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Babylonian patient safety

11 Oct

by Stephen Campbell, Director of the NIHR Greater Manchester PSTRC

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One of the twelve stone displaying the Code of Hammurabi

Every patient, every person, deserves safe quality care. The quality and safety of care varies between countries and within countries; even within hospitals or general practices, dental practices or pharmacies. Some people will benefit from exemplary care (both clinical and inter-personal) whereas most will experience safe quality care. However, the reality is that some people / patients will receive poorer care and, in a minority of cases, unsafe, or unacceptable quality of, care.

How should this be addressed? Quality and safety improvement literature refer to various forms of incentives and rewards or penalties to reflect the safety and quality of care delivered. These can relate to financial, professional, regulatory and reputational standards and reflection of performance. It’s important to emphasise that care is provided within organisations within systems and usually as part of a team. Most unsafe and poor care is often the result of systems errors.

The idea that there will be incentives or consequences for the safety and quality of care delivered is new…is wrong. There have been some interesting approaches over the centuries. Do they have anything in common with health and social care today? Yes – they reflect the fact that it’s been recognised that care varies and patient outcomes vary and that there is an arbiter (a regulatory body or an individual) of safety and quality who will decide on the consequences for patient outcomes. Leaving aside issues of ethics, morals and legality…not to mention fairness…

Between the fifth and third centuries BC, the Hippocratic Oath required a new physician to swear, by a number of healing Gods, to uphold specific ethical standards. In essence, “First do no harm” (Latin: Primum non nocere). The “do no harm” was not new. King Hammurabi (B.C.1795-1750) was king of Babylonia who is credited with the legal Code of Hammurabi (a set of 282 laws written on twelve stones and displayed publicly for all to see). These were designed to regulate Mesopotamian society. Perhaps the most well-known is: “Eye for eye, tooth for tooth.” Delve deeper and one law stipulates that “If a doctor has opened an abscess of the eye and has cured the eye, he shall take ten shekels of silver”… however…“If a doctor has opened an abscess of the eye and has caused the loss of the eye, the doctor’s fingers shall be cut off”.

The focus on quality and safety of healthcare is mostly a post-war agenda. While it would not be appropriate to compare any existing health and social care regulatory body such as the Care Quality Commission to Mesopotamian society, it’s interesting to reflect on the fact that “regulation” of healthcare and patient outcomes is certainly not new. Thankfully, however, the current focus on “each person receives appropriate person-centred care and treatment” does not require anyone to have their fingers chopped off.

Using Artificial Intelligence to help primary care triage

5 Oct

by Ben Brown, GP and Researcher in the NIHR Greater Manchester PSTRC’s Safety Informatics theme

Working on laptop, close up of business man

Researchers at The University of Manchester and Spectra Analytics are developing an Artificial Intelligence (AI) system to help support GP practices triage requests for appointments – the Patient Automated Triage and Clinical Hub Scheduling (PATCHS) system.

It’s often difficult to get an appointment with a GP, and it’s estimated that over a quarter of GP appointments could have been dealt with in an alternative way, for example by another clinician (such as a nurse) or through patient self-care. One solution may therefore be to allocate GP appointments to patients that really need them. 

While receptionists at GP practices can direct patients to the most appropriate care provider, not all practices do this, and often patients are unwilling to disclose their problems to them. PATCHS plans to tackle this by providing an online tool that will efficiently direct patients to the right place, 24 hours a day. Patients will input their reasons for requesting a GP appointment, and PATCHS will analyse this request, taking into account the patient’s medical history, in addition to other factors such as the weather, to come to a triage decision. It is hoped the system could ultimately be integrated into practice websites and medical records, ensuring effective triage at the beginning of a patient’s care pathway.

The project is funded by Innovate UK and is currently in the development stage: PATCHS is currently learning from existing data about how patients are triaged when booking a GP appointment. However, the team are looking for volunteers – both patients and doctors – to participate in the project. If you’d like to know more please contact Dr Ben Brown on benjamin.brown@manchester.ac.uk.

What can we learn from North America about the role of community pharmacy teams in suicide awareness and prevention?

10 Sep

by Hayley Gorton, Pharmacist and Research Associate

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Hayley Gorton (r) with Bloom pharmacist Melissa at Haliburton Pharmacy, Antigonish

It is the NIHR Greater Manchester PSTRC I have to thank for starting the metaphorical journey that is my study of community pharmacy teams in suicide prevention. I joined the original Greater Manchester PSTRC in 2014 to undertake, and later complete, a PhD in the epidemiology of suicide and self-harm (epidemiology looks at how often and where diseases or healthcare events happen). Throughout my time, I was acutely aware of my profession and practice as a community pharmacist: “how would I help someone with thoughts or actions of suicide or self-harm in my pharmacy practice?” I didn’t know, but made it my mission to find out.

This summer, I spent a month in the USA and Canada exploring this question, thanks to a fellowship from the Winston Churchill Memorial Trust (WCMT) and support from the Greater Manchester PSTRC. There is too much to cover in one short blog, but you can find out about each leg of my trip by reading my own blog series. I’ve been back for a month and only now getting some clarity on which (of my many) research questions to pursue, fostering collaborations with those people I met en route and looking at how I can inform UK policy and practice with my WCMT findings. It was a brilliant experience in chronological order from grassroots research to mandatory training.

How was it for you? Reflections on involvement

2 Aug

This edition’s reflection comes from Kay Gallacher, a member of the public who is involved in the NIHR Greater Manchester PSTRC Patient Safety Guide.

Kay Gallacher PSG_lightened_cropped

Why did you become involved in the Patient Safety Guide project?

I have long been aware of the issues that elderly family and neighbours, in particular have experienced trying to manage contact with their GPs and pharmacies.  The brilliant, simple idea behind this Patient Safety Guide seems to address many of the concerns in a practical and tangible way.  I was also attracted by the fact that this was a collaborative project where patients, carers and medical professionals all have an equally important input into the design and delivery of both the paper- based Guide and the mobile app, hopefully making it a 360 degrees (all round) useful tool.

How do you think the Greater Manchester PSTRC benefitted from your involvement – what difference do you feel that you made?

I guess it’s for others to judge what impact, if any, I’ve had on the project.  However, I’ve brought a genuine understanding of the problems patients face when coming into contact with primary care and producing leaflets and guides was bread and butter for me in my marketing career.  So, I hope I’ve been helpful in producing and delivering an effective product.

How do you feel that you benefitted from your involvement?

I am involved with several projects, but this one in particular has sharpened my understanding of how the GP/ patient dynamic operates.  I came to this project with a patient’s viewpoint but I now have a better insight into the challenges GPs face in establishing and maintaining effective communication with patients.  Also, the deep personal satisfaction of feeling that I’ve made a positive contribution.  Importantly, I can’t overstate the pleasure I’ve derived from being part of a cohesive, effective and well-led team composed of great people from a wide range of backgrounds.

Would you recommend becoming involved in research to other patients and carers? If so, why?

Definitely!!  What you get from being involved largely depends on what you put into it but I can absolutely guarantee that, regardless of your starting point, you will have a better understanding of the workings of medical research and the wider world of medicine in general.

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

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

by Andy Carson-Stevens

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

by Stephen Campbell, Director of the NIHR Greater Manchester PSTRC

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

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by Bella Starling

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.