Tag Archives: primary care

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.

Why does PPI benefit research?

13 Jul

by Sally Giles, Research Fellow in Core PPI Research theme and Philip Hammond, PPI Coordinator

PPI blog post_July2017

Why do PPI?

“All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety + quality of care” Berwick Review, July 2013

We believe that including the patient voice in our research makes it more meaningful and relevant to the real world.  We have experienced examples of when patient feedback has influenced our research.  As part of the Greater Manchester PSTRC we wanted to look at how PPI impacted on our research in an academic context.  To do this we had a look at the academic literature, firstly to find out why people involve members of the public in their research. We discovered that people who use health services can help to ensure that issues that are identified and prioritised are important to them and therefore to health care, public health and social care as a whole.  Public involvement can help to ensure that money and resources are not wasted on research that has little or no relevance and that being involved in research can help empower people living with a medical condition.  We used this as a basis to develop our own PPI structure within the Greater Manchester PSTRC.

The Research User Group (RUG)

The RUG started off as a group of 12 members of the public, who met every 6 weeks.  Each of the research themes within the Greater Manchester PSTRC were allocated 2 or 3 members to their theme.  A RUG evaluation highlighted that some researchers were heavily reliant on their aligned members for all projects within their theme.  It also highlighted that it was challenging to see how the RUG was having an impact on research, as this impact was mainly happening at project level.   Based on feedback of RUG members and in an attempt to widen involvement by bringing in more associate members of the public, a restructure to the RUG took place.  It was agreed that there should be a split between governance and project level PPI.  This new structure was implemented two years into the centre.

The restructure enabled us to focus more on project level PPI, and we have a number of examples of how PPI has benefitted the research on specific projects.  Some examples follow below:

1.   Multimorbidity Research Advisory Group (MRAG) was set up to involve patients and carers in the development of resources and new research projects for the Multimorbidity theme.  It consisted of 18 group members who provided feedback on research, shared ideas, helped to set research priorities and supported two applications for further funding.

2.   In the Interface & Informatics theme patients and public contributors have been involved in enhancing research by taking part in a number of  sessions aimed at investigating the relevance of an established patient portal for patients with long term conditions (PatientView) and identifying strategies for improvement. This group also commented on draft study protocols, designed and co-facilitated a larger workshop and helped to identify social media and patient associations as an additional recruitment strategy (resulting in 25% more recruits).

3.      In the Medication Safety theme members of the public have been involved in the recruitment of participants for focus groups, co-facilitation of focus groups and coding of transcripts using an existing framework.

4.      For the Core theme members of the public have helped develop the Primary Care Patient Measure of Safety (PC_PMOS) study.  They helped to develop the items to be included in the PC_PMOS and recruited patients in GP practices to complete the PC_PMOS, Patients were able to relate more easily to the PPI members than the research team, which helped to increase participation in the study

5.      In the GP theme there has been public and stakeholder involvement in the patient safety guide project via 3 different involvement groups with key stakeholders.

Thoughts for the future

Our advice to anyone wanting to develop a PPI structure within a large (or small) research centre is to plan carefully by starting with a clear strategy, but be willing to accept that this will constantly change as the needs of those involved evolve.  Involvement needs to continue to be an iterative process, people have different (and changing) needs and get involved for different reasons, and equally research studies have different aims and priorities which need to be addressed when planning involvement.  We see involvement as being broader than patients or members of the public.  Often the end users of our research have been health professionals and as such, our definitions of involvement and engagement have evolved to include all relevant stakeholders.

Black and minority ethnic involvement in health research: Veena Parmar

20 Jun

Veena Parmar_photo_June 17

Veena Parmar has been providing a patient/public perspective for NIHR Greater Manchester PSTRC student Shoba Dawson’s PhD project about barriers to involvement in research among BME (black and minority ethnic) groups.  In this article she chats to Jill Stocks (Research Fellow, Core theme) about her experience.

Jill: Hi Veena, tell me a little about your background.

Veena: I am a second generation Indian born in Nairobi and educated in the British colonial system. My family is a blend of Anglo Indian Portuguese culture. It’s great when we have family gatherings to exchange our various views. The Portuguese family go on about Vasco da Gama, Christopher Columbus, Cork, port wine and the spice trade while we Anglo Indians brag about the industrial revolution, trains, the cotton and motor industry, and so on. Since being married I have lived in and around Manchester.

Jill: Before becoming involved with the Greater Manchester PSTRC what did you know about Patient and Public Involvement (PPI) in research?

Veena: I had only heard about people who were participating in clinical trials, I had some friends who were part of a rheumatism trial.

Jill: What made you decide to become involved in PPI?

Veena: At first I was dubious but Shoba really encouraged me to come and meet her and the other PPI partner. At the meeting I found the topic really interesting, we read some case studies and gave our opinions.

Jill: What have you personally got out of the involvement?

Veena: I learnt a lot and found myself reflecting on my own multicultural experience through our discussions. Shoba is a kind person and always very supportive.

Jill: What support or advice were you able to provide?

Veena: I offered advice on how to get BME communities involved in research. I had lots of ideas and suggestions about how to work through community leaders and how to approach women in socially-conservative communities.

Jill: What aspects did you enjoy least or find difficult?

Veena: I was asked to give a presentation and imagined it would be in a theatre with a large audience so I felt unable to do it. In fact it was an informal talk with a small audience so I felt a bit disappointed because I would have felt confident to talk if I had known that.

Jill: What advice would you give to anybody thinking about getting involved as a PPI partner?

Veena: Make sure you understand what you are getting yourself in to and ask questions. Keep an open mind and you will learn a lot.

Jill: Would you do more PPI in future?

Veena: Yes – absolutely.  Although I am about to retire and hope to do some travelling so it would have to be as a short term commitment…

Community Pharmacy Patient Safety Collaborative: Safety Initiatives

14 Jun

Chui Cheung photo

My name is Chui Cheung, working as a community pharmacist in Wigan, Lancashire.  I joined the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative Study with the University of Manchester in November 2015.  Looking back, it was curiosity that led to my participation and I was worried how I would handle the research projects.  Nevertheless, the title of patient safety attracted me to find out more.

Patient safety is at the centre of our everyday tasks whether we are pharmacists, technicians, dispensers, medicine counter assistants or other members of the team. Whatever we do in the course of our work, we must do it safely.

At the start of the first year project, there were 8 to 10 pharmacists with a range of different working backgrounds and age groups.  We attended a full day session every 4 to 6 weeks at the University.  We were relieved to discuss openly and share our experience on patient safety.  The aim was to build a safety case using our working environment and team resources.  My project centred on dispensing safety: ‘Are we dispensing safely?’ and later on was refined to a quantitative safety incident claim.

We were introduced to specific tools: Hierarchial Task Analysis (HTA), Failure Mode and Effect Analysis (FMEA), System Human Error Reduction & Production Approach (SHERPA) to help our analysis of the safety profile. Our team broke down the complex dispensing tasks into smaller working steps or processes systematically. On a practical application, the Proactive Risk Monitoring (PRIMO) questionnaire was helpful to use as a team to identify various patient safety risk factors.  We then made risk assessments of the dispensing processes through the SHERPA and used Plan, Do, Study, Act (PDSA) cycles to evaluate improvement.

The whole team began to monitor and record near misses and dispensing incidents on a more conscious level than before and made voluntary changes towards an open, no-blame working culture. The goal of safer dispensing became a number one priority all the times.  The team’s brainstorming revealed many common triggers or events of ‘the vulnerable moment’ during the dispensing processes.  Several checking procedures were used as checker reminders.

The pooled data of errors showed high times of errors, typical error categories and even the common medicines.  Individually, we were able to find out when and how we perform best and made aware of the pitfalls.  We discovered that we were prone to errors particularly when we were ‘expected’ to have ultra-quick dispensing.  Through a member’s suggestion and our dispenser’s effort, we now display a shop poster giving a summary of ‘the way we prepare your medicines’ and give customers opportunities to read through the additional copies whenever there is a queue forming.  It works really well and the feedback is positive too.  The team and customers seem happier.

In year 2 of the project, we came across analytical tools (Faulty Tree Analysis, Bowtie diagram) to look at our safety claim.  We continued to expand our safety interests and used a more sophisticated reporting form called  ‘Incident Investigation Form’ which covers error description, the factors causing the error, the risk category, course of the event and improvement plans.   We have since modified the form for in-house use.  The bundle of safety data showed how we had been dispensing safely or otherwise.  As a result, we implemented a couple of measures (such as safety shelf reminders, Top 20 common error medicines list) to help us improve on a regular basis.  The data is also useful in staff appraisal.

Moreover, we felt fortunate to have the ready-made patient safety data for Quality Payment application.  My experience in the patient safety collaborative has been overwhelmingly good and positive.  I wouldn’t have known about these analytical methods and thought about the improvement plans if I hadn’t been part of the study group.

I recommend that any pharmacy team who is interested should come along for a taster session to see if this is right for you.

Introducing…Safer Care Transitions

1 Jun

by Justin Waring (University of Nottingham) and Harm van Marwijk (University of Manchester)

Safer Care Transitions will be one of the research themes in the NIHR PSTRC Greater Manchester which will run from 1 August 2017 until 31 July 2022.

Safer Care Transitions blog icon

Patient journeys are full of care transitions. By transitions, we mean that the responsibility for patient care is transferred or handed over from one team, department or organisation to another.

If we think about someone who experiences an accident at work, they might be seen at first by a paramedic before being transported by ambulance to their local hospital’s emergency department. There they might receive urgent care before being admitted into the hospital for follow-up care. When recovered, the patient will then be discharged home or to community setting where they could receive rehabilitation, nursing care, social care and follow-up treatments by their GP, under the primary medical responsibility of the GP.  The GPs’ medical records can follow most of such transitions and provide an overarching view, but others (patients) cannot access such data now. GPs would be seen to have an overarching responsibility to facilitate seamless management between settings but little work has been done on this.

Transitions are common to virtually all patient journeys, because healthcare services are provided by specialists and professionals who work in different clinics, surgeries and hospitals. Although there is now better understanding of what makes for safer care within each of these care settings, there is less of a clear picture about what makes for safer care transitions between these care settings, and how to develop problem-based records that capture transitions and are accessible to more than GP practices.

There is mounting evidence from around the world that care transitions are a high-risk stage in the patient journey. Research from the US, for example, suggests that as many as two out of every ten hospital discharges will experience some form of safety incident. These safety incidents take the form of incorrect medicines, missing equipment, or inappropriate care planning.  Research within the NHS suggests that it is often difficult to coordinate the involvement of different professionals and specialists because of common communication breakdowns and the difficulties of finding time to work together to identify solutions to common problems or work from a shared and validated record. A recent Healthwatch report highlighted the enormous suffering and anxiety experienced by patients as they approach hospital discharge, often because of the uncertainties about when they will go home, who will look after them, and how they will cope. Current resources constraints within the health and social care sectors have seemed to make these problems worse, with limits on the availability of social care to support safe hospital discharge.

The Patient Safety Translational Research Centre Greater Manchester is leading a programme of research that will develop new learning about what makes for safer care transitions. It will look to ways of working and technological breakthroughs in other sectors to learn lessons for the NHS. For example, many courier and supply chain services use advanced technologies to track their deliveries. There is also greater scope to empower patients to coordinate their own care through developing smart technologies that enable them to manage and share their own records with different healthcare professionals. There is also much healthcare services could learn from other industries about ensuring continuous accountability for care, so that someone is always there to speak up for and protect the safety of patients, and ways to develop such support for the most vulnerable trajectories such as around cancer and frail older people.

The projects developed in this theme will address the safety of care transitions in primary and secondary care, in mental health services, in chronic conditions, cancer care, and end of life care, to ensure learning and innovations are shared across the health and social care sectors.

Further information:

Healthwatch (2016) Safely Home, London: Healthwatch. http://www.healthwatch.co.uk/safely-home

Waring, J., Bishop, S., & Marshall, F. (2016). A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC health services research, 16(1), 297.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1568-2

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of internal medicine, 138(3), 161-167.

NIHR Greater Manchester PSTRC Meet the Team – Sally Giles

12 May

The seventh in our NIHR Greater Manchester PSTRC ‘Meet the Team’ series introduces Sally Giles, Research Fellow in our Core PPI research theme

Sally Giles_Meet the Team_v1

Sally Giles_Meet the Team_v1Sally Giles_Meet the Team_v12

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.