Babylonian patient safety

by Stephen Campbell, Director of the NIHR Greater Manchester PSTRC

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.

British Journal of General Practice Research Conference 2018

Dr Sudeh Cheraghi-Sohi recently attended the inaugural British Journal of General Practice (BJGP) Conference, held at the Royal College of General Practitioners (RCGP), on March 23rd. This one-day conference was opened by Dr Helen Stokes-Lampard, Chair of the RCGP, and the journal’s editor Professor Roger Jones. Plenaries were provided by Professor Richard Hobbs and Professor Pali Hungin, who gave an overview of some the key primary care research successes and discussed the future of general practice respectively.

Common to both talks was the focus on the growing primary care workforce crisis and the increasing workload that the diminishing workforce is attempting to deliver. From a patient safety perspective, safe staffing levels in hospitals and from an access perspective, GP provision are critical to safe service delivery.

Various solutions were suggested and the acknowledgement that there was no magic bullet. Dr Cheraghi-Sohi gave an oral presentation on her work on measuring diagnostic errors in UK general practice. An audience of primarily clinicians attended the fifteen minute presentation and engaged in a lively and positive debate on the topic once the presentation finished covering various aspects of the methods and findings. Indeed, the issue of workload was discussed and how this may contribute to the increasing occurrence of diagnostic errors.

In addition to the oral presentations, poster sessions and workshops on critical reading, peer review and how to beat procrastination in your writing were offered throughout the day.  In summary, there was a well-balanced structure to the conference programme with plenty of free-time for networking.

Health Innovation Manchester Patient Safety Collaborative

The PSTRC’s second core aim is to deliver “a translation pipeline” that feeds the outputs, products and learning from our work to local and national policymakers and health and care providers. The PSTRC works closely with Health Innovation Manchester, which is an academic health science system that brings together the research, education and clinical excellence of the Department of Health and Social Care (DHSC)-designated Manchester Academic Health Science Centre (MAHSC) with the expertise and national connections of the Greater Manchester Academic Health Science Network (GM AHSN). This will ensure scarce financial and workforce resources are used to provide value for money and safer health and care.

The PSTRC has developed strong links with the Health and Social Care system in Greater Manchester and Health Innovation Manchester, as well as the Patient Safety Collaboratives and Academic Health Science Networks in Greater Manchester and the East Midlands.  PSTRC staff are members of the Health Innovation Manchester Patient Safety Collaborative Steering Group (Ashcroft, Campbell) and the Research and Evaluation Committee for Patient Safety Collaborative-East Midlands (Waring).

Examples of specific projects will include the PSTRC working with:

• The Greater Manchester Patient Safety Collaborative on its deteriorating patient agenda with plans to develop an ‘early warning’ tool for identifying and responding to deteriorating patients following discharge from hospital to a community setting
• The Christie NHS Foundation Trust on on optimising safe follow-up and patient experience after discharge from out-patient care
• A range of health and care and voluntary organisations in developing its research on homelessness
• NHS England and NHS Improvement to reduce the level of medication error across the NHS
• NICE, DHSC, NHS England and Health Education England to reduce suicide rates and self-harm
• The Manchester Patient Safety Collaborative to implement the Patient Safety Toolkit across Greater Manchester.

Pharmacists working towards safety improvements

The Greater Manchester PSTRC’s Community Pharmacy Patient Safety Collaborative was set up by the PSTRC to encourage a mutually-beneficial dialogue between community pharmacy workers and researchers, and ultimately to improve patient safety.

The PSTRC’s Medication Safety team shares their knowledge on best practice in patient safety and risk management techniques with the Collaborative and in turn, the Collaborative shares their experiences and insights of practical day-to-day pharmacy practice with the PSTRC.

The group of 9 pharmacists are employed in a range of pharmacies from small independents to large chains, and they meet on a monthly basis. Sessions involve teaching of safety concepts and risk management techniques, sharing of experiences and discussions on the issues currently impacting on the safety of work in pharmacies. Outside of the sessions, the Collaborative engages in research-based activities – such as audits, or applying the taught risk management techniques to their own practice – with a view to sharing their insights within the group.

Pharmacists have seen real-world benefit through their involvement in the Collaborative:

• James Hind, Community Pharmacist, says:  “I developed the idea of label that could be attached to the dispensing bag. I wanted something that could be used as a quick check (have we got the right patient; did we tell them what their medication was for, and are they confident that they know how to use it).”
• Tomasz Niebudek, Community Pharmacist, says: “The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. 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.”
  

You can read more about the Community Pharmacy Patient Safety Collaborative in our blog series.

Improving patient safety: linking PSTRC research and expertise to policy and practice

Linking up with policy-makers and clinical services is an important part of the work of the NIHR Greater Manchester PSTRC.  Nav Kapur, who is a Professor at the University of Manchester and one of the Research Leads for the Centre, really values the wider engagement he has had with NICE (he chaired the NICE self-harm and depression guidelines), the Department of Health and Social Care,  and Health Education England amongst others.  

Nav says: “We are proud to be a leading centre for research into self-harm and suicide and it’s been a privilege to inform policy and practice.  As an academic, being involved in guideline development allows you to get a wider view of the worldwide literature and its impact on patients.  As a clinician, I like the fact that being involved in guidelines and policies allows you to improve the care of all patients, not just the patient in front of you.”

He continues: “As part of my role as a member of the National Suicide Prevention Strategy Advisory Group for England I contributed to the new suicide prevention strategy, particularly its emphasis on self-harm, as well as contributing to initiatives on confidentiality and responding to new methods of suicide.  My work with Health Education England aims to develop competencies for all NHS staff in the assessment of patients who present with suicidal thoughts or self-harm.” 

Nav also values his role contributing to the induction of new chairs for NICE Guidelines. He explains: “In some ways I find it quite strange that I am now one of the most experienced guideline chairs!  But I really enjoy sharing my experiences of chairing groups and guideline development with people just embarking on the process and I hope they find it helpful too.” 

Nav and colleagues including Roger Webb and Caroline Sanders who lead the Safety in Marginalised Groups theme are looking forward to contributing further to guidelines and policy and practice.  In particular the planned work on the management of self-harm, the safety of mental health services, and improving care for marginalised groups could have a major impact on patient safety and patient care.        

Drug Utilisation Research Group (Euro DURG)

Stephen Campbell attended the European Drug Utilisation Research Group (Euro DURG) Conference 2017, in Glasgow in November 2017 to present at a workshop on the “Quality of quality indicators”. Healthcare and medication use are changing and the field of drug utilisation research is evolving in a digital world.

Drug utilisation is an eclectic scientific discipline that includes many methods for the “quantification, understanding and evaluation of the processes of prescribing, dispensing and consumption of medicines and for the testing of interventions to enhance the quality of these processes”.  It has overlap with the PSTRC focus on medication safety, transitional care for those with multimorbidity and safety informatics but is linked also to the broader field of pharmacoepidemiology (the study of the uses and effects of drugs in defined populations) and health outcomes research and health economics.

The overall aim is to improve the safe and efficient use of medicines in populations to shape health policy and clinical practice.  The economic and health consequences of inappropriate drug use are substantial and patients are the end users of medicines. Those in marginalised groups can experience more inconsistent outcomes due to medication. The conference emphasised the need for a partnership between researchers, policy-makers and patients.

ISQua 34th annual conference

In October 2017, Sudeh Cheraghi-Sohi chaired a workshop at The International Society for Quality in Health Care (ISQua) 34th annual conference. The workshop was entitled “Developing and improving a systems approach to diagnostic safety in primary care” and was developed with collaborators Hardeep Singh from the Veterans Affairs organisation based in Houston, Texas and Ian Litchfield from the Institute of Applied Health Research, Birmingham University.

The workshop covered three major areas in diagnostic error and safety.  Firstly, Sudeh introduced the concept and various definitions of diagnostic error, along with the various causes of such errors and how to measure them. This was followed by Ian Litchfield presenting some work on a specific cause of diagnostic errors: poor or non-existent test results follow-up. Ian Litchfield described where these issues commonly occur e.g. clinicians being unaware that ordered tests had not come back from the lab. Finally, Hardeep Singh summarised the future research agenda in this area and highlighted how Information Technology will play an increasing role in diagnostic safety.

Many in the audience expressed surprise as to how little focus there had been on this area given its importance and expressed support of our current work and the future research agenda. Diagnostic error is still a niche area, but is gaining prominence due to America’s Institute of Medicine’s 2015 Improving Diagnosis report and The World Health Organization’s Technical Series on Safer Primary Care, which both prioritised errors in diagnosis as a global priority for patient safety.