1. Developing Patient Safety in Primary Care in Scotland Neil Houston, Arlene Napier

2. Historically– Acute Focused  IHI 100,000 lives  Scottish Patient Safety Programme  NPSA Reporting

3. Patient Safety in Primary Care - Why Bother?  High Volume 95% of patient contact  Increasing complexity  Adverse Events in the community cause:  12% of Admissions to hospital  5.5% of Deaths in hospital  Under reporting 0.4% NPSA

4. Collaborative  32 Volunteer Practices  Patients  Clinical Effectiveness / Governance Staff

5. Project Aims 7 Steps to Patient Safety 1. Lead, teach and support staff 2. Integrate risk management activity 3. Promote reporting 4. Involve patients 5. Learn and share lessons 6. Implement solutions 7. Develop safety culture

6. Training  Clinician / Administrator  What is Patient Safety  Developing Risk Registers  Reporting  SEAs  Involving Patients  Medication errors

7. Homework

8. Follow Up – 6 Months Share the learning  Sharing risks and SEAs  Finding Solutions  Projects  Developing Team Culture  Next Steps

9. Year 2  16 more practices  Updated training  Ongoing support  Build local capacity  Sharing Sharing Sharing

10. Evaluation  Culture survey x2  Training  Outputs  Involving patients  SEAs wider learning  External evaluation

11. Project Aims 7 Steps to Patient Safety 1. Lead, teach and support staff 2. Integrate risk management activity 3. Promote reporting 4. Involve patients 5. Learn and share lessons 6. Implement solutions 7. Develop safety culture

12. Wider Impact?  On Health Boards  On NHS Scotland

13. Lead, Teach and Support Staff  Training valued  Confidence and skills Protected learning and facilitation valued  Involving all staff  Need GP leadership

14. Risk Register

15. Integrating Activity  All identified an area of risk in prescribing  All worked to reduce risk in this area  Shared risk and solutions with others

16. Promote Reporting - National Context  NPSA  IR1s  Datex  SEAs  Enhanced Services – Warfarin and Near patient testing

17. DES  “Practices are required to audit adverse incidents and to notify clinical governance leads all emergency admissions or deaths of any patient where the adverse event is due to the usage of the anticoagulant.”

18. Say that again…  Report what?  To Whom?  By When?  Analyse?  Hands Up?

19. Ideal reporting systems  IT based  < 2 mins  Trusted  Feedback  Action  Used by all How does the IR1 and NPSA match up?

20. NHS Scotland Current reporting systems- IR1s  Paper based  Too slow  ? feedback/ action  ? trusted  ?used  Slips and trips

21. Project – IR1s  Training  Encouraged  eIR1 pilot  Incident logs

22. Feedback  “We found it absolutely awful”  “It’s a huge form to fill in – its ridiculous actually”  “It doesn’t work in a small organisation.. and it doesn’t work well in the hospital either..!”

23. Significant Event Analysis Familiar territory Almost all practices do it QOF  12 in last 3 years  3 per year GP Appraisal External peer review

24. Promoting Reporting  Incident Reporting Forms (IR1s) - not useful or used  SEA’s More skills  Positive and negative SEA’s  More inclusive  More structured  More detailed in reporting

25. Sharing Significant Events Most Practices submitted SEAs Fulfilled QOF criteria but:  No standardised format for submission  Variable Quality  Change/ impact often unclear  No wider learning

26. Learning and Sharing Lessons  Practices submitted SEA’s for wider learning  Newsletter  Extended to all practices in FV  Volunteering SEAs  Common Interface Themes emerging

27. Incident Reporting – SEA’s

28. Issues  Lack of trust ?? anonymity  Negative impact on practice  “ I think there was a feeling that you’d be washing your dirty linen in public and the partners were not prepared to do that”  GPs more negative than others

29. More Issues  Did practices receive it?  Did they send it round staff?  How best to disseminate?  How relevant?  Does it change behaviour?

30. SEA and Risk Issues  Medication reconciliation at interface

32. SEA and Risk Issues  Medication reconciliation at interface  Drugs that look alike sound alike

33. Looks Can Be Deceptive Spot the Difference?

34. SEA and Risk Issues  High Risk Medication  Patient misidentification  Patients lost to follow up especially across care settings  Communication within and between teams and settings

35. Low Tech Solutions  Sticky Tape  Wipe Boards  Talking over coffee at 11 am!

36. IT Solutions Patient Identification  Warning messages  Searches under CHI Confidentiality  Telephone Headsets  Paper light records  Results - Docman

37.  Limited success  Workshops – input valued  Leaflets 20% - found it useful  Labour intensive  Patient groups  How to do it without raising alarm? Involving Patients

38. Culture

39. Patient Safety Culture Scoring Highly >75% most criteria Could be developed in areas of:  Shared Decision making  Communication  Informing staff when errors occur

40. Progress…. “ Its not about blame, its about it not happening again” Awareness Involvement Non clinical staff

41. Benefits to Health Board  Increased Capacity Collaboration  Common Risks Identified  Action on interface issues  System wide approach now adopted  Culture change ??

42. For NHS Scotland  Generating interest  National Patient Safety Programme should involve Primary care  ?Enhanced service  Clinical Governance guidance for contract  SEA’s - systems for wider learning

43. SpreadEngageSustain Culture Involve Measure

44. What role do you think IT has …  As a source of Risk?

45. What role do you think IT has …  As a method of risk reduction?

46. IT Solutions  Medication Reconciliation  Computer Prescriptions  Alerts  eWard discharge letters  OOH  Anticipatory care  Single Electronic Record

47. IT  Email  Results downloaded to GP Notes  Protocols Accessible on web /via patient records  Incident Reporting

48. Any Questions?