1. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 The NHS Care Records Service – Improving Patient Safety Mr. Ian Scott, National Clinical Lead for Hospital Doctors, NHS Connecting for Health

2. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 TOPICS TO BE COVERED Introduction to NHS Connecting for Health Safety approach Clinical reality presentation Human factors and safety

3. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 PATIENT SAFETY National Patient Safety Agency (NPSA) have identified three principal areas for concern: Right patient, right treatment Prescribing and dispensing medications Communication between health professionals

4. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 PASSIVE SAFETY Software has to do what it says on the tin Clinician safety training Close working with Software Houses safety processes

5. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 ACTIVE SAFETY Designing safe practice into software Do Once and Share E-pathway design E-prescribing

6. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 IMPLEMENTATION SAFETY Recent experience has highlighted this area of the programme Clinical Risk and Safety Board aware Establishing small group to share experiences and promote good practice

7. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 The NHS Care Records Service – Improving Patient Safety Maureen Baker CBE, National Clinical Safety Officer, NHS Connecting for Health

8. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO – BILL’S STORY 67 year old retired foundry worker Artificial heart valve for many years Takes Warfarin Suffers from severe osteoarthritis

9. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO - ARTHRITIS Has flare-ups of arthritis, painful and caused difficulty walking Becomes housebound during flare-ups Flare-up week before Christmas Visited by locum GP at end of locum’s week in practice It is a Friday

10. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO – THE PRESCRIPTION Locum GP prescribed NSAID (Non Steroidal Anti-Inflammatory Drug) for arthritis Did not notice Bill taking Warfarin Prescription written on FP10 form in Bill’s home

11. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO – THE PHARMACY Bill’s wife brought prescription to pharmacy Exceptionally busy – just before Christmas Pharmacist dispensing prescription interrupted by query from shop floor Did not therefore pick up Bill on Warfarin

12. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO – THE HOSPITAL Normal Blood Testing Clinic delayed, as Christmas He missed his previous clinic appointment Bill developed Gastro-Intestinal bleeding New Year’s Day Brought to Accident & Emergency (A&E) Department as emergency No record of NSAID on repeat prescription Bill was too ill to give accurate history

13. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SCENARIO – THE HANDOVER Bill’s condition critical A&E busy (bank holiday) Destined for Medical admission, but delayed Regular observations not carried out while still in A&E Bill’s family didn’t want to bother the staff – as A&E is so busy Bill dies in A&E 3 hours after arrival

14. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 HOW WOULD NATIONAL CARE RECORD SERVICE HELP? INR (International Normalised Ratio) Clinic GP clinic Pharmacy A&E Department

15. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 INTERNATIONAL NORMALISED RATIO (INR) CLINIC Knowledge about arthritis problems and medications Reinforce warnings about drug interactions – especially Warfarin with arthritis medication

16. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 GP CLINIC As now, information about other healthcare episodes and medication prescribed elsewhere Access to medication record from remote sites?

17. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 COMMUNITY PHARMACY Pharmacist will have access to medication history Opportunities for comprehensive decision support on pharmacy systems

18. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 A&E DEPARTMENT Access to patient records from INR clinic and from GP practice Access to medication history

19. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 CONCLUSION Access to relevant information on patient history whenever and wherever patient presents Access to medication history Less reliance on patients/carers to provide critical information Potential for major contribution to patient safety

20. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 The NHS Care Records Service – Improving Patient Safety James Reason Professor Emeritus University of Manchester Human Factors & Patient Safety: System Issues

21. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 THE HUMAN FACTOR Errors dominate the risks to patient safety (as in all hazardous systems). IT does not eliminate error, it relocates it and can also change its form: –Centralised mistakes rather than localised slips and lapses –A greater potential for rare but catastrophic organisational accidents

22. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 THE BATHTUB CURVE. Probability of technical and human failures Age of system Change creates errors. Expect them. Don’t stigmatize them. Share them. Learn from them. Keep system transparent. Make it forgiving.

23. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 ELEMENTS OF AN ORGANIZATIONAL ACCIDENT (SWISS CHEESE) Some holes due to active failures Other holes due to latent ‘pathogens’ Successive layers of defences, barriers, & safeguards Hazards Victims

24. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 DEFENSIVE WEAKNESSES Active failures: errors and violations at the ‘sharp end’—often short-lived in their consequences. Latent pathogens: seeded into the system by designers, programmers, managers, etc.—long-lasting in their effects, but present now.

25. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 SOME ‘BROAD BRUSH’ ISSUES What are the hazards? What defences exist to prevent these hazards from harming patients? What are the possible scenarios of failure (when hazards come into harmful contact with patients)?

26. Care Record Development Board Your Care, Your Record Thursday 23 rd November 2006 TAKE-HOMES Radical changes require trial-and-error learning. Errors and screw-ups are inevitable—but they also mark the boundaries of acceptable performance. The mental skills of error detection and error correction are essential: become error-wise and error-vigilant. Learn global rather than local lessons.