1. Risk management in general practice Eric Bater 6 th November 2013

2. Aim of programme  to apply the principles of risk management to practical situations and relate these to personal experiences  to improve the quality of care by implementing initiatives to remedy deficiencies in the service provided.

3. Aim  To help reduce the risk of harm to patients, staff and visitors by improving safety and the quality of care in practice

4. Harvard Medical Practice Study New England Journal of Medicine 1991  3.7% patients suffered an adverse event  Of these 13% died  58% events related to system errors

5. Summary of New Complaints Procedure (1998, 9/12 period) MDU experience  Failure or delay in diagnosis most common reason (28%)  24% of complaints made after bereavement  Non-clinical issues accounted for 34% of complaints  10% of complaints related to attitude  93% settled at local resolution

6. MDU Settled Claims Against UK GPs  Failure to diagnose - 51%  Medication error - 26%  Pregnancy including labour - 13%  Minor surgical procedure - 7%  Other - 3%

7. MDU Claims Settled  Quality of medical care - 7%  Medical record issues -60%  System failures-33%

8. Clinical Governance  Clinical risk management  Complaints procedures  Adverse incident reporting  Clinical audit  Evidence- based practice  Whistle blowing  Performance review

9. Risk “The possibility of incurring misfortune or loss”

10. Living with risks Risk is part of everyday life  At home  When travelling  With patients You can minimise your risks by improving your systems

11. 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

12. 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

13. Top key risks in UK general practice  95% Confidentiality  92% Prescribing  90% Health and safety  85%Communication  84% Record keeping  84% Test results MPS Risk Consulting August 2006

14. 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

15. 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

16. 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

17. 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

18. 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

19. Infection control Common issues:  No infection control policy  Specimen handling  Hand washing issues

20. 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

21. ■ 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 What is clinical risk management?

22. RISK MANAGEMENT A careful examination of what 1.could cause harm 2.its significance and 3.what precautions are needed to eliminate the risk or reduce it to an acceptable level

23. Risk Management Benefits  for patients – improved quality of care and service – enhanced patient safety – confidence in the service  for health care professionals – protection of confidence and reputation – quality procedures and staff involvement – decreased numbers of complaints and claims

24. The four principles of risk management 1. Identify the risks – what’s likely to go wrong? 2. Assess the risk – what are the chances of it going wrong, what could happen, does it matter? 3. Reduce/eliminate the risk – what can you do about it 4. Cost the risk – what are the costs of getting it right v. the cost of getting it wrong?

25. Risk Management Techniques  Complaint handling  Risk assessment  Staff awareness/training  Protocol and guidelines monitoring  Good medical records  Adverse incident reporting

26. Risk Areas  Staff - especially locums  Organisation  adequate staffing  regular guideline review  Communication  Consent  Record keeping

27. Clip 2 – Morning Surgery Identified Risks  Breaches of confidentiality – front desk/reception area etc.  Health and safety issue.  Lack of systems.  Phone call interruptions.  Verbal requirements regarding nurse visit.  Inappropriate roll/responsibilities of receptionist. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

28. Clip 3 – Test Result / Minor Surgery Identified Risks  Dealing with smear results.  Aseptic techniques.  Lack of chaperones.  Unreasonable patient request.  Lack of informed consent.  Disposal of clinical waste/needles. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

29. Clip 4 – Home Visit Identified Risks  Examination.  Response to collapsed patient.  Communication regarding hospital admission.  Communication with mother.  Dealing with request for repeat prescription.  Dealing with aggressive patient. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?

30. Aims of Assessment  Improve patient care  Ensure safe standards of practice  Ensure patient/staff safety and well being  Decrease the number of complaints and claims  Lessen the stress associated with litigation

31. The ‘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.

32. Self Bucket Level of knowledgenewly qualified Level of skillcompetence and experience Level of experienceinvoluntary automaticity, under/over confidence Current capacity to do the task fatigue, time of day, negative life events

33. Equipment and devicesusability, not available Physical environmentlighting, noise, temperature Workspaceworking environment, writing space, Team and supportleadership, stability and familiarity, trust Organisation and management safety culture, culture, targets and workload Context Bucket

34. Errorsomission errors, primary goal achieved before all steps complete, lack of cues from previous steps Task complexity calculations Novel taskunfamiliar or rare events Processtask overlap, multi-tasking Task Bucket

35. Reason’s Swiss cheese model

37. Department of Consumer and Employment Protection Resources Safety Reason’s Swiss cheese model James Reason’s ‘Swiss cheese model’