Improving Patient Safetyin general practice

Edited version from a talk by Dr Robert Varnam

OVERVIEW

• What do we know?• Why do we reliably fail?• How to gain different perspectives?• Significant event analysis• Detecting & measuring adverse events• What to improve?

Patient Safety in General Practice

... what do we know?

What do we know?

What do we know?

• size of the problem– 25% of >75s experience healthcare associated harm each year– 5% of admissions = preventable adverse drug events

• impact of safety incidents– 73% of adverse events in >75s required some intervention

Series of 4400 patientswith 1400 adverse events

Approx 1m consultations per dayin general practice

What do we know?

Adverse events in general practice are wasteful→ increased costs→ reduced opportunities→ reduced staff morale

Improving safety requires good staff, good processes responsive, learning organisations generic measurement & improvement skills good access, high quality care

Patient safety culture

• ‘shared values, norms and attitudes, which combine to create the environment within which staff work’

• good safety culture– a constant and active awareness of the potential for things to go

wrong– open and fair, encourages people to speak up about mistakes– everyone takes up their responsibility for safety

Why do we reliably fail?

What causes harm to patients?Where should we focus our improvement efforts?

Lessons from Human Factors Research

• Errors are common • Errors are predictable• The causes of errors are known

• Many errors are by-products of useful cognitive functions

• Many errors are caused by activities that rely on weak aspects of cognition– short-term memory – attention span

SRK Framework

Conscious Automatic

Control ModeSituation

Routine

Novelproblem

Skill-basedbehaviour

Skill-basedbehaviour

Rule-basedbehaviour

Rule-basedbehaviour

Knowledge-basedbehaviour

Knowledge-basedbehaviour

Human Error

• “Failure of planned actions to achieve their desired ends” (Reason 1990)

PlanPlan ActionsActions OutcomeOutcome

Planning mistakesPlanning mistakes

Execution errorsExecution errors

Necessary ViolationNecessary Violation

Optimising ViolationOptimising Violation

Routine ViolationRoutine Violation

Knowledge-BasedMistakesKnowledge-BasedMistakes

Intended ActionIntended Action

Errors / Unsafe ActsErrors / Unsafe Acts

Human Error Taxonomy

UnintendedActionUnintendedAction

SlipSlip

LapseLapse

MistakeMistake

ViolationViolation

AttentionFailuresAttentionFailures

MemoryFailuresMemoryFailures

Rule-BasedMistakesRule-BasedMistakes

Skill-based slips & lapses

• Often due to inattention and distraction

• Double capture slips• Omission following interruption• Reduced intentionality• Perceptual confusion• Interference problems

Rule-Based Errors

• Application of a good rule to the wrong situation

• Situation not well specified• Cognitive overload• Situation is an exception to a robust rule

Knowledge-Based Mistakes

• Inadequate understanding of situation

• Bounded rationality

• Difficulty in creating complete and accurate mental representations of the problem space

• Heuristic strategies to cope with and reduce complexity may result in mistakes

Summary

Human Error Type

Typical Forms Common Prevention Strategies

Slip / Lapse

•Double capture•Omission•Interference•Perceptual Confusion

•Minimise interruptions•Forcing functions•Colour-coding, highlighting differences•Checklists, memory aids

Rule-Based Mistake

•Strong-but-wrong•Exception to rule•Cognitive overload

•Minimise / highlight exceptions•Provide feedback•Manage workload

Knowledge-Based Mistake

•Confirmation bias•Out of sight, out of mind•Encystment•Vagabonding

•Decision support•Team work & CRM training

Human error

The search for and understanding of errors has not made patient care much safer

Error is normal ... what are you going to do about it?

Violations

Professor Renee Amalberti

Key ReferenceAmalberti, Vincent et al. Violations and migrations in

healthcare: a framework for understanding and management. Quality and Safety in Healthcare 2006; 15; 66-71

Who always drives at 30mph?

PERFORMANCE

ACCIDENT

Systemic Migration to BoundariesV

ER

Y U

NS

AF

E S

PA

CE

The speed limit is 30 mph- the ‘legal’ space

Belief Systems

Life Pressures

INDIVIDUAL BENEFITS

Driving 35 mph- the ‘Illegal-normal’ space

Driving50 mph – the ‘illegal-illegal’ space (for almost all of us!)

Perceivedvulnerability

Prescribing a PPI with NSAID

• What is your policy for prescribing a PPI with a NSAI for patients over 60 years old?

• Do you observe it every time?

• When do you (choose) to violate?

• How far is it safe to migrate?

PERFORMANCE

ACCIDENT

Systemic Migration to BoundariesV

ER

Y U

NS

AF

E S

PA

CE

Every patient >60 on a NSAID gets a PPI

Belief Systems

Life Pressures

INDIVIDUAL BENEFITS

PPI for patients >60 when I remember or those with history of GI disease

I’ve never had a patient harmed by NSAID so don’t use a PPI

Perceivedvulnerability

System productionCommercial stressCoping and resiliencyIndividual advantages

Performance must be understood in a broad context

Productivity

• Migrations/violations are often seen first as benefits with immediate payback– saving time– increasing productivity

• Tension between following protocol and productivity

Results of Migration

• Migrations lead to a large range of illegal practices

• Over time these become “normal” for the system - stabilized

• All stakeholders in the system migrate and violate– Migrations differ for individuals and roles– E.g. senior management or actors in the field

What not to do

Don’t conclude “Policies must be stricter, clearer, and implemented” – Individuals make cost/benefit decisions on compliance. Too

stringent implementation can lead to violation/migration.

Don’t resort to exhortation “Work Harder/Better”– Don’t just send a memo about the old, written rule– Take a systems view

PERFORMANCE

ACCIDENT

Managing MigrationsV

ER

Y U

NS

AF

E S

PA

CE

Expected safe space of action as defined by professional standards

Market Demand

Life Pressures

INDIVIDUAL BENEFITS

‘Illegal-Normal’

Always/Sometimes

‘Illegal-Illegal’ Space

Never/Sometimes Technology

Never/ Never

Policy, Protocols, Regulation

‘Real Life’

BTCUs

Always/Always

1. Individual or collective experience of incidents, share storiesAgree stop rule to migration

2. Acknowledge individual variation in risk acceptance. System response required3. Forbidden

space, except under extreme pressure/ conditions

4. Agreed forbidden space for all staff

Accept and adapt protocols and defences

Suppress triggering conditionsHuman FactorsReliability

Add defences and Just Blame

Work harder. Be more vigilant. Follow the protocol and other useless interventions!

Human error

“We can’t change the human condition, but we can change the conditions

under which humans work”

James Reason

A systems approach

• make it easier to do the right thing

• make it harder to do the wrong thing

• redesign processes, to allow you to spot & stop errors reaching the patient

A systems approach

Factors Influences

Patient Condition (complexity & seriousness)Language and communicationPersonality and social factors

Task and Technology

Task design and clarityAvailability and use ofAvailability and accuracyDecision-making aids

Individual (staff) Knowledge and skillsCompetencePhysical and mental health

Team Factors Verbal communicationWritten communicationSupervision and seeking helpTeam structure (congruence, consistency, leadership)

A systems approach

Factors Influences

Work Environmental Staffing levels and skills mixWorkload and shift patternsDesign. availability and maintenance of equipmentAdministrative and managerial supportEnvironment

Organisanonal & Management

Financial resources & constraintsOrganisational structurePolicy, standards and goalsSafety culture and priorities

Institutional Context Economic and regulatory contextNational health service executiveLinks with external organisations

A systems approach

Conduct review of organization– Are processes simple and standardized?– Are failure identification and mitigation systems in place? (more on this

later)

Conduct a task analysis– How many interruptions are there during the work shift?– How complex are the tasks or instructions?

Conduct human factors audits– Noise levels; distractions; design of workspace; label format; work hours

and reviews

Train staff in human factors awareness

Adapted from REASON, 2005

People

Environment

Workspace

TaskEquipment

Staff

Patients

The ‘system’Factors within the healthcare system that could potentially lead to harm

Staff act as harm absorbers

Organisation

‘Three bucket’ model forassessing risky situations

(Reason, 2004)

1

2

3

SELF CONTEXT TASK

The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

Assessing the risk

Serious risk: don’t go there / change something

Moderate to serious: be very wary

Routine to moderate: proceed with caution3

5

7

9

Self Bucket

Level of knowledge training

Level of skill competence and experience

Level of experienceinvoluntary automaticity,under/over confidence

Current capacity to do the task

fatigue, time of day, distractions, feelings

Equipment and devices availability, familiarity

Physical environment lighting, noise, temperature

Workspace working environment, writing space, layout

Team and support leadership, stability and familiarity, trust

Organisation and management

safety culture, goals, targets and workload

Context Bucket

Taskcomplexity

calculations, multiple cognitive tasks

Novel task unfamiliar or rare events

Process task overlap, multi-tasking

Task Bucket

‘Three bucket’ model forassessing risky situations

(Reason, 2004)

1

2

3

SELF CONTEXT TASK

The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

Understanding & measuringpatient safety

Take a broader viewUse information appropriately

Prioritise deliberatelyBe more proactive

Use casenote review

So many questions!

• How many of our patients are harmed?

• Which areas need most attention ?

• What’s causing adverse events ?

• What changes could we implement?

• Are the changes an improvement ?

We need a metric

•Focus on actual patient harm

•How many patients had an adverse event last year?

•What are the common areas of harm?

•Have our changes succeeded in reducing the incidence of harm ?

Primary Care Trigger Tool

Casenote review• objective• focus on outcomes• focus on common

events

• large numbers• reliable over time

Staff reporting• subjective• focus on error• focus on memorable

events (rare)

• v small numbers• variable over time

We need casenote review

Primary Care Trigger Tool

Problems of casenote review• lengthy, experienced clinician• wasteful (reviews with no adverse events)

Trigger Tools – a solution• filtered & targetted → quicker, cheaper, less wasteful

1.Filter out patients with low likelihood of adverse event

2.Target clinical review where harm is suspected

We need trigger tools

Step-by-step A. Sample

• List of all patients > 75 years

• Place in random order

• Each month, select 25-100 for PCTT review

• Review the past 3 months

1. Search for triggers [clerical]

• unambiguous proxy indicators of harm risk

Step-by-step B. Review

2. Search for adverse events [clinical]

• iatrogenic harm events

Sample

NO0 events

30 patients

20 patientsYES

NO0 events

10 patients

10 patientsYES12 events

50 patients

Event rate = 12 / 50 = 0.24

Step-by-step C. Analyse

Change 1

Step-by-step C. Analyse

Primary Care Trigger Tool

Developed by NHS Institute, in partnership with 32 GP practices across England

Analysis of 4400 casenote reviews1400 adverse events

25% resulting in hospitalisation/permanent harm/death

Independent expert academic review

81% sensitivity4 min/pt

Primary Care Trigger Tool

Identify common harms

Measure improvement over time

× Not valid for benchmarking

Primary Care Trigger Tool

Medication

Repeat medication discontinued

Prescribing of opioid analgesia

Prescribing oral NSAID/COX2

Prescribing warfarin

Prescribing insulin

Prescribing methotrexate

Prescribing amiodarone

General Care

Seen > once in 2 days

Fall if age > 75

Fracture if age > 75

Pressure sore or ulcer

Urinary catheter in situ

VTE

Proven DVT or PE

Patient transfer

Readmission to hospital within 2 weeks of discharge

Laboratory

Na+ <130 or >150 mmol/l

K+ <3.5 or >5.5 mmol/l

INR <2 or >5

Haemoglobin <9g/dl

MRSA positive

C.diff positive

Positive wound/skin swab

eGFR <= 20

End of life

Death

Key diagnosis

New diagnosis of CVA/TIA

New diagnosis of acute confusional state

eg – Warfarin & bleeding .. Trigger

• INR > 5 is a trigger on the PCTT

• Many patients with an INR > 5 come to no harm

• This is not an adverse event (even if results from error)

eg – Warfarin & bleeding .. Adverse event

• Retinal bleed caused by Warfarin INR > 5

• Patient has come to harm

• This is an adverse event (whether result of error or not)

www.institute.nhs.uk/safercare/TTPwww.institute.nhs.uk/safercare/TTP

Primary Care Trigger Tool

Getting trainees stuck in

• theoretical training

• role model openness

• get them stuck in– MaPSaF– walkround– PCTT– process map to identify defects– PDSA– continual measurement