Archive | Quality and Safety RSS feed for this section

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.

How can we improve safe communication and co-ordination of care between primary and secondary care?

19 Apr

Part four in the James Lind Alliance Primary Care Patient Safety Priority Setting Partnership blog series: Part One, Part Two, Part Three

by John Taylor, patient attendee of the JLA Primary Care Patient Safety PSP final workshop

JLA PSP Top 10_Number 3Question 1 for me is, have there been any high grade research papers published already on this subject? If yes, then are there meta-analyses showing useable findings, and how old are these and have the findings been overtaken by newer recommendations?

Acting as Devil’s Advocate I would ask ‘who has posed this topic’ and ‘what evidence has been the basis for it’ and ‘how reliable or high grade is the evidence?’

As a  patient with multimorbidity, I personally feel that communications and coordination of care between primary care in its broadest sense and secondary care are often multi-centred and compartmentalised by ‘treatment episodes’ only indirectly linked, and even then through less than state of the art IT systems which may or may not be multi-site interoperable, which makes communication often slow, occasionally lost in space or paper chases and definitely not entirely in the best interest of good patient care.

So, how could improvements which would benefit the whole system be researched and put into practice?

Should lessons be learned from commercial users of communication systems who successfully run large scale businesses and care for the wants and needs of customers in ways which fulfil demand and generate repeat business, i.e. satisfied end users, and also learn from systems which have failed in their purpose due to poor design or uneconomic cost over runs or just failing to understand the needs of the users. Best practice should produce the designed outcomes consistently and be adaptable to cope with new needs as they are identified and designed to do this with minimum disruption and cost, there are many Healthcare Providers who have produced local workarounds which suit the needs of patients and providers with safe communications and care, NHS England, NHS Digital or NIHR RfPB (National Institute for Health Research Research for Patient Benefit) might be the vector to investigate how these develop and how well they might scale up.

I am constantly amazed and delighted at how, for example, Amazon handle their returns communications and customer care, they will respond to a ring back request within seconds, take the details, issue a printable label, arrange pick up and confirm by email then refund or replace as soon as the item is received at their depot. If Amazon and others can do this why is it so difficult for primary, secondary and, dare I say it, social care to learn how to communicate safely, rapidly and without arguing over ownership between themselves and patients, so that information flows freely, accurately and safely through the system, benefiting patients and providers alike.

Accurate and timely information is the key to good outcomes and thus improvements need to be constantly sought and implemented, carrying on doing what we have always done is not an option.

James Hind, member of the Community Pharmacy Patient Safety Collaborative, scoops Clinical Excellence Award at Superdrug’s annual Awards Ceremony

23 Feb

by Penny Lewis, Medication Safety theme

james-hind-superdrug-awards_cropped

James Hind, pharmacist and member of the Greater Manchester Community Pharmacy Patient Safety Collaborative, scooped the Clinical Excellence Award at Superdrug’s Annual Awards ceremony in Heathrow last week. The ceremony which aims to celebrate employees’ successes and achievements also marked 25 years of Superdrug Pharmacy. Other awards included Nurse of Year, Operational Excellence Award and Pharmacist of the Year (for which James was also nominated). James was awarded this honour after being recognised for his outstanding contribution to patient safety as part of his work with the Community Pharmacy Patient Safety Collaborative.

James, who has undergone training in risk assessment techniques and incident analysis as part of the collaborative, has shared his learning across the company via their online ‘Hub’. One of James’ innovations has been the design and production of bag labels to prompt both staff and patients to check their medications or ask any questions before leaving the pharmacy. James has conducted a survey to explore patients’ views of the label which has shown that the label is well received by patients and can, in some cases, prompt patients to take a more proactive approach to checking. James hopes to evaluate the impact of the label on patient safety incidents over the next few months.

James’s passion for improving patient safety engendered by his work with the collaborative has inspired James to work more closely with Superdrug’s Safety Office and also suggest improvements to their incident reporting system. James also noted that error reporting has increased threefold as a result of his participation in the collaborative and that his team are now far more reflective of their practice when things go wrong.

Well done James!

Read James Hind’s blog post on his involvement with the Community Pharmacy Patient Safety Collaborative here

Reflections on ISQua 2016

16 Nov

by Sally Giles, Research Fellow in Core theme

isqua-2016-logo

This year’s International Society for Quality in Healthcare (ISQua) conference took me to the vibrant city of Tokyo, famous for its incredible technological growth, its seismic activity and geological features. For me, as a former geographer, this diversity was certainly fascinating and a real attraction! The Tokyo International Forum was the chosen venue, and with its numerous different levels, it even provided a challenge to those with the best sense of direction! 

The conference this year covered eight main themes, with hundreds of concurrent sessions to choose from; including 50 minute plenary sessions, 90 minute workshops and 15 or 5 minute oral presentations. There was also an impressive display of posters in the exhibition hall. One of the main highlights of the conference was the Japanese Bento lunch boxes, which made a welcome change to the often bland and uninteresting lunches provided at conferences. I was however slightly disappointed to see so little primary care research. I therefore challenge all Greater Manchester PSTRC researchers to place primary care patient safety research on the ISQua agenda in 2017.

This year I was allocated a 15 minute oral slot as part of the Person Centred Care theme. I took to the rather large stage and presented the findings from an NIHR Research for Patient Benefit (RfPB) study, “Developing a Patient-Led Electronic Feedback System for Quality and Safety within an existing Electronic Health Record”, which has since been accepted for publication in the Journal of Renal Care. My presentation was well received with particular interest in how we were going to take the patient reporting system forward and what training would be required for the patients who may wish to use it. Definitely food for thought!