VTS PATIENT SAFETY TRAINING DAY Dr Christine Johnson, National Patient Safety Agency Dr Jane Carthey, Human Factors Specialist, JCC - PowerPoint PPT Presentation

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VTS PATIENT SAFETY TRAINING DAY Dr Christine Johnson, National Patient Safety Agency Dr Jane Carthey, Human Factors Specialist, JCC

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Title: VTS PATIENT SAFETY TRAINING DAY Dr Christine Johnson, National Patient Safety Agency Dr Jane Carthey, Human Factors Specialist, JCC


1
VTS PATIENT SAFETY TRAINING DAYDr Christine
Johnson, National Patient Safety AgencyDr Jane
Carthey, Human Factors Specialist, JCC
2
Objectives of the day
  • To update you on the field of patient safety
  • To explore patient safety issues in primary
    care
  • Introduce you to the work of national agencies
    who have a role in improving patient safety
  • To encourage you to consider how this work
    applies to your practice.

3
Todays Agenda
  • 09.30- 09.40am Introduction and purpose
  • 09.40-10.25am Patient Safety for GPs What
    are the issues?
  • 10.25-10.40am Patient safety in Primary
    care Setting the Scene
  • 10.40-11.00am Coffee Break
  • 11.00-12pm Patient Safety Research A GPs
    personal perspective
  • (Professor Aneez Esmail)
  • 12-12.30pm E-learning demonstration
  • 12.30-1.15pm Lunch
  • 1.15-2.15pm Prescribing oral anti-coagulants
    safely
  • 2.15-3.30pm Being open
  • 3.30-4.00pm Feedback and evaluation of the day


4
Format of the day
  • Mixture of presentations and group work
  • Aims to be interactive and discursive
  • E-learning material
  • Video and forum theatre based Being open session

5
Patient Safety for GPs What are the issues?
  • Dr Christine Johnson, National Patient Safety
    AgencyDr Jane Carthey, Human Factors
    Specialist, JCC

6
Patient Safety for GPs What are the issues?
  • Work in groups at your table
  • Introduce yourselves to each other
  • Identify the patient safety issues that occur in
    a GP Practice.
  • Types of patient safety incidents you have
    experienced or heard about through local incident
    reporting or discussions with colleagues.
  • Capture your responses on flip chart paper
  • 30 minutes group discussion
  • 15 minute feedback session

7
Patient Safety In Primary Care Setting the Scene
  • Dr Jane Carthey

8
Patient Safety In Primary Care Setting the Scene
  • Types of errors and incidents in primary care
  • National agencies with a role in improving
    patient safety

9
Errors during GP consultations
  • Sandars and Esmail (2003) reviewed eleven studies
    relating to medical error in primary care to
    identify the frequency and nature of errors.
  • Overall, the studies reported wide differences in
    rates of errors in primary care, varying from
    five to 80 per 100 000 consultations.

10
Errors during GP consultations
  • Diagnostic errors were consistently the most
    frequent incident type across all studies,
    varying from 26 to 78 of identified errors.
  • Both delayed and missed diagnoses were identified
    as the error type most likely to result in major
    harm.
  • The second most common category of error type
    related to treatment, either delayed or
    inappropriate, varying from 11 to 42 of
    identified errors.
  • These errors were less likely to result in major
    harm to the patient.

11
Errors in GP practices
  • UK study using an anonymous self-reporting system
    to identify errors occurring in the GP practices
    in the North East of England
  • Two week data collection period 940 errors were
    recorded from 10 practices 42 (397/940) were
    related to prescriptions, although only 6
    (22/397) of these were medication errors.
  • Communication errors accounted for 30 (282/940)
    of errors and clinical errors 3 (24/940).
  • The overall error rate was 75.6/1000 appointments
    (95 CI 71 to 80) (Rubin, George et al., 2003).

12
Prescribing errors
  • Incorrect drug, dose, frequency, drug
    interactions etc..
  • Avery et al., (2005) GPs expectations and
    beliefs about electronic prescribing systems
  • Many GPs were unsure as to whether the system
    they were currently using possessed key features.
  • Some GPs erroneously believed that their
    computers would warn them about potential
    contraindications or if an abnormal dose
    frequency had been prescribed.
  • Only a minority had received formal training on
    the use of their system's patient safety features

13
National agencies
  • National Patient Safety Agency
  • NICE
  • Royal Colleges (including RCGP)
  • National Institute for Innovation and Improvement
  • Healthcare Commission
  • NHSLA
  • Plus many others

14
National Patient Safety Agency
  • Collect and analyse information on patient safety
    incidents in the NHS
  • Assimilate other safety related information from
    within the UK and worldwide
  • Learn lessons and ensure that they are fed back
    into practice
  • Where risks are identified - produce solutions to
    prevent harm, specify national goals, establish
    mechanisms to track progress
  • Building a safer NHS for patients
  • Department of Health (2001)

15
National Reporting Learning System (NRLS)
Feedback
International Collaboration Australia USA Europe
NPSA
Standardised reporting
NHS Trusts
PractitionersStaff
Healthcare Commission MHRA NHS Complaints NHS
Litigation Authority
Patients Carers
16
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17
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18
Alert 18 Actions That Can Make Anticoagulant
Therapy Safer
19
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20
Reasons Swiss cheese model
Levels of defence
LATENT CONDITIONS poor design,
procedures, management decisions etc..
Patient Safety Incident
ACTIVE ERRORS
21
Any Questions?
22
Patient Safety Research A GPs Personal
Perspective
  • Professor Aneez Esmail,
  • Professor of General Practice,
  • School of Medicine.
  • University of Manchester

23
E-learning introduction and demonstration
  • Alan Mullen, E-learning advisor
  • Adam Crowley, E-learning advisor
  • E- Learning for Health

24
Prescribing oral anti-coagulants safely
  • Dr Jane Carthey Dr Christine Johnson

25
Safe Medication Practice Work Programme 2007 -
2008
  • Five Patient Safety Alerts on High Risk Issues
  • Actions that can make the use of anticoagulants
    safer
  • Promoting safer measurement and administration of
    oral liquid medicines
  • Promoting safer practice with injectable
    medicines
  • Safer practice with epidural injections and
    infusions
  • Reducing the risk of hyponatraemia when
    administering intravenous infusions to children
  • Work led by Professor David Cousins at the NPSA

26
Alert 18 Actions That Can Make Anticoagulant
Therapy Safer
27
UnderstandingAnticoagulant Incidents
  • The NPSA contacted the medical and pharmacy
    defence organisations as well as the NHS
    Litigation Authority.
  • There have been 480 reported cases of harm or
    near harm from the use of anticoagulants in the
    UK from 1990-2002.
  • In addition there have been 120 deaths reported
    over the same time period.
  • Deaths from the use of warfarin is responsible
    for 77 (92 reports) and heparin is responsible
    23 (28 reports).

28
Incidents Reported to NRLS
29
Incidents Reported to NRLS
30
The 3-bucket model forassessing risky situations
(Reason, 2005)
3
2
1
Self Context Task
31
Warfarin incident scenario 1
  • Read through first page of the scenario ONLY!
  • In your groups, discuss what went wrong
  • Think about the Three Buckets and Swiss Cheese
    Models (i.e. errors and systems)
  • 10 minutes discussion
  • Capture discussion on flip chart paper

32
Warfarin incident scenario 2
  • Read through second page of the scenario
  • In your groups, discuss what could have prevented
    this incident
  • 10 minutes discussion
  • Capture discussion on flip chart paper

33
The Safer Practice Alert
34
Alert 18 Actions That Can Make Anticoagulant
Therapy Safer
35
Yellow Book
  • Worked with BSH and patient group
  • Increased information and requirement to store
    records will require size to be A5
  • Will incorporate credit card sized alert card
    with basic patient information
  • Space at back to store records of INR, dose, next
    clinic appointment (could be two part
    computerised form or hand written)

36
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37
Competency development
  • NPSA developed the following sets of
    competencies using a Skills for Health framework
  • Initiating anticoagulant therapy
  • Maintaining oral anticoagulant therapy
  • Managing anticoagulants in patients requiring
    dental surgery
  • Dispensing anticoagulants
  • Preparing and administering heparin therapy
  • Reviewing the safety and effectiveness of an
    anticoagulant service

38
Safety Indicators
  • Developed by the British Committee for Standards
    in Haematology (BCSH) and the NPSA
  • Compliment the guideline form BCSH on oral
    anticoagulation updated in 2006.
  • To be used as audit standards
  • A template (word document) for audit of Safety
    Standards can be downloaded from the BCSH website
    and modified for local use

39
Safety Indicators For Inpatients
  • patients following loading protocol
  • patients developing INR gt 5
  • patients in therapeutic range at discharge
  • patients suffering a major bleed in first month
    of therapy and percentage suffering major bleed
    with INR above therapeutic range
  • of new referrals to anticoagulant service with
    incomplete information
  • of patients that were not issued with patient
    held information and written dosage instructions
    at start of therapy
  • patients that were discharged from hospital
    without an appointment for next INR measurement
    or for consultation

40
Safety Indicators Ambulatory Care
  • Proportion of patient-time in range
  • Percentage of INRs gt 5.0
  • Percentage of INRs gt 8.0
  • Percentage of INRs gt 1.0 INR unit below target
  • Percentage of patients suffering adverse outcomes
  • Percentage of patients lost to follow up
  • Percentage of patients with unknown diagnosis,
    target INR or stop date
  • Percentage of patients with inappropriate target
    INR for diagnosis, high and low
  • Percentage of patients without written patient
    educational information
  • Completion of risk assessment of standard
    operating procedures

41
E-learning modules
  • Two e-learning modules commissioned
  • Initiating anticoagulant therapy
  • Maintaining patients on anticoagulant therapy
  • Aimed primarily at junior doctors
  • Will be available on the BMJ learning website

42
Safer Practice RecommendationsFor Anticoagulants
  • Repeat prescriptions check blood test results
    on prescribing and dispensing
  • Safer practice when co-prescribing an interacting
    medicine

43
Safer Practice RecommendationsFor Anticoagulants
  • Safe management of patients requiring dental
    treatment
  • Standardise the range/strengths of anticoagulants
    used
  • Safe procedures for anticoagulants in care homes

44
Support materials
  • To aid implementation
  • Risk assessment tool, patient held information,
    posters, guidelines, protocols, work competences,
    e-learning modules,
  • To aid evaluation
  • Patient safety indicators, audit protocols and
    audit collection forms.

45
Juliet Brown wants to know what went wrong with
her mothers care
  • How would you communicate empathetically to the
    patients relatives?

46
Being open Communicating with patients and/or
carers about patient safety incidents
  • Illustrative Workshop

47
Purpose of the Session
  • To provide an overview of the NPSAs Being open
    policy and training
  • For participants to learn key communication
    skills that underpin effective communication with
    patients and/or carers following a patient safety
    incident.

48
NPSAS Being open work
  • Being open policy
  • Safer Practice Notice
  • E-learning toolkit
  • One day training workshops

49
The Ten Principles
  • 1. Acknowledgement
  • 2. Truthfulness, timeliness and clarity of
    communication
  • 3. Apology
  • 4. Recognising patient and/or carer expectations
  • 5. Professional support
  • 6. Risk management and systems improvement
  • 7. Multidisciplinary responsibility
  • 8. Clinical governance
  • 9. Confidentiality
  • 10. Continuity of care

50
Actions for healthcare organisations
  • Develop and implement a local Being open policy
    by June 2006.
  • Identify local Being open leads and clinicians to
    attend Being open training workshops.
  • Raise awareness of the Being open e-learning
    locally and ensure staff have access to it.

51
The benefits of Being open
52
Patient/Carer Testimony
53
Effects of Patient Safety Incidents
  • On Patients and/or Carers
  • What would you have wanted to happen in this
    situation and/or if the patient was a member of
    your family?
  • What 3 things do you think patients and/or carers
    involved in this type of incident would want
    most?
  • On Healthcare Professionals
  • How would you feel if you had been the healthcare
    professional involved?
  • What would you want to happen as healthcare
    professionals?

54
Patient/Carer Testimony
55
Discussing incidents with patients and carers
56
The 3 Phases of the Discussion
  • Phase 1 Open the Discussion
  • Preparing for the discussion
  • Introducing all parties and agreeing purpose
  • Apologising and acknowledging
  • Phase 2 Discuss the Incident
  • Checking the patients and/or carers
    understanding
  • Clarifying the known facts of what happened
  • Answering questions and noting concerns

57
The 3 Phases of the Discussion
  • Phase 3 Outline the Next Steps
  • Explaining the incident investigation process
  • Outlining the plan to medically repair or redress
    the harm done as appropriate
  • Offering support, counselling and information
    sources
  • Documenting and agreeing further actions
  • Confirming ongoing communication contact details

58
Nick Oliver and the Blood Transfusion
  • Forum Theatre Exercise

59
Key Learning Points
  • Being open helps patients and/or carers deal with
    the effects of a patient safety incident
  • Consideration should be given to who the right
    person is for the initial Being open discussion
  • Most patients want
  • An apology
  • An explanation
  • Reassurance that it wont happen again
  • Information on what, if anything, can be done to
    repair the harm done

60
Key Learning Points
  • Saying sorry to patients and/or carers is not an
    admission of legal liability
  • NHS organisations will support staff throughout
    the Being open process
  • There are ten Being open principles
  • Being open is a process, not a one off event
  • There is no one size fits all solution.

61
Stacey and the Penicillin
62
  • Any questions?
  • www.npsa.nhs.uk

63
Feedback and evaluation
  • Please complete your evaluation sheets
  • Leave them with myself or Christine
  • Thank-you for attending todays VTS Patient
    Safety
  • Training Day.
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