Safety incidents in the general practice setting: a - - PowerPoint PPT Presentation

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Safety incidents in the general practice setting: a - - PowerPoint PPT Presentation

Jan 08, 2024 209 likes •534 views

Safety incidents in the general practice setting: a cross-sectional study @PhilippaCRees Safety incidents in the general practice setting: a mixed methods cross-sectional study Ms. Philippa Rees Dr. Colin Powell Mr. Peter Hibbert Prof.

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@PhilippaCRees

Safety incidents

in the

general practice

setting: a cross-sectional study

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Safety incidents in the general practice setting: a mixed methods cross-sectional study

  • Ms. Philippa Rees
  • Dr. Colin Powell
  • Prof. Andrew Carson-Stevens
  • Prof. Adrian Edwards
  • Dr. Ben Carter
  • Dr. Huw Williams

Dr Sharon Mayor

  • Sir. Liam Donaldson
  • Mr. Peter Hibbert
  • Dr. Meredith Makeham

This project was funded by the National Institute for Health Research HS&DR (project number 12/64/118) Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR, NIHR, NHS or the Department of Health.

  • Prof. Aziz Sheikh

Dr Sukhmeet Panesar

  • Prof. Anthony Avery
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WORST CHILD MORTALITY

One of the rates in Western Europe

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  • 3,000,000 deaths

prevented annually

26% of child deaths have identifiable failures in care

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National Reporting & Learning System (NRLS)

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Under-reporting Reporting bias Selective deposit

1 2 3

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Aims

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Incident characteristics Contributory factors Harm severity

Explore the nature, range and severity of safety incidents involving children as reported to the NRLS from general practice in England and Wales to include:

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Classification system

New concepts emerge Iterate frameworks Re-classify Read free text Classify what happened Classify contributory factors Classify harm severity Check inter-coder reliability Discuss findings

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Results

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1788

included reports

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100 200 300 400 500 600 700 800 Number of incidents Incident types

The number of harmful and non-harmful incidents described for each incident type

Harm No harm

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Reported paediatric safety incidents

Resource issues (n=145) Documentation errors (n=207) Clinical skills errors (n=93) Other (n=194) Inadequate patient records Transfer of records Treatment provision errors Communication Errors in patient assessment Staff knowledge Poor continuity of care Staff mistakes (n=145) Failure to follow protocol (n=109) Treatment protocol Human resources Equipment availability & safety Treatment availability Child protection protocol Acutely illness Other protocol Other clinical skills Inadequate guidelines/ protocols
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Medication provision

Assessment and referral

Safe treatment

1 2 3

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Medication incidents

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Prescribing n=119 Dispensing Administering Adverse reactions n=53 n=25 n=9

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Risperidone dose (5mg BD) recommended by child and adolescent mental health team for a child that they had assessed. The family doctor requested a consultant’s opinion and was informed that this was the dose agreed by the team. Patient later presented with signs

  • f

toxicity (dyskinetic tongue).

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Reported paediatric safety incidents

Resource issues (n=145) Documentation errors (n=207) Clinical skills errors (n=93) Other (n=194) Inadequate patient records Transfer of records Treatment provision errors Communication Errors in patient assessment Staff knowledge Poor continuity of care Staff mistakes (n=145) Failure to follow protocol (n=109) Treatment protocol Human resources Equipment availability & safety Treatment availability Child protection protocol Acutely illness Other protocol Other clinical skills Inadequate guidelines/ protocols
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Assessment & Referral

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Mother of a 3-year-old noticed blood on child’s pyjamas. Physician diagnosed cystitis and prescribed antibiotics without examining child or taking a urine sample. Bleeding in a 3-y-old is unusual, and physician should have sought a paediatric

  • review. Patient seen by paediatrician 5 d later

when it was discovered that child had been sexually abused.

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Reported paediatric safety incidents

Resource issues (n=145) Documentation errors (n=207) Clinical skills errors (n=93) Other (n=194) Inadequate patient records Transfer of records Treatment provision errors Communication Errors in patient assessment Staff knowledge Poor continuity of care Staff mistakes (n=145) Failure to follow protocol (n=109) Treatment protocol Human resources Equipment availability & safety Treatment availability Child protection protocol Acutely illness Other protocol Other clinical skills Inadequate guidelines/ protocols
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Safe treatment & procedures

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Patient saw family doctor with 3-week history of symptoms of diabetes. After documenting high blood sugar, she was started on an oral hypoglycemic drug. Brought to emergency department with blurred vision. Patient was inappropriately treated and not referred promptly.

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Patient attended with laceration to nose caused by someone throwing a canister . Wound glued but treatment

  • f laceration caused eye to be glued
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Reported paediatric safety incidents

Resource issues (n=145) Documentation errors (n=207) Clinical skills errors (n=93) Other (n=194) Inadequate patient records Transfer of records Treatment provision errors Communication Errors in patient assessment Staff knowledge Poor continuity of care Staff mistakes (n=145) Failure to follow protocol (n=109) Treatment protocol Human resources Equipment availability & safety Treatment availability Child protection protocol Acutely illness Other protocol Other clinical skills Inadequate guidelines/ protocols
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Main findings

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Medication provision

Assessment and referral

Safe treatment

1 2 3

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SLIDE 29 Implementation of technology adjuncts e.g. bar code scanning Introduce a justification barrier when prescribing branded as opposed to generic drug choices Mandatory postgraduate paediatric training for general practitioners Unified referral system between general practice and paediatric services Incorporate a mandatory physiological assessment tool for all referrals relating to acute illness Improve quality of referral written communication Safe and evidence-based treatment Timely and accurate assessment and referral Medicines management Improve paediatric safety in general practice

Primary drivers: Secondary drivers:

Incorporation of electronic decision aids into consultation
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Thank you

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Any questions?

@PhilippaCRees ReesPC1@cf.ac.uk uk.linkedin.com/pub/philippa-rees www.researchgate.net/profile/Philippa_Rees