General practice – risky business? Reducing Risk – Improving patient safety and quality of patient care Good afternoon – thank you for inviting me here this afternoon. I hope you enjoy the session. My name is …. And I am a GP executive account manager with the Medical Protection Society. I am your MPS contact so if you have any queries re your membership package I will be only to happy to assist. Now before I start this talk can I just get to know all of you. If not too many ask who each one is and what they do at the practice. E D U C A T I O N Y O U C A N P U T I N T O P R A C T I C E Copyright 2008 All Rights Reserved

Aim To help reduce the risk of harm to patients, staff and visitors by improving safety and the quality of care in practice And so to the session talk. I am going to do a short presentation highlighting the common risks in general practice from our experience. Our overall aim is to keep patients safe and reduce harm to not only patients but also staff within the practice

“The possibility of incurring misfortune or loss” Risk “The possibility of incurring misfortune or loss” So lets start of with looking at RISK. What does risk mean to you? Risk is defined as “the chance of something happening that will have an impact on objectives. “ Risk may have a positive or negative impact Quote from AS/NZS 4360:2004 Risk Management Standard Simply put: A risk is the chance that something (usually bad) will happen to you because of something else, e.g. if you smoke a pack of cigarettes a day you have a 1 in 10 chance of dying from lung cancer. Banks are on the radio and TV all the time relating to the Risk

You can minimise your risks by improving your systems Living with risks Risk is part of everyday life At home When travelling With patients So risk management is simple and we all do it. We have talked about risk management when travelling, in our homes and perhaps now you can start to think about what risk management you do already in the practice.. But remember we can’t always get rid of risk , we can take steps to reduce the risk and sometimes we can’t do anything about the risk - we just have to live with it. You can minimise your risks by improving your systems

In hospitals… Study in England estimates that around 10% (900,000) patients admitted to NHS hospitals have experienced an adverse event (patient safety incident) 50% could have been prevented 33% led to moderate or greater disability or death. Vincent C et al BMJ 322:517-19 Seven steps to patient safety NPSA 2003 So lets look at some facts is health care risky? some facts,! In hospital: Are there risks? Audience may say MRSA C Difficil etc The facts: On the best available data in England Vincent C undertook a small study in 2 acute trusts based in London. He found that 10% of patients admitted to NHS hospitals have experience an adverse event, now called a patient safety incident and that up to half of these could have been prevented with ordinary standards of care. A third of adverse events led to moderate or greater disability or death. These results suggest that adverse events are a serious source of harm to patients and a large drain on NHS resources. Some are major events but others are frequent minor events that go unnoticed in routine clinical care but together have massive economic consequences. Vincent C, Neale G, Woloshynowych M: Adverse events in British hospitals: preliminary retrospective record review BMJ 2001;322:517-519 ( 3 March ) Presenter info: A patient safety incident is defined by the NPSA as any unintended incident that could have or did lead to harm for one or more patients receiving NHS funded healthcare. The terms PSI and patient safety incident (preventable) will be used to describe adverse events clinical errors and near misses respectively.

In general practice… Average GP will provide about 200,000 consultations during their career 25% of adverse events occur in primary care And, it is estimated that 1% of GP consultations (one a week) are associated with a significant adverse outcome Making amends DH 2003

Incident reports to the National Patient Safety Agency 2600 reports from October 2006 to September 2007 from general practice: 29% Medication errors 14% Documentation 11% Access/admission/transfer/discharge 10% Consent/communication/ confidentiality 0.33% of all reports received NPSA National Reporting and Learning Data Summary Issue 7 December 2007 Before showing info ask if anyone heard of NPSA – some staff may not have therefore explain . The National Patient safety Agency in UK is a Special Health Authority created in July 2001 to co-ordinate the efforts of the entire country to report, and more importantly to learn from, mistakes and problems that affect patient safety. As well as making sure errors are reported in the first place, the NPSA is trying to promote an open and fair culture in the NHS, encouraging all healthcare staff to report incidents without undue fear of personal reprimand. It will then collect reports from throughout the country and initiate preventative measures, so that the whole country can learn from each case, and patient safety throughout the NHS can be improved. So what errors are reported re general practice in the England and Wales (NB does not include N Ireland and Scotland (don’t yet report to NPSA) http://www.npsa.nhs.uk/patientsafety/patient-safety-incident-data/quarterly-data-reports/ A Report from NPSA from October 2006 – Sept 2007 Of the 2600 reports received, the results are as follows: Oh these incidents no harm was reported in 76% of incidents, 21incidents a death had occurred (0.8%) However the 2600 represents only 0.33% of the incidents reported to NPSA – could this be because there aren’t many incidents that occur in GP or is it that GP are underreporting??? Leave that one with you. Either GP do not have many incidents or staff don’t report!! 73% from acute hospitals.

MPS Risk Consulting Experience of clinical risk assessments: 400 CRSAs completed Many practices – above average, excellent systems in place All practices had a number of areas where further action would improve level of service What follows is based on the CRSAs that the MPS has undertaken and to date they have undertaken over 400 of these risk assessments. MPS Risk Consulting (MPSrc) , a department within MPS, undertakes clinical risk assessments across the UK general practices. To date they have undertake 400 CRSAs In the last few years we have undertaken over 400 risk assessments . In general We found that there were exemplars of good clinical and administrative practice within the practices visited. However all practices had some risk areas that needed addressing

Top key risks in UK general practice 95% Confidentiality 92% Prescribing 90% Health and safety 85%Communication 84% Record keeping 84% Test results By analysing the findings of practice risk assessments (CRSAs) it has undertaken in the UK between September 2004 – July 2006, MPSrc has named potential breaches of patient confidentiality as the top risk, with 95 per cent identifying issues in this area, in a recent report. I will share with you some of the risks that we have identified in these categories. Risks associated with General Practice. 95% of the practices we visited had risks associated with confidentiality. MPS Risk Consulting August 2006

Excellence Examples of good practice The dedication and commitment of all the staff The organisation of the practice administration team The impressive ‘learning from events’ system The test results process The clinical and administrative audits undertaken But first example of good systems that we have seen: The organisation of the practice administration team by the practice manager; in particular the organisation of staffs’ roles and responsibilities the staff appraisal system staff training

Confidentiality Common issues: Breaches of confidentiality in waiting rooms and reception areas Staff contracts do not include a clause covering confidentiality post-employment Not all patient-identifiable information is shredded Patient medical records are not securely stored Computers may be left on and unattended 95% of practices had risks associated with maintaining confidentiality Information about patients that is learnt during the course of professional duties should be treated as confidential. The GMC is clear that ‘information must not be given to others unless the patient consents or you can justify the disclosure’. It is important that members of staff, including the cleaners, are trained in confidentiality issues and that the message is regularly reinforced. Go through the risks: At the front desk- many practices now have open plan desks and it is very difficult to maintain patient confidentiality. One practice we visited had turned all the chairs around to face away from the reception desk and put a television up on the wall to act as a distraction. Most practices had got staff to sign a confidentiality statement but these statements did not always contain a clause relating to post employment. Many of the staff live in the area they work so very important to reinforce the need to keep this information confidential. We find that most practice use a shredder in the office but found that some information in the consulting rooms was discarded with household rubbish. Perhaps consider providing mini shredders in the consulting room of provide a box for shredding. Record stored on shelves not locked away.

Breach of confidentiality Can lead to: Breakdown of practitioner/patient relationship Lack of trust/confidence in other healthcare professionals Failure to seek further treatment Disciplinary action by GMC and employers

Prescribing Common issues: No repeat prescribing protocol No designated receptionist to record or generate repeat prescriptions Reception staff are allowed to add medication to the computer Medication reviews are undertaken on an ad hoc basis. No system for recalling patients on long-term medication Uncollected prescriptions are destroyed 92% of practices had risks associated with prescribing. Common issues: Some practices we visited had no repeat prescribing protocol And some that did have them had them hidden away in an office. No designated receptionist to record or generate repeat prescriptions – these are generated in the reception on an ad hoc basis, i.e. when time permits throughout the day. Ideally train more than one member of staff to handle this rolel Reception staff are allowed to add medication to the computer – acute and repeat medications. Medication reviews are undertaken on an adhoc basis. No review dates are set on the computer. There is no system for recalling patients on long-term medication, e.g. lithium, thyroxin or anti-convulsants. Uncollected prescriptions are destroyed. It is not known what happens to prescriptions not collected from the pharmacy. Congunctivitus cream and cuplex cream story

Health and Safety Common issues No health and safety assessment undertaken No personnel protective clothing provided Storage of waste and sharps No panic alarms Unsafe furniture/fixtures Although the risk assessment process is not designed to be a thorough assessment of health and safety issues (we’re not experts in that field) concerns were discussed during the risk assessments. 90% of practices did not fully comply with all Health and Safety legislation (Health and Safety at Work etc. Act 1974) and were advised of these issues in their reports. The table below details gives examples of the issues identified. As the practices did not comply with all Health and Safety legislation, immediate attention was required. Some practices had panic alarms but did not have a plan as to what to do if the alarm was activated!!!

Record keeping Common issues: Illegible writing in the records Letters scanned into wrong record Telephone advice not always recorded Medical records go missing Home visits not always recorded on the computer 84% of practices had risks associated with record keeping within their practices. Common issues: Illegible writing in the records Letters scanned onto computer occasionally saved into wrong record Telephone advice not always recorded Medical records go missing Home visit consultations not always recorded on the computer

Test results Common issues: No tracker system to ensure that patients are followed up No system of knowing when all a patient’s test results have been returned Test results not recorded onto the computer Non-clinical staff allowed to inform patients of their result and treatment required 84% of practices had risks associated with test results within their practices. Common issues: No tracker system to ensure that patients are followed up No system of knowing when all a patient’s test results have been returned Test results not recorded the onto the computer Non-clinical staff allowed to inform patients of their result & treatment required. Chest xray story from Richard Stacey. Also said that some practices given their patients a little card and instruct them to call back in a week etc

Infection control Common issues: No infection control policy Specimen handling Hand washing issues 71% of practices had issues relating to infection control Specimen handling here in the picture the receptionist is taking a sample of urine form a patient without any gloves on, she will then touch computer keyboard, telephone etc. And of course patients sometimes bring specimens in inappropriate containers e.g. lucozade bottles!!! Don’t let your receptionist take your urine sample like that. An idea is to put a box on the side and let the patients put their sample in it.

Hand washing For effective hand washing consider the following : Liquid hand dispenser Paper towels Elbow/foot operated mixer taps Alcohol based hand rub No sink plug Remove jewellery Designated hand wash basin What’s wrong in this patient toilet? Show words this is what the toilet should have

What is clinical risk management? Common sense Identification, measurement and control of risk to avoid harm to patients and staff Involves everyone Relates to the whole package of care Equates to good practice So what is clinical risk management Everyone at the practice should be involved not just the GPs It is paramount to patient safety that the practice assess their risks and implement strategies for dealing with those risks. By having a risk assessment this could help you to get started. I have a flyer if you are interested.

About MPS The leading provider of comprehensive professional indemnity and expert advice 250,000 members worldwide Not an insurance company Thanks for that A little about MPS …..

What does MPS offer to GPs Comprehensive indemnity The best professional protection First rate service Over 21,000 GP members The GP Practice Package Education and Risk Management

MPS publications Casebook Your Practice GP Registrar Fact sheets Medicolegal booklets ‘Clinical Risk Management in Primary Care’

The MPS website Update personal details or renew membership Courses and events Case reports Practice Packages Request publications Subscription rates Further details of all our publications etc can be obtained from our website. Thanks you for your attention. I hope you have enjoyed this overview of risks. Are there any questions. http://www.medicalprotection.org/uk

Contact me by email, telephone/fax Bev Hampshaw GP Account Executive Contact me by email, telephone/fax