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What patient safety incidents are causing the most harm to my patients?

21 Jun

 

Andy Carson-Stevens_300x300

Andrew Carson-Stevens MBBCh PhD
Cardiff University PI for the Avoidable Harm study. Patient Safety Lead, PRIME Centre Wales

 

340 million primary care consultations take place across the UK each year.  Of those, around 2% of patients experience a so-called ‘patient safety incident’ which is defined as any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare.(1) Who could disagree with the seemingly common-sense reasoning that: “We must learn from the things that go wrong.”? With upwards of 6.8 million people experiencing unsafe primary care in the UK each year, there are a lot of opportunities to learn how to make future care safer.

Efforts to learn from medical error in hospitals have enabled an era of implementing interventions to reduce the burden of harm. Patient safety research in primary care is often talked about as lagging behind hospital efforts. However, in the UK, a collaboration comprised of Cardiff University, the University of Nottingham, the University of Manchester and the University of Edinburgh, have led major studies of national and international relevance to move this agenda on. We have undertaken the largest analysis of patient safety incidents from general practice internationally, (2) and have developed methods like coding frameworks aligned to the World Health Organization’s International Classification for Patient Safety to support the detection of incidents that cause the most severe harm to patients.(3,4) With the Royal College of General Practitioner’s Spotlight programme, we launched a workshop series for primary care teams, developed an open access e-learning module on RCGP learning, and have written a practical guide for practices to identify and learn from patient safety incidents experienced by their patients. (5) However, at workshops, attendees want to know, “What patient safety incidents are causing the most harm to my patients?” The problem is our best answers can only be informed by insights from previous studies of variable quality,(1) or based on hypotheses generated from patient safety incident reporting and learning systems.(2)

Led by Professor Tony Avery at the University of Nottingham, with collaborators from the aforementioned universities, the Department of Health and Social Care has funded a study called ‘Understanding the Nature and Frequency of Avoidable Harm In Primary Care’. The study’s aim is to identify the most severe harm experienced by patients in primary care to start to prioritise the design of safer care processes for future patients. We  recruited 12 general practices from across England to review the electronic case notes belonging to their patients. Our specially trained GPs reviewed the notes for evidence of omissions (i.e. not doing what they should have done to reduce the risk of harm, as per evidence-based guidelines) or commissions (i.e. doing something wrong and causing harm) made in care delivery. This process has enabled us to identify the systemic weaknesses that contributed to error(s) and to outline priorities for intervention development to prevent future recurrences.

For further information, we’ve published the study protocol with BMJ Open.(6) We complete the study at the end of June 2018 and will report on our findings shortly afterwards.

References

  1. Panesar SS, deSilva D, Carson-Stevens A, Cresswell KM, Salvilla SA, Slight SP, Javad S, Netuveli G, Larizgoitia I, Donaldson LJ, Bates DW, Sheikh A. How safe is primary care? A systematic review. BMJ Qual Saf. 2016 Jul;25(7):544–53.
  2. Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, Deakin A, Shiels E, Gibson R, Butlin A, Carter B, Luff D, Parry G, Makeham M, McEnhill P, Ward HO, Samuriwo R, Avery AJ, Chuter A, Donaldson LJ, Mayor S, Panesar S, Sheikh A, Wood F, Edwards A. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Southampton (UK): NIHR Journals Library; Health Services and Delivery Research 2016 4(27).
  3. World Health Organization. The conceptual framework for the international classification for patient safety. World Health Organization. 2009;2009:1–149.
  4. Cooper J, Williams H, Hibbert P, Edwards A, Butt MA, Wood F, Parry G, Smith P, Sheikh A, Donaldson L, Carson-Stevens A. Classification of patient-safety incidents in primary care. Bulletin of the World Health Organization. Available online first from: http://www.who.int/bulletin/online_first/BLT.17.199802.pdf?ua=1
  5. Carson-Stevens A and Donaldson L. Reporting and learning from patient safety incidents in general practice: a practical guide. Royal College of General Practitioners; 2017 Apr. Available from: http://www.rcgp.org.uk/-/media/Files/CIRC/Patient-Safety/Reporting-and-learning-from-patient-safety-incidents.ashx?la=en
  6. Bell BG, Campbell S, Carson-Stevens A, Evans HP, Cooper A, Sheehan C, Rodgers S, Johnson C, Edwards A, Armstrong S, Mehta R, Chuter A, Donnelly A, Ashcroft DM, Lymn J, Smith P, Sheikh A, Boyd M, Avery AJ. Understanding the epidemiology of avoidable significant harm in primary care: protocol for a retrospective cross-sectional study. BMJ Open. 2017 Feb 17;7(2):e013786.

Helping parents of children with respiratory tract infections decide when to consult primary care

19 Jun

Mother taking care of her sick child

Primary care is under extreme pressure and struggling to cope with demand for care. Children with Respiratory Tract Infections (RTI) are the most common reason for parents contacting primary care internationally. Parents and patients are offered little, if any, advice on if, when or how to use primary care services. Methods to improve the appropriateness of seeking help could assist primary care to deliver an improved service to the patients in most need. There is considerable parental uncertainty regarding if and when to consult a general practice healthcare professional when children fall ill with RTIs and RTI consultation rates vary widely between GP practices. Safer, cost-effective and more practical interventions are needed urgently to help parents make better use of scarce resources. This requires clear, relevant and unambiguous advice. Valid and reliable criteria are needed to support parents when they are deciding whether (and when) to consult when their child has a (suspected) RTI.

Funded by the NIHR School for Primary Care Research, researchers from the NIHR Greater Manchester PSTRC (Stephen Campbell, Rebecca Morris) and the Universities of Bristol (Alastair Hay) and Oxford (Gail Hayward) will see if professional consensus can be reached on the signs and symptoms that should be used by parents / guardians when deciding if and when to consult, both during the day and out of hours. It will use the RAND/UCLA Appropriateness Method to develop symptom scenarios and appropriateness criteria.  These will enable us to work with patients / members of the public and health professionals to develop a practical guide to support parents in deciding whether they need to contact clinical services for their child. A study working group will oversee the study involving representation from relevant health professions and including PPI/parental representation as an integral part of the research. Co-design events with parents, patients, GPs and pharmacists will then be used to develop the practical guide for parents as well as to develop the support tool for using the guide.

The guide for parents will inform the design of future interventions that could (once proven safe and effective) be implemented by GP practices and other NHS primary care providers (such as NHS 111), e.g. via general practice and NHS websites.

WellMed and clinical uncertainty

8 Jun

WellMed

Dr Sudeh Cheraghi-Sohi recently attended the Third International Meeting on Wellbeing and Performance in Clinical Practice (WELLMED 3) held in Thessaloniki, Greece.  The conference, which takes place every two years, focuses on the connection between physician health and the quality and safety of care they provide.  The keynote presentation was from Professor Christina Maslach, University of California, Berkeley, USA. As the author of the most widely used tool to measure burnout, the Maslach Burnout Inventory (MBI), Professor Maslach’s perspective on burnout in health care staff, which is a growing problem , was informative as was her recommendation for policy-makers to  focus on the workplace environment and not just the individual.

Dr Sudeh Cheraghi-Sohi chaired and presented a symposium on Clinical Uncertainty, which comprised of three presentations followed by discussion.  Dr Sudeh Cheraghi-Sohi introduced the topic and discussed two recent studies in the area to illustrate how uncertainty is composed of cognitive, emotional and ethical aspects as well as being dynamic. She also noted that the literature in the area is scarce but that uncertainty has real consequences on patients, physicians and the health system.

Dr Evelyn Tsiga presented a study on physicians’ emotional reactions to uncertainty and its impact on decision making in primary care to illustrate how physician behaviour can be affected by uncertainty resulting in undesirable behaviours, such as over-referrals.

The final presentation was given by Dr Avril Danczak. Dr Danczak presented her work on training to manage uncertainty, which highlighted that physicians value such training. She emphasised that clinical uncertainty is normal and it has consequences, yet medical curricula and professional training does not acknowledge or equip clinicians to manage it.

The symposium generated much discussion and the need to address the issue of uncertainty was agreed to be an area of importance for future research.

ReVerse: creative conversations between mental health service users and staff

6 Jun

Words_ReVerse illustration_cropped

Mental health service users, carers and staff have much in common these days coping with stress and distress, especially at a time of huge pressure on services.

ReVerse workshops aim to equalise the space between mental health service users and staff, to creatively nurture insight, dialogue and healing relationships about patient safety in mental health services and research.

We think a good way to do this is through poetry and spoken word. Creative formats can provide a different angle and unique insight into ourselves, others and our collective wellbeing, and provide those who often feel they are not heard with an opportunity to express their voices. Exploring metaphor and meaning can offer new dimensions to personal and professional health and research relationships.

The workshops are open to mental health service users, carers and staff (including clinical, research, managerial, administrative and support staff). We aim to have an equal mix of staff and service users. ReVerse workshops will include:

  • Examples and readings of poetry and/or spoken word, drawing from different experiences of mental health 
  • Discussions and reflections
  • Having a go: producing your own poetry or prose.

The ReVerse initiative is a collaboration between David Gilbert (poet, Patient Director and mental health service user) and Bella Starling (Wellcome Trust Engagement Fellow, Director of Public Programmes Team, Manchester University NHS Trust) and the NIHR Greater Manchester PSTRC.

For more information behind the workshops, see David’s recent blog post.

Our first workshop takes place in Ziferblat Media City on Tuesday 3 July, register your interest on our Eventbrite page. Registration is free, but requires a commitment to attend.

These workshops are pilots as part of an exciting new initiative. Those involved will help to shape the future development of this ReVerse Programme.

NHS70 Excellence in Primary Care Award for Nottingham’s Medicine Safety Research Group

22 May

Print

The Medicine Safety Research Group at The University of Nottingham is the regional winner of the Excellence in Primary Care Award category of the NHS70 Parliamentary Awards and is shortlisted for the national award.

The research group was nominated by the East Midlands Academic Health Science Network (EM AHSN), who highlighted a number of developments which are already improving, and will continue to improve, prescribing safety in primary care. These include:

  1. Improving the safety of medicines prescribing through the design and testing of an intervention called PINCER.
  2. Development of ‘prescribing safety indicators’ which are now used in GP computer software to avoid prescribing errors
  3. Identifying the frequency, nature and causes of prescribing errors in general practice, leading to:
  4. Developed a Patient Safety Toolkit for GPs, which is available on the RCGP website and has been accessed over 10,000 times.

The Medication Safety theme of the NIHR Greater Manchester PSTRC has worked closely with the award-winning Nottingham-based research team on many of the developments. A number of these projects and interventions will be developed further over the coming years, through a continued collaboration between the Greater Manchester PSTRC and the University of Nottingham.

Coded fairy tales at Medical Informatics Europe conference

16 May

Sleeping Beauty_cropped

Niels Peek and Richard Williams from the NIHR Greater Manchester PSTRC’s Safety Informatics theme recently attended Medical Informatics Europe (MIE) in Gothenburg, Sweden. MIE is the leading European health informatics conference and saw delegates attending from all corners of the world. While there, Richard beat off stiff competition to win the prestigious Science Slam – a competition held at MIE where contestants have up to 8 minutes to present their work in a humorous and entertaining way.

Richard talked about clinical codes, which clinicians use as a short cut to describe medical concepts e.g. hypertension is represented by the code G2 and Type 2 diabetes by the code C10F. Richard highlighted the absurdity of some clinical codes such as “U102700 – Fall involving ice-skates, skis, roller-skates or skateboards, occurrence on farm”, the dreaded “TE63100 – Moray eel bite”, and that there are no fewer than 11 codes for falling off a cliff including “U10F200 – Fall from cliff, occurrence at school”.

Richard then translated fairy tales into clinical codes – care to guess the following?

1. Female baby (634..12), black magic (13y8.00), wiccan (13yD.00), puberty (ZV21100), accident caused by spinning machine (TG3y500), excessive sleep (1BX1.00), contact with plant thorns and spines and sharp leaves occurrence at other specified place (U12Ay00), concussion with more than 24 hours loss of consciousness and (S603.00)… manual resuscitation (8731.00) …return to pre-existing conscious level (S603.00 cont.), married (1332.00).

2. Newly wed (1332.12), infertility problem (1AZ2.11), specific food craving (E275800), unborn child subject to child protection plan (13Iv000), female baby (634..12), imprisonment (ZV62511), abnormalities of the hair (M242.00), fall from turret (TC25.00), accident caused by plant thorn (TG4y600), foreign body entering into or through eye or natural orifice occurrence at other specified place (U11Qy00), acquired blindness both eyes (F490900), length of time homeless (13D8.00), tearing eyes (1B87.14), patient cured (2129.00).

3. Female baby (634..12), pale colour (1674.00), mother dead (12K3.00), father remarried (13HJ.00), has stepmother (133D100), hunter’s syndrome (C375.12), ran away (13HW.00), mining engineers (058..12), dwarfism (C1z4.00), found dead (R213100), manual resuscitation (8731.00), found dead (R213100), manual resuscitation (8731.00), found dead (R213100), suspected food poisoning (1J8..00), manual resuscitation (8731.00), married (1332.00).

Answers on a postcard.

On a more serious note, the talk also highlighted that the current coding system used in UK general practice (Read Codes) is in the process of changing to SNOMED (an internationally recognised coding system). This is a major project with potential implications for the continuity of patient care if managed poorly, but also with large implications for researchers in the UK who have much experience of working with databases of Read Codes but little experience of working with SNOMED.

What does the future hold? “God only knows (R2yz.11)”.

Past PhD Fellows: where are they now? Jonathan Stokes

3 May

In this series, we catch up with past Greater Manchester PSTRC PhD Fellows to see what they are doing now and how their PhD projects affected patient safety. This edition, our past PhD Fellow is Jonathan Stokes.

What did you learn during your PhD project?

My PhD project examined evidence for effectiveness of ‘New Models of Care’ (commonly called ‘integrated care’) for patients with multiple long-term conditions (multimorbidity).

As well as learning a great deal about the specific topic, I also learned a number of transferable research skills. For example, the requirement to balance the ideal question, data and methodology with what is realistically possible to do and answer; the publishing process, to accept paper rejection based on the priorities of some journals and to positively move on and improve a paper in response to reviewer comments; that research evidence does not automatically translate to policy change, that the policymaker has more to consider than the scientific evidence (e.g. public opinion), and that a research paper also needs to be written in additional formats (e.g. blogs, policy briefs, media) to improve its usefulness in the policy arena.

How has your PhD changed the patient safety landscape?

My research showed the limitations of one of the most popular integrated care models being rolled out, case management. It highlighted that an increase in one outcome, e.g. patient satisfaction, does not necessarily translate to a beneficial effect in another desired outcome, e.g. improving health or reducing the cost of care. We don’t always know what’s good for us/what’s good for us might not be what’s good for the overall system…

More recent emphasis on new models of care has been to focus on delivering organisational and incentive changes to promote more preventative care. Incentives have changed for primary care in an attempt to improve the case management process too, by trying to identify less high-risk patients (who might already be past the point of successful intervention). I hope my research contributed in some small way to this change in focus.

What you are doing now and where you see yourself going in your future career?

I’m currently working as a Research Fellow in the Manchester Centre for Health Economics. I’m working on a multi-country EU project, similarly to my PhD, looking at how models of care can be improved for treating patients with multimorbidity.

In the future, I’d like to continue a similar vein of research, but I hope to focus forthcoming work on understanding how we can improve prevention of developing multimorbidity, rather than just better treatment.