1. Developing a Patient Safety Programme for Primary Care

2. 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.

3. 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”

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

5. Key Areas
Communication
Interface
Tests
Medicines management

6. 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

7. 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

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

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

10. 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.

11. 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.

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

13. 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

14. 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

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

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

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

18. “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”

19. 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

20. 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.

21. 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

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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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?

31. 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

32. Developed and tested in Scotland …..

33. 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”

34. DMARDS Composite
Key
____ Practice Data
____ Board Data

35. Tayside

36. Lothian

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

38. 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.

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

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

41. 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

42. 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