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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.

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

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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.

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.

Working together to help patients and carers to be more involved in safety

3 May

Patient Safety guide logo_cropped

The patient safety guide has been co-developed with patients, carers, general practitioners and pharmacists. We have worked together from the initial idea, to decide the focus of the guide, the first draft all the way through to refining it.

One key discussion we had early was a preference to develop a digital app based version to compliment the paper version which we are now doing. In March we held two more co-design events. In the first event we discussed what the app should include and key features that people like in an app, what they don’t like and what the guide app should include.

At the second event we discussed testing and piloting the guide package in practice for patients and carers and how would it be used with GPs, pharmacists and other healthcare staff. These discussions will be used to shape the next phase of the guide project to develop an app and test the full guide package.

Thanks to everyone who came along and got involved! If you’d like to find out more about the patient safety guide project or future opportunities to get involved please contact Dr Rebecca Morris.

Risk Management: developing a learning resource to support pharmacy teams across England

3 May

Risk man guide supported by NIHR GM PSTRC

Good risk management is well recognised as the cornerstone of safe practice in the workplace and risk assessment has long been part of legal requirements for health and safety in UK workplaces.

In 2017, the World Health Organisation highlighted the importance of medication error by choosing the issue of medication-related harm as the focus of its Global Challenge. In response to this, the Medication Safety theme of the Greater Manchester PSTRC worked with CPPE (The Centre for Pharmacy Postgraduate Education) to develop their learning resources on Risk Management.

This was an ideal opportunity for the PSTRC, allowing the team to apply their broad expertise in theoretical risk management concepts to the challenges of the pharmacy context but also enabling them to incorporate the expertise and insights from the PSTRC’s Community Pharmacy Patient Safety Collaborative – a group of current in-practice community pharmacists working in the Greater Manchester region (see blog post for more information).

This ensured that the guide would be both theoretically sound in terms of risk management but also enriched with examples that pharmacists saw as pertinent to their day to day work.

Through the co-development of this guide, it was recognised that this could be part of something with much greater impact and, as a result, CPPE dedicated their 2018 learning campaign to be focussed on the topic of Patient Safety, using the guide as a focal point to provide the theoretical background for the campaign.

The guide was distributed to over 67 500 pharmacy professionals as part of CPPE Patient Safety campaign. The PSTRC continued to support CPPE designing appropriate learning activities that would be delivered by CPPE – including face to face “focal point” sessions with over 100 events due to run nationally throughout England and online weekly activities in Feb/Mar 2018 – including an e-challenge quiz and encouraging involvement via Twitter, Instagram and Facebook. This resulted in over 1500 individuals signing up to the campaign activities over the six week period and continuing beyond this with pharmacists still adding their intentions to improve patient safety on CPPE’s ‘Pledge Wall’.

Matthew Shaw, interim director of CPPE, was delighted at the opportunity to collaborate with PSTRC recognising the huge value of building an evidence base into this core learning programme. He commented “It has been a great opportunity to work with PSTRC to link theory with practice and through this to support pharmacy professionals across the country to make their practice safer, and to reduce the risks to people using our services.”