Archive | Patient Safety RSS feed for this section

Innovative IT system that prevents prescription errors wins prestigious national prize

5 Dec

Richard Williams_John Perry award_CROPPED

Richard Williams, a Senior Software Engineer at The University of Manchester, based in the NIHR Greater Manchester Patient Safety Translational Centre (Greater Manchester PSTRC) and Centre for Health Informatics, has been awarded the respected John Perry Prize by BCS: The Chartered Institute for IT.

Announced at a glitzy ceremony in early October, the prize recognises Richard’s outstanding contribution to Primary Care Computing.  Having been awarded annually since 1985 it is one of the IT industry’s most respected accolades, acknowledging innovation and excellence in computer science.

The Prize along with £500 cash was awarded in recognition of Richard’s work developing and disseminating the Smart Medication Safety Dashboard (SMASH).  This potentially life-saving piece of software, which was developed with support from the Greater Manchester PSTRC and Health eResearch Centre (HeRC), was created to improve patient safety by reducing the number of prescription errors.  Such errors occur in 5% of prescriptions according to a recent study of English general practices with one in 550 considered to be life-threatening.

Richard’s work involved the development of an algorithm that trawls GPs’ patient databases in search of high-risk – and possibly dangerous – prescription and/or disease combinations. Once identified, these prescriptions are flagged up to a relevant pharmacist who is able to investigate, question and where appropriate refer prescriptions back to the GP for review.

The high-risk combinations that SMASH could identify might, for example include a patient receiving a complex blend of high-strength medications that need to be carefully managed or someone who has been receiving an un-checked repeat prescription for a long time.

Alongside the digital infrastructure required to develop and implement SMASH, Richard also created an easy-to-view front-end platform.  This allows pharmacists to clearly and quickly identify any risks without the need for complex and time-consuming analysis.

SMASH is now being used by 43 active practices across Greater Manchester. Richard created SMASH by building upon previous work conducted at The University of Nottingham. The team are in the process of analysing the impact, but preliminary results look good. As of January 2017 the number of patients at risk in practices using the dashboard had reduced by 50% – a mean reduction of 21 patients per practice.

Richard was named the overall winner of the prize in the face of tough competition and now joins a respected list of previous recipients including Kate Warriner and Dr Amir Hannan.  Speaking about the prize, Richard said:

“John Perry was pioneering in the field of primary care computing and for his work on developing the first clinical coding terminology for GPs. It’s a great honour to be associated with him, and is particularly relevant as my current research is around how researchers build, reuse and share sets of clinical codes.”

The Smart Medication Safety Dashboard (SMASH) was funded by the NIHR Greater Manchester Patient Safety Translational Research Centre and delivered by the Health eResearch Centre.  Find out more information about the development of the dashboard on the SMASH page of the PSTRC website.

Putting patient safety first

4 Dec

by Maria Panagioti, Senior Research Fellow

GP & Patient pulse_square

Delivering safe healthcare to patients and preventing patient harm is an international priority. Despite this, patient safety incidents are not uncommon. Around 10 per cent of patients experience a harmful patient safety incident whilst being treated. Such harmful incidents could be due to actions of healthcare professionals, healthcare system failures or a combination of both. Medication errors, misdiagnosis, wrong-site surgery, hospital-acquired infections and in-hospital falls are all examples of serious patient safety incidents which can result in patient harm.

While eliminating patient harm is a desirable goal, in practice it may not always be possible. A certain level of harm is considered inevitable because harm cannot always be predicted. For example, some adverse drug reactions occur in the absence of any error in the medication process and without the possibility of early detection.

Focusing on prevention

This understanding has recently led researchers and policymakers to focus on reducing preventable harm. Although full consensus about the nature of preventable harm has not yet been reached, most working definitions include the idea that preventable harm is identifiable, in that it can be attributed to medical care and modifiable in that it’s possible to avoid by adapting a process or adhering to guidelines. The focus on preventable harm could help policy makers and healthcare practitioners to devise more efficient and reliable plans to predict and prevent patient harm.

There has been a lack of clarity in the literature about the prevalence and main types of preventable harm – and how often severe harm such as death and severe injuries are likely to occur. In response to the need to better understand preventable harm, the General Medical Council commissioned our team to undertake a large systematic review and meta-analysis to understand the nature of preventable patient harm across healthcare settings including hospitals, primary care and specialty settings. The aim of this review is to help the GMC and stakeholders get a better understanding of types, causes and patterns of harm – with a view to identifying ways of mitigating them.

Letting numbers do the talking

We reviewed 149 published studies through this work and our findings in relation to the importance and impact of preventable patient harm were striking:

  • Six in 100 patients experience preventable harm and 13% of this preventable harm leads to permanent disability or patient death.
  • Medication incidents such as errors in ordering, prescribing and administering medication, and misdiagnoses are the main causes of preventable patient harm.
  • Preventable patient harm might also be higher in certain medical specialities such as surgery.

These findings provide useful direction on areas where regulators, the NHS and Government should invest to reduce preventable patient harm. For example, investment in interventions to reduce medication errors (particularly at the stages of prescribing and administration of medication) and preventing misdiagnoses would be encouraged by our findings.

In line with our findings, the importance of improving medication safety is fully recognised by the World Health Organisation who have recently identified Medication Without Harm as the theme for their third Global Safety Challenge. Given the large number of studies we reviewed, the quality and depth of data on preventable patient harm is relatively low. We need to invest in better research and reporting practices to understand which types of patient harm clinicians and healthcare systems can prevent.

In recognition of the importance of patient safety research, and following on from previous research undertaken in Manchester and London already having an impact on NHS frontline services, the NIHR announced funding of three new NIHR PSTRCs. Work began in August at the Centres – located in London, Manchester and Leeds – and their aim is to turn patient safety discoveries into practice.

By understanding the nature of preventable patient harm we can work towards eliminating it – saving lives and reducing unnecessary medical interventions. Investing in reducing key sources of preventable harm and improving reporting standards of future research studies on preventability of patient harm could be a major contribution to the safe care of patients.

The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity

15 Nov

by Jonathan Stokes, Research Associate in the Manchester Centre for Health Economics

J Stokes_Foundations Framework diagram

With colleagues at the Universities of Bristol, Glasgow and Dundee, we have published a framework aimed at improving care for patients with multimorbidity (two or more long-term conditions).

Long-term conditions and multimorbidity are a global health priority. Patients with multimorbidity receive more fragmented care and have worse health outcomes, and health systems struggle to address their needs. We need new ways of delivering care to address this.

To date, there has been limited success at delivering care that improves outcomes for these patients. One major problem is that there is no agreement on how to describe care for patients with multimorbidity. This makes it difficult for researchers to talk about their work, and to explain these new ways of delivering care to patients and policy makers. Our framework offers a starting point for addressing this issue.

Our framework describes care for multimorbidity in terms of the foundations:

  •  the theory on which it is based
  • ·         the target population (‘multimorbidity’ is a vague term, so we need to define the group carefully, e.g. a patient with diabetes and hypertension might have very different care needs than a patient with dementia and depression)
  • the elements of care implemented to deliver the model.

We categorised 3 elements of care: (1) the clinical focus (e.g. a focus on mental health), (2) how care was organised (e.g. offering extended appointment times for those who have multimorbidity), and (3) what was needed to support care (e.g. changing the IT system to better share electronic records between primary and secondary care).

We used our framework to look at current approaches to care for multimorbid patients. We found:

  • Care for multimorbidity is mostly based on the well-known Chronic Care Model (CCM). This was designed for people with single diseases, and may not be fit for purpose for patients with multimorbidity.
  • Much care is focussed on elderly or high-risk patients, although there are actually more people aged under 65 with multimorbidity. We need to make sure that models don’t neglect the needs of younger patients, or those who are at lower risk, who might have most to gain in preventing future health problems.
  • We need to look more at the needs of low-income populations (where multimorbidity is known to be more common), and those with mental health problems (multimorbid patients with a mental health issue are at increased risk for worse health outcomes).
  • There is an emphasis on self-management, but patients with multimorbidity frequently have barriers to self-managing their diseases.
  • The emphasis on case management (intensive individual management of high-risk patients) should take into account the evidence that while patient satisfaction can be improved, cost and self-assessed health are not significantly affected.

Health systems have only recently begun to implement new models of care for multimorbidity, with limited evidence of success. Careful design and reporting can help develop evidence more rapidly in this important area. We hope our framework can encourage better research which is urgently needed to improve care for those who use it most.

This free to read article can be found at the following link: http://www.annfammed.org/content/15/6/570.full

Stokes J, Man M-S, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. The Annals of Family Medicine. 2017;15(6):570-7.

Diagnostic Error in Medicine: key topics

2 Nov

by Sudeh Cheraghi-Sohi, Research Fellow in Safety in Marginalised Groups: Patients and Carers theme

DEM 10th conference_cropped

I recently attended the 10th International Conference on Diagnostic Error in Medicine (DEM) held in Boston and organised by the Society to Improve Diagnosis in Medicine (SIDM).  I was invited to attend the research summit as well as to display some of my work from the 2012-2017 NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (PSTRC).

The research summit was an excellent forum for discussing the key areas of interest in the field of DEM research.   This year’s topics of interest were around uncertainty and the role of the team and teamwork. For the first topic, I was really interested to participate in discussions as I have already done some work in the area of uncertainty in terms of a review[1] around the various aspects of uncertainty and the PSTRC has also developed a training package[2] to help peoples’ awareness of the issues and in managing their uncertainty.  The discussions were very lively and a keynote speech at the conference given by Dr Arabella Simpkin also resonated with the conference delegates.

The second topic is an area that the Institute of Medicine, in their 2015 report on Improving Diagnosis, placed a focus on. The role of team in making a diagnosis may not be obvious to many people, particularly in the context of UK general practice where patients probably think about the one-to-one consultation with their general practitioner, but even in general practice, there are often multiple people involved in making a diagnosis. For example, the phlebotomist and the practice nurse/nurse practitioner may have already seen a patient prior to the GP consultation and performed certain tasks and provided prior information for the GP to work with. Also, when GPs make referrals, they are seeking the expertise of others and then utilising all the gathered information to inform their diagnostic thinking and hopefully coming up with an accurate diagnosis. This is certainly an area that I would like to explore more. 

Finally, the main conference itself was fascinating. There was a superb talk given by Don Berwick, one the world’s leading patient safety experts, as well as many interesting workshops to attend. I am also happy to say people were very interested in the Greater Manchester PSTRC’s work around Missed Diagnostic Opportunities[3] and I will write another blog when we are able to share more of our findings from this project.

Learning from each other: the International Society for Quality in Healthcare (ISQua) Conference 2017

24 Oct

by Rebecca Morris, Research Fellow in the Safety in Marginalised Groups theme

ISQua 1_CROPPED_Becci Morris

The International Society for Quality in Healthcare (ISQua) conference was held this year at the QEII conference centre in London next to Westminster Abbey and Palace of Westminster which was a prestigious backdrop to an interesting and diverse range of presentations.  This year’s conference focused on learning at the system level to improve healthcare quality and safety and was supported by the Health Foundation. It was great to see that the conference was awarded the Patients Included status which reflected the conference’s focus on incorporating the experience of patients whilst ensuring that they are not excluded or exploited. This was evident within presentations that I attended that included patients speaking alongside researchers and clinicians and I felt this was a welcome development from last year’s conference. Sharing and valuing different experiences and expertise is an important recognition of different types of expertise that need to be involved, particularly when we are looking at healthcare quality and safety.

There was a fantastic array of workshops, plenaries, oral and poster presentations. I wanted to be in more of the streams than I could attend in one day! I had both a 15 minute oral presentation and a poster presentation to discuss two of the projects in the NIHR Greater Manchester PSTRC. My oral presentation was part of the Quality in the community theme and it was great to hear about different community approaches to quality and safety across the world. I presented the James Lind Alliance Primary Care Patient Safety Priority Setting Partnership and the top 10 priorities for future research. This is important in shaping the direction of future work which prioritises the questions which patients, carers and healthcare professionals need answering. Also in-keeping with the theme of incorporating the experience of patients and turning that into action, I presented a poster on the co-development of the patient safety guide for primary care where we have co-produced the guide package with patients, carers, GPs and pharmacists. The poster was a great opportunity to discuss the patient safety guide, co-production and networking with people from a range of places, from Canada to India, about the work and sharing ideas and building links.

After last year’s conference where there was a limited discussion of primary care and the community, it was great that there were so many of us there to represent the work that we’ve been doing working with patients, carers and clinicians. Fellow Greater Manchester PSTRC researchers, Caroline Sanders and Sudeh-Cheraghi Sohi, were part of workshops discussing the use of patient experience data and diagnostic safety respectively, along with posters from Penny Lewis and Christian Thomas exploring safety in community pharmacy.

To finish off an interesting day I was invited to a Health Foundation reception at Westminster Abbey to carry on the conversations and it was great to meet and discuss how our work can lead to improvement in the system and experiences of people who use and deliver healthcare services. A great way to end the day and I’m looking forward to how we can build on this over the next year.

Patient Safety in Community Pharmacy: the importance of teamwork

19 Oct

by Tomasz Niebudek, Pharmacist

Tomasz Niebudek_CROP_blog pic_Oct17

My name is Tomasz Niebudek. I work as a community pharmacist in the Salford area. Last year at the end of May our Superintendent Pharmacist forwarded to me an e-mail asking if anybody would be interested in taking part in a project at The University of Manchester. In a nutshell, the aim of the project was to improve safety in community pharmacy. I expressed my interest in participating, thinking that this would be an interesting challenge, that would allow me to reflect on and improve safety in my pharmacy and across the whole company.

One of the key things that I learnt by joining the collaborative is that we should look, not only at reactive ways of analysing errors, but also use proactive methods  to prevent errors from occurring before they’ve happened. The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was basically a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. This led to many interesting observations and reflections. It was encouraging to see that staff members who are usually quiet during the staff meetings had very strong views on certain matters. Some team members identified a problem and were able to provide a solution to it almost immediately. It was so motivating to see that they care about safety and it was also interesting to discover that my staff members have observed issues that I have never picked up on. I have very carefully analysed all the data from those questionnaires and shared my conclusions with my whole team during a staff meeting. We have straight away implemented changes to our practice. As you all know, change within organisations can be met with resistance by staff. However, the fact that the ideas were generated by the staff themselves made a huge difference (a positive one, of course). Doing that questionnaire made me realise that staff need to be fully onboard when safety is being considered.

I now encourage all staff in my branch to report near misses and dispensing errors, as previously, this was a task only/usually undertaken by myself. We work together to think of ideas to improve practice and safety in the pharmacy. Initially, I was worried that some staff might have the attitude that “this is not my problem”, which is an approach that I think is partially to blame for errors in primary care. However, I’ve learned that if you respect your team for the valuable input they can have in improving practice, and work with them to achieve this aim, it pays back.

Big thanks to The University of Manchester researchers in helping us to look at safety from a different perspective.

The purpose of the Community Pharmacy Patient Safety Collaborative is to work as a group exchanging ideas and sharing experiences. The same approach must be used on an individual pharmacy level- pharmacists can only improve the safety of their patients with his or her team on board.

Safety Informatics: Using every opportunity to learn

11 Sep

by Niels Peek, Research Lead for Safety Informatics theme

shutterstock_587141294_healthinformatics

As our world is quickly becoming more connected, a transformative potential emerges to make it safer. Digital technologies are now commonplace within the NHS and in our daily lives, producing rich data on all aspects of health.

For instance, my smartphone captures my whereabouts through its GPS sensor and thus knows that I’m currently in China. It also measures my physical activity by counting my daily steps. The electronic health record maintained by my GP describes all interactions that I’ve had with primary care, including symptoms, observations, measurements, test results, prescriptions, and referrals. Hospital records capture rich data on diseases (e.g. through high-resolution images) and provide detailed accounts of any hospital care that I have received.

Connecting these data sources can help us gain a deep understanding of patient safety issues and the factors that can increase risk. Not only can they tell us that an adverse event has happened (e.g. someone was admitted to A&E) but they can also help us to trace back the chain of events leading up to this (e.g. a trip abroad; followed by a period of staying at home, not feeling well; a GP visit).

Advanced analytical methods such as Artificial Intelligence can subsequently facilitate early assessments of risk, and support patients and clinicians in preventing adverse events. This structured, system-level approach is also known as a learning healthcare system: an integrated healthcare system which harnesses the power of data and analytics to learn from every opportunity, and feed the knowledge of “what works best” back to patients, clinicians, public, health professionals and other stakeholders to create rapid cycles of continuous improvement.

The Safety Informatics theme within the NIHR Greater Manchester PSTRC will utilise the learning healthcare system approach to understand real-world contexts in which safety issues arise and what is required to take corrective actions. We will build on the established “ACTION” infrastructure to provide real-time feedback to primary care clinicians in Greater Manchester which is already used to improve medication safety, support long-term conditions management, and facilitate antibiotic stewardship.Specific projects will focus on:

  • reducing diagnostic errors
  • enabling automated monitoring of late treatment effects in cancer survivors
  • prevention of pulmonary complications after surgery
  • more timely and accurate computer-assisted monitoring of lab test results by both    patients and clinicians.