GPs at SEA A ‘train the trainer’ workshop for people supporting Significant Event Audit in General Practice e: academy@yhahsn.nhs.uk/ t: 01274 383926 www.improvementacademy.org Or visit our Academy Office: Bradford Institute for Health Research Temple Bank House / Duckworth Lane / Bradford / BD9 6RJ
Housekeeping
Objective To be sufficiently equipped with the knowledge and tools needed to support GP practices to carryout Significant Event Audit (SEA) in a way that optimises the chances of improving patient safety. #
Pre-course learning 12 Responses: Very consistent correct answers for 10 of the questions.
An injury caused by medical management (rather than the underlying disease) that either prolongs patient hospitalisation, or produces a disability at the time of discharge, or both. ADVERSE EVENT OR MEDICAL NEGLIGENCE
Which of the following would you presume to not be a component of effective team communication? DEFERENCE TO THE AUTHORITY OF THE MOST EXPERIENCED PHYSICIAN IN A MEDICAL EMERGENCY STANDARDISATION OF ALL CLINICAL OPERATING PROCEDURES AND TERMINOLOGY TEAM LEADER UTILISES A “COMMAND AND CONTROL” APPROACH DURING A MAJOR INCIDENT
What is a patient safety incident? • Error [is when] a planned sequence of mental or physical activities fails to achieve its intended outcome…. James Reason • A Patient Safety Incident is any unintended or unexpected incident that did or could have led to patient harm…. National Patient Safety Agency
Ferner RE, Aronson J, Clarification of terminology in medication errors: definitions and classification. Drug Saf 2006;29:1011-22
Scale of the problem The error rate in primary care is poorly understood. GP prescribing error rate 7.46% of items (Garfield & Barber, 2009) Dispensing error rate 3.3% of Items (Climente-Marti et al, 2010) Clinical Severity: 67% minor, 32% moderate, 1% severe
Human Fallibility and the Inevitability of Error Every time a human being touches something it’s likely to go wrong . James Reason
Stroop Effect Experiment • In this illustration, you are required to say the colour of the word, not what the word says.
Test 1 • Colour test easy
Test 1 • Colour test hard
Test 2 Selective perception test www. youtube .com/watch?v=vJG698U2Mvo
Test 3 warfarin methotrexate prednisolone bisoprolol simvastatin tramadol levothyroxine paracetamol folic acid furosemide
Person Centred View • The Perfection Myth: If I try harder I won’t make a mistake. • The Punishment Myth: If we punish a person who makes an error they won’t make the error again. • Johnsons Substitution test: Could some equally motivated, comparably qualified staff member have made the same error under similar circumstances?
Incident Decision Tree
Feelings after an adverse event or near miss
Hospitals and healthcare organisations adequately support doctors in dealing with the stress associated with near misses or adverse events
Human Factors Human Factors in healthcare is an approach to enhancing clinical performance through an understanding of the effects that teamwork, tasks, equipment, workspace, culture and organisation have on human behaviour and abilities. “Things that make it easier to do the right things, to the best of our ability.”
Why it sometimes goes wrong. Systems Based Approach External influences Organisational factors Working conditions HARM from Active Failure Individual factors Representation of James Reason’s Swiss Cheese Model
Ladbroke Grove train disaster (Lawton and Ward, 2005) Organization Organization Defenses Task/Environment Individuals Processes Unsafe Acts Conditions Region of Bright sunlight Organisational Hazards Complexity of learning Driver misread Track layout signal Signal Poor or signal aspect obstructions management of Training Inappropriate Signalers SPAD response expected the Planning and Accident Training driver to stop design of Poor local and so did not Paddington Communication act with haste Layout about hazards Inadequate defences Inadequate engineered safety devices, signalling procedures and sighting standards
The Yorkshire Contributory Factors Framework, (Lawton et al, BMJ Q&S, 2012) BMJ Qual Saf 2012;21:369e380. Rebecca Lawton, Rosemary R C McEachan, Sally J Giles, Reema Sirriyeh, Ian S Watt, John Wright
Refreshments and Networking
An injury caused by medical management (rather than the underlying disease) that either prolongs patient hospitalisation, or produces a disability at the time of discharge, or both. ADVERSE EVENT OR MEDICAL NEGLIGENCE
Which of the following would you presume to not be a component of effective team communication? DEFERENCE TO THE AUTHORITY OF THE MOST EXPERIENCED PHYSICIAN IN A MEDICAL EMERGENCY STANDARDISATION OF ALL CLINICAL OPERATING PROCEDURES AND TERMINOLOGY TEAM LEADER UTILISES A “COMMAND AND CONTROL” APPROACH DURING A MAJOR INCIDENT
Yorkshire Contributory Factors Framework BMJ Qual Saf 2012;21:369e380. Rebecca Lawton, Rosemary R C McEachan, Sally J Giles, Reema Sirriyeh, Ian S Watt, John Wright
Significant Event Audit - Benefits “The best way to reduce harm is for the NHS to embrace wholeheartedly a culture of learning .”* * A promise to learn – a commitment to act, The National Advisory Group on the Safety of Patients in England, chaired by Don Berwick, August 2013
Significant Event Audit 1. Awareness and prioritisation of a significant event. 2. Information gathering. 3. Analysis of event in team meeting. 4. Agree, implement and monitor change. 5. Report, share and review.
Involving patients Significant event audit may be improved for both patient and practice if it includes the patient as a “witness” and “adviser”. This is because of the emotional driver for change the patient brings.
Strictly Warfarin
What changes improve safety • Stronger Actions • Moderately strong actions • Weaker actions
What changes improve safety Moderate Stronger Weaker • Increase in staffing / • Double checks • Architectural / physical plant decrease in workload or equipment changes • • Warnings and Software • New device with usability enhancements / labels testing before purchasing modifications • • Eliminate / reduce • New procedure / Engineering controls (interlock distractions / forcing function) policy / Training • Checklist / cognitive • Simplify the process and aid • Additional study / remove unnecessary steps • Eliminate look and • analysis Standardise equipment or sound-a-likes processes or care plans • Enhanced • Disciplinary documentation • Tangible involvement and action • Enhanced action by leadership in communication support of Patient Safety
Lunch
Lets Get Critical Use what you know to analyse some SEA.
National Reporting and Learning System Reporting incidents onto NRLS supports nationwide analysis of patient safety concerns. Reporting is easy. Using: https://report.nrls.nhs.uk/GP_eForm Feedback relies on locally managed systems. Access NRLS through your Governance Team or https://report.nrls.nhs.uk/nrlsreporting/CreateUser.aspx
NRLS GP e-form
Closing the loop Sharing patient stories to affect change. Set the context to Describe a patient story show it is an issue of local concern Include a menu of Describe the lessons Include a menu of behaviours or tasks & actions identified processes that would that would make by the practice make patients safer patients safer Link it to items in the Cascade the Provide signposts to media or of local “hot information in a further reading & topics” conversation Resources
Part 2 – Training the Practices Maureen McGeorge Programme Manager AHSN’s Improvement Academy
So what next? • Recruit a cohort of six individual GPs/GP practices to receive the SEA training. • Report back to the Improvement Academy (IA) on progress after 3 months and again at 6 months including the number of incident reports uploaded to NRLS weekly by your member individuals/practices. • Encourage and support two of your GPs/GP practices to complete the IA silver level ‘quality improvement training for teams’ which is taking place on 18 November 2015 . Note: the subject of the training will be focused around key findings from their significant event audits.
So what next? • SEA should be an improvement activity • You and your teams will get out what you put in • Levels of engagement: Deliver SEA training … who, when, how often? Encourage collection of NRLS data Support completion of SEA (and submit to IA for critical review) Support teams become ‘improvers’ (based on identified issues)
Resources to support the work
Resources for SEA • NRLS e-form • NPSA quick-reference guide • SEA template • Contributory Factors Checklist • YCCF • E-learning package • NPSA guide to SEA • Critical review by Improvement Academy
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