be learnt from it? What changes could be implemented? As the cases are fictional you may need to pretend it happened in your own practice to consider how to change the scenario Don’t have time to write up a full

Case Study 1 Mr X’s son made an appointment with Dr G to complain about the care of his father. Mr X’s father had attended Dr G seven days previously, feeling unwell, and Dr G had taken a blood test, and told the patient he would phone him with the result. Four days after seeing Dr G, Mr X had been admitted to hospital, where a blood test demonstrated severe anaemia. The hospital staff said that they could not find the original blood test taken by Dr G on the hospital computer. The son felt that action should have been taken sooner and the blood result acted upon. Unfortunately there was no record of the blood test having gone to the laboratory or the result having been received by the practice.

Case Study 2 Mr T arrives at the reception desk and begins to shout at the receptionist demanding to see the doctor because his prescription had been changed. Mr T had taken his usual prescription to the pharmacist who had dispensed a generic tablet instead of the usual branded tablet. When Mr T queried this, the pharmacist had told him that the practice had changed the tablets as they were ‘cheaper’. Mr T was irate and threw the tablets at the receptionist narrowly missing her.

End. Any questions?