Archive | November, 2013

A game of two halves: GM PSTRC at ISQua 2013

22 Nov

by Denham Phipps, Research Fellow on Medication Safety theme and Sally Giles, Research Fellow on Core theme Image What do healthcare trust directors and premiership football managers have in common? This was just one of the things that 2013’s International Society for Quality (ISQua) conference led us to think about.  This year the conference took place in Edinburgh, much to the delight of those who like hills as much as they do healthcare research.  The clicker-count alone was impressive, with 1200 delegates arriving from 73 countries to listen to 250 speakers and look at 370 posters.  That’s a lot to pack into four days by anyone’s standards, and so we were able to experience only a sample of what ISQua had to offer.  The proceedings opened on Sunday with a session on the Francis Report.  As well as being informative, it led to some lively and thought-provoking discussion, including that analogy involving trust directors.  Like their sporting counterparts, their positions are apparently less secure than they once were, given the level of scrutiny that now tends to be directed at any individual holding either type of post.  Is it a good thing for trusts (or football clubs) to have a constant turnover of leader?  Do we pay as much attention to addressing the social, political and economic factors that set the scene for the problems at Mid Staffordshire?  And why do we hear less about the high-performing trusts? On the next three days came the main conference sessions.  There were many interesting presentations here; a particularly creative one was the mock trial of a nurse, doctor, pharmacist and hospital director who had apparently been involved in a serious medication error.  It was instructive for us in the audience to hear these healthcare professionals being grilled by a real-life legal professional, and to be given the task of delivering the verdict on each of them.  The take-home message was clear: the justifications that one might create in the office to support risky practice can, in the courtroom, turn out to be a house of cards. It was particularly reassuring to see a strong emphasis on involving patients and the public to help improve quality and safety at ISQua 2013.  There were examples from different countries; such as involving patients’ families in death review in New Zealand, patients accessing their medical records in Taiwan, and in the UK, patients reporting patient safety concerns in a hospital setting.  One presentation that we saw included the relative of a patient who had been harmed as a result of a medical error; a great example of how healthcare professionals, healthcare researchers and service users can work in collaboration to bring about improvements in quality and safety.  However, although there was a clear message that involving patients and the public is worthwhile, there were only a small number of examples of how this can be done successfully, none of which were in a primary care setting.  So, it seems, there is a need for further work in this area, and we at GM PSTRC aim to rise to that challenge. We look forward to ISQua 2014 where we can bring primary care into the PPI in patient safety arena!

Errors in General Practice? Yes, but how many and where…

13 Nov

by Sudeh Cheraghi-Sohi, GM PSTRC Research Fellow on General Practice theme


Since the publication of the landmark report ‘To Err is Human’ in 1999, patient safety has received considerable attention worldwide. One area that hasn’t, is General Practice. General Practice is not necessarily somewhere that one thinks of as ‘unsafe,’ and of course thankfully for the most part it isn’t, however the sheer volume of patient contacts, approximately 300 million per year, mean that there are plenty of opportunities for safety incidents and errors to occur.

So what types of things am I talking about? Well the two most common areas for errors to occur are thought to be in 1) diagnosis, in terms of diagnoses being missed, delayed or simply wrong; and 2) treatment, for example, prescribing the wrong drug or dose etc. (Sandars et al. 2003).  We now have good evidence for the latter via The PRACtICe Study,but beyond prescribing errors, the evidence base in the UK is not robust and therefore we have no idea of the true prevalence of error more generally.

One of our major tasks in the GP theme therefore is to produce an estimate of the prevalence of error in general practice. This is a huge and complex undertaking and we are currently designing our study to hopefully produce this figure and I will update you on this once we have finalised our plans.

So what will we do when we have calculated our prevalence estimate? Well by knowing how many errors are occurring and more importantly where they are occurring, we can direct our attention to how we might reduce the frequency of them actually happening. One way we can do this is via educational interventions.

This neatly leads me into another project that we are developing namely, Simulation Laboratories. In partnership with Salford Royal Foundation Trust, we are going to design and build our simulation lab as well as develop the materials used within them to help train clinicians such as General Practitioners to practice safely. That’s the plan anyhow!

Finally, you can also find out about another area of work we are currently doing around so called ‘Never Events’ by looking at another post I wrote for our Centre for Primary Care blog by clicking here