1. 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

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

3. 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.

4. Your Aims For The Day

5. 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

6. 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

7. World First

8. Why Bother
High Volume Increasingly complex Multi morbidity

10. 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

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

12. 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

13. 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

14. 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

15. 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

18. 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

19. A Story from the front line…..

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

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

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

24. 6048 prescriptions 5% Prescriptions have an error 1 in 550 serious
9 out of 11 from Warfarin
Processing errors not knowledge

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

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

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

28. 28

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

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

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

32. A patient on Warfarin…….

33. Medication Reconciliation

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

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

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

37. 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

38. Scottish Patient Safety Programme Acute Focus

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

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

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

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

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

50. 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

52. Questions/ Comments