1. Improving Patient Safety in general practice Edited version from a talk by Dr Robert Varnam

2. OVERVIEW What do we know? Why do we reliably fail? How to gain different perspectives? Significant event analysis Detecting & measuring adverse events What to improve?

3. Patient Safety in General Practice... what do we know?

4. What do we know?

5. size of the problem – 25% of >75s experience healthcare associated harm each year – 5% of admissions = preventable adverse drug events impact of safety incidents – 73% of adverse events in >75s required some intervention Series of 4400 patients with 1400 adverse events Approx 1m consultations per day in general practice

6. What do we know? Adverse events in general practice are wasteful → increased costs → reduced opportunities → reduced staff morale Improving safety requires good staff, good processes responsive, learning organisations generic measurement & improvement skills good access, high quality care

7. Patient safety culture ‘shared values, norms and attitudes, which combine to create the environment within which staff work’ good safety culture – a constant and active awareness of the potential for things to go wrong – open and fair, encourages people to speak up about mistakes – everyone takes up their responsibility for safety

8. Why do we reliably fail? What causes harm to patients? Where should we focus our improvement efforts?

9. Lessons from Human Factors Research Errors are common Errors are predictable The causes of errors are known Many errors are by-products of useful cognitive functions Many errors are caused by activities that rely on weak aspects of cognition – short-term memory – attention span

10. SRK Framework ConsciousAutomatic Control Mode Situation Routine Novel problem Skill-based behaviour Rule-based behaviour Knowledge-based behaviour

11. Human Error “Failure of planned actions to achieve their desired ends” (Reason 1990) PlanActionsOutcome Planning mistakes Execution errors

12. Necessary Violation Optimising Violation Routine Violation Knowledge-Based Mistakes Intended Action Errors / Unsafe Acts Human Error Taxonomy Unintended Action Slip Lapse Mistake Violation Attention Failures Memory Failures Rule-Based Mistakes

13. Skill-based slips & lapses Often due to inattention and distraction Double capture slips Omission following interruption Reduced intentionality Perceptual confusion Interference problems

14. Rule-Based Errors Application of a good rule to the wrong situation Situation not well specified Cognitive overload Situation is an exception to a robust rule

15. Knowledge-Based Mistakes Inadequate understanding of situation Bounded rationality Difficulty in creating complete and accurate mental representations of the problem space Heuristic strategies to cope with and reduce complexity may result in mistakes

16. Summary Human Error Type Typical FormsCommon Prevention Strategies Slip / Lapse Double capture Omission Interference Perceptual Confusion Minimise interruptions Forcing functions Colour-coding, highlighting differences Checklists, memory aids Rule-Based Mistake Strong-but-wrong Exception to rule Cognitive overload Minimise / highlight exceptions Provide feedback Manage workload Knowledge- Based Mistake Confirmation bias Out of sight, out of mind Encystment Vagabonding Decision support Team work & CRM training

17. Human error The search for and understanding of errors has not made patient care much safer Error is normal... what are you going to do about it?

18. Violations Professor Renee Amalberti Key Reference Amalberti, Vincent et al. Violations and migrations in healthcare: a framework for understanding and management. Quality and Safety in Healthcare 2006; 15; 66-71

19. Who always drives at 30mph?

20. PERFORMANCE ACCIDENT Systemic Migration to Boundaries VERY UNSAFE SPACE The speed limit is 30 mph- the ‘legal’ space Belief Systems Life Pressures INDIVIDUAL BENEFITS Driving 35 mph- the ‘Illegal- normal’ space Driving 50 mph – the ‘illegal- illegal’ space (for almost all of us!) Perceived vulnerability

21. Prescribing a PPI with NSAID What is your policy for prescribing a PPI with a NSAI for patients over 60 years old? Do you observe it every time? When do you (choose) to violate? How far is it safe to migrate?

22. PERFORMANCE ACCIDENT Systemic Migration to Boundaries VERY UNSAFE SPACE Every patient >60 on a NSAID gets a PPI Belief Systems Life Pressures INDIVIDUAL BENEFITS PPI for patients >60 when I remember or those with history of GI disease I’ve never had a patient harmed by NSAID so don’t use a PPI Perceived vulnerability

23. System production Commercial stress Coping and resiliency Individual advantages Performance must be understood in a broad context

24. Productivity Migrations/violations are often seen first as benefits with immediate payback – saving time – increasing productivity Tension between following protocol and productivity

25. Results of Migration Migrations lead to a large range of illegal practices Over time these become “normal” for the system - stabilized All stakeholders in the system migrate and violate – Migrations differ for individuals and roles – E.g. senior management or actors in the field

26. What not to do Don’t conclude “Policies must be stricter, clearer, and implemented” – Individuals make cost/benefit decisions on compliance. Too stringent implementation can lead to violation/migration. Don’t resort to exhortation “Work Harder/Better” – Don’t just send a memo about the old, written rule – Take a systems view

27. PERFORMANCE ACCIDENT Managing Migrations VERY UNSAFE SPACE Expected safe space of action as defined by professional standards Market Demand Life Pressures INDIVIDUAL BENEFITS ‘Illegal- Normal’ Always/ Sometimes ‘Illegal- Illegal’ Space Never/ Sometimes Technology Never/ Never Policy, Protocols, Regulation ‘Real Life’ BTCUs Always/ Always 1. Individual or collective experience of incidents, share stories Agree stop rule to migration 2. Acknowledge individual variation in risk acceptance. System response required 3. Forbidden space, except under extreme pressure/ conditions 4. Agreed forbidden space for all staff Accept and adapt protocols and defences Suppress triggering conditions Human Factors Reliability Add defences and Just Blame

28. Work harder. Be more vigilant. Follow the protocol and other useless interventions!

29. Human error “We can’t change the human condition, but we can change the conditions under which humans work” James Reason

30. A systems approach make it easier to do the right thing make it harder to do the wrong thing redesign processes, to allow you to spot & stop errors reaching the patient

31. A systems approach FactorsInfluences PatientCondition (complexity & seriousness) Language and communication Personality and social factors Task and Technology Task design and clarity Availability and use of Availability and accuracy Decision-making aids Individual (staff)Knowledge and skills Competence Physical and mental health Team FactorsVerbal communication Written communication Supervision and seeking help Team structure (congruence, consistency, leadership)

32. A systems approach FactorsInfluences Work EnvironmentalStaffing levels and skills mix Workload and shift patterns Design. availability and maintenance of equipment Administrative and managerial support Environment Organisanonal & Management Financial resources & constraints Organisational structure Policy, standards and goals Safety culture and priorities Institutional ContextEconomic and regulatory context National health service executive Links with external organisations

33. A systems approach Conduct review of organization – Are processes simple and standardized? – Are failure identification and mitigation systems in place? (more on this later) Conduct a task analysis – How many interruptions are there during the work shift? – How complex are the tasks or instructions? Conduct human factors audits – Noise levels; distractions; design of workspace; label format; work hours and reviews Train staff in human factors awareness

34. Adapted from REASON, 2005 People Environment Workspace Task Equipment Staff Patients The ‘system’ Factors within the healthcare system that could potentially lead to harm Staff act as harm absorbers Organisation

35. ‘Three bucket’ model for assessing risky situations (Reason, 2004) 1 2 3 SELFCONTEXTTASK The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

36. Assessing the risk Serious risk: don’t go there / change something Moderate to serious: be very wary Routine to moderate: proceed with caution 3 5 7 9

37. Self Bucket Level of knowledgetraining Level of skill competence and experience Level of experience involuntary automaticity, under/over confidence Current capacity to do the task fatigue, time of day, distractions, feelings

38. Equipment and devicesavailability, familiarity Physical environment lighting, noise, temperature Workspace working environment, writing space, layout Team and support leadership, stability and familiarity, trust Organisation and management safety culture, goals, targets and workload Context Bucket

39. Task complexity calculations, multiple cognitive tasks Novel taskunfamiliar or rare events Processtask overlap, multi-tasking Task Bucket

40. ‘Three bucket’ model for assessing risky situations (Reason, 2004) 1 2 3 SELFCONTEXTTASK The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

41. Understanding & measuring patient safety Take a broader view Use information appropriately Prioritise deliberately Be more proactive Use casenote review

42. So many questions! How many of our patients are harmed? Which areas need most attention ? What’s causing adverse events ? What changes could we implement? Are the changes an improvement ?

44. We need a metric Focus on actual patient harm How many patients had an adverse event last year? What are the common areas of harm? Have our changes succeeded in reducing the incidence of harm ? Primary Care Trigger Tool

45. Casenote review objective focus on outcomes focus on common events large numbers reliable over time Staff reporting subjective focus on error focus on memorable events (rare) v small numbers variable over time We need casenote review Primary Care Trigger Tool

46. Problems of casenote review lengthy, experienced clinician wasteful (reviews with no adverse events) Trigger Tools – a solution filtered & targetted → quicker, cheaper, less wasteful 1.Filter out patients with low likelihood of adverse event 2.Target clinical review where harm is suspected We need trigger tools

47. Step-by-step A. Sample List of all patients > 75 years Place in random order Each month, select 25-100 for PCTT review Review the past 3 months

48. 1.Search for triggers [clerical] unambiguous proxy indicators of harm risk Step-by-step B. Review 2.Search for adverse events [clinical] iatrogenic harm events Sample NO 0 events 30 patients 20 patients YES NO 0 events 10 patients YES 12 events 50 patients Event rate = 12 / 50 = 0.24

49. Step-by-step C. Analyse Change 1

50. Step-by-step C. Analyse

51. Primary Care Trigger Tool Developed by NHS Institute, in partnership with 32 GP practices across England Analysis of 4400 casenote reviews 1400 adverse events 25% resulting in hospitalisation/permanent harm/death Independent expert academic review 81% sensitivity 4 min/pt

52. Primary Care Trigger Tool Identify common harms Measure improvement over time ×Not valid for benchmarking

53. Primary Care Trigger Tool Medication Repeat medication discontinued Prescribing of opioid analgesia Prescribing oral NSAID/COX2 Prescribing warfarin Prescribing insulin Prescribing methotrexate Prescribing amiodarone General Care Seen > once in 2 days Fall if age > 75 Fracture if age > 75 Pressure sore or ulcer Urinary catheter in situ VTE Proven DVT or PE Patient transfer Readmission to hospital within 2 weeks of discharge Laboratory Na+ 150 mmol/l K+ 5.5 mmol/l INR 5 Haemoglobin <9g/dl MRSA positive C.diff positive Positive wound/skin swab eGFR <= 20 End of life Death Key diagnosis New diagnosis of CVA/TIA New diagnosis of acute confusional state

54. eg – Warfarin & bleeding.. Trigger INR > 5 is a trigger on the PCTT Many patients with an INR > 5 come to no harm This is not an adverse event (even if results from error)

55. eg – Warfarin & bleeding.. Adverse event Retinal bleed caused by Warfarin  INR > 5 Patient has come to harm This is an adverse event (whether result of error or not)

56. www.institute.nhs.uk/safercare/TTP Primary Care Trigger Tool

57. Getting trainees stuck in theoretical training role model openness get them stuck in – MaPSaF – walkround – PCTT – process map to identify defects – PDSA – continual measurement