Tag Archives: Patient Safety

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.

Diagnostic Error in Medicine: key topics

2 Nov

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

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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

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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

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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

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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.

Patient safety and children with long-term health conditions

4 Sep

by Sue Kirk, Professor of Family and Child Health

Juvenile diabetes patient with his mother

Increasing numbers of children and young people are living with a long-term health condition such as diabetes or asthma. Over the past 20 years we have also seen more children with complex healthcare needs being cared for in their own home rather than in hospital.  These changes have led to parents (and the children themselves) taking on roles and responsibilities that would have been unthinkable in the past. This includes monitoring their individual health, managing their own medication and treatment, using complex medical equipment such as ventilators, acting as care coordinators, and in some cases organising and managing home care teams.

Parents and young people don’t only manage these health conditions within the relatively controlled environment of the home. Children and young people go to school and college, take part in social activities with their peers and families, go on holiday and may spend time in hospices and other care settings. They may also receive services from a vast array of health, social care and voluntary sector organisations. This presents challenges for communication, both between professionals and between families and professionals, and consequently for care integration. This is worsened as young people transfer to adult services.

Surprisingly there has been little research that has examined patient safety for this marginalised group. We don’t know how families or health care professionals understand, monitor and manage safety in this complex situation or how safety could be promoted and improved.  This is what we intend to look at as part of the Safety in Marginalised Groups: Patients and Carers theme of the Greater Manchester PSTRC.

Placing ALL patients and carers at the heart of patient safety research: introducing our new theme on marginalised groups

23 Aug

by Caroline Sanders, Research Lead in Safety in Marginalised Groups: Patients and Carers

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In his 2013 review for improving patient safety, Don Berwick emphasised the importance of seeking out the voice of patients and carers, and ensuring they are ‘present, powerful and involved’ at all levels. This has been a major focus of our earlier research, our involvement and engagement work, and led to our priority setting partnership in conjunction with the James Lind Alliance in March 2017. This identified the number 1 question for future research is to understand ‘How can patient safety be assured for the most vulnerable in society?’. This recognises the widespread concerns and evidence showing that patients and carers who are already disadvantaged and marginalised, may also be at greater risk of harm within the healthcare system.  Additionally, we have not yet done enough to ensure we hear the voices and understand the experiences of marginalised groups to be able to develop appropriate and effective interventions to support patient safety for ALL patients and carers.

Our starting point for the new research that will evolve along with our further Patient and Public Involvement (PPI) work, is to acknowledge that people may be disadvantaged and marginalised by multiple factors such age, disability, ethnicity, sexuality, gender, and socio-economic disadvantage.  For example, we know that BME groups have poorer health outcomes, and poorer access and experiences of healthcare services. People may also be marginalised because of stigma and poor access to services for specific conditions (e.g. mental health problems); or they may be marginalised because of the circumstances or settings in which they live (e.g. living alone, caring for someone at home, living in a rural setting, in a care home or prison, being homeless).

In this theme, we will be working closely with other themes and our PPI contributors to focus on and understand safety risks and concerns for specific population and patient groups. For example, what are the particular challenges in relation to communication, which we know is considered by patients and carers to be a crucial foundation for safe care? What are the challenges for marginalised groups of patients in the ever-changing care context, where there are new responsibilities and health care practices expected as a part of enabling better self-management? We will co-design or adapt tools to support patient safety that will be tailored for such groups.  This may include use of mobile apps or other technologies, and we will also focus on the help and support that people might need to make sure they can use these, or enable appropriate alternatives. We know this means we need to be creative in reaching out to communities and groups who currently feel disempowered or hidden in relation to healthcare research and service provision. We are looking forward to this exciting opportunity to seek out some of the quietest and most hidden voices to ensure the most vulnerable can have better and safer care.

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