Good morning, & welcome to this fabulous primary care centre. It gives me great pleasure to talk briefly today about clinical risk assessment in GP. I intend to do a whistle stop tour down the centuries and across continents, touching down in Ancient Greece, then a quick trip across the atlantic to America, then back to Dublin. Then I’ll invite you down to my own practice in Glanmire, Cork. I feel exhausted already! I’ll then concentrate on my own mistakes: its always nice to listen to other peoples errors. Human beings, in all lines of work, make errors. Hands up anyone who has never made a clinical error! If anyone here would like to share their own examples of error please raise your hand ! Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.
Millennia ago, Hippocrates recognized the potential for injuries that arise from the well intentioned actions of healers. Greek healers in the 4th Century B.C., drafted the Hippocratic Oath and pledged to "prescribe regimens for the good of my patients ...........and never do harm to anyone” In health care, building a safer system means designing processes of care to ensure that patients are safe from accidental injury.
To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. Although many of the available studies have focused on the hospital setting, medical errors present a problem in any setting, not just hospitals.(1) Yet silence surrounds this issue. For the most part, patients believe they are protected. The decentralized and fragmented nature of the health care delivery system (some would say "nonsystem") also contributes to unsafe conditions for patients, and serves as an impediment to efforts to improve safety. When patients see multiple providers in different settings, none of whom have access to complete information, it is much easier for something to go wrong than when care is better coordinated. At the same time, the provision of care to patients by a collection of loosely affiliated organizations and providers makes it difficult to implement improved clinical information systems. Most third party payment systems provide little incentive for a health care organization to improve safety, nor do they recognize and reward safety or quality. Given current knowledge about the magnitude of the problem, the committee targeted a 50 percent reduction in errors over five years. In summary! Patient thinks they are safe, doctors don’t talk about patient harm, multiple health care providers with little integration, no quality incentives! This is AMERICA, couldn’t be Ireland.............could it??? 1. Phillips, David P.; Christenfeld, Nicholas; and Glynn, Laura M. Increase in US Medication-Error Deaths between 1983 and 1993. The Lancet. 351:643–644, 1998
This fact is clearly paralled in the MPS claims experience in recent years. Litigation is rising globally & we are not immune. We successfully and comprehensively addressed road deaths. We can do the same with patient safety.
There is no single solution to road safety: The enormous reduction in road fatalities required multiple agencies working together, continuously for years, across a range of agencies. Safer vehicle design, Improved road engineering, reduced urban speed limits, Driver education, Drink driving enforcement, Penalty points. ,Police enforcement of traffic rules ( using mobiles, wearing seat belts, child restraints etc) There is no silver bullet, but dramatic results are achievable, in a reasonable timescale. THIS IS A Continuously evolving landscape.
There is no "magic bullet" that will solve challenge of patient safety, A comprehensive approach to improving patient safety is needed. no single recommendation should be considered as the answer. Rather, large, complex problems require thoughtful, multifaceted responses. I hope to show you this response is available in general practice. The goal is for the external environment to create sufficient pressure to make errors costly (to patients, physicians and the health service), so we are compelled to take action to improve safety. At the same time, there is a need to enhance knowledge and tools to improve safety. We must break down legal and cultural barriers that impede safety improvement. Given current knowledge about the magnitude of the problem, the IOM committee targeted a 50 percent reduction in errors over five years. We did it with road safety.........we can do it with patient safety.
We recognised that we needed to review our systems and work more cohesively as a practice team. In 2008, wanting to improve the quality and safety of care provided to our patients, we took an innovative step and commissioned an external risk assessment of the practice, which included risk management training for all staff. We were the third practice in Ireland to do so. There was anxiety & resistance at the start of this journey from some members of the team due to concern of an outside organisation scrutinising our practice. However the CRA was conducted in a supportive manner. We all actually enjoyed the experience. Prior to the CRSA all staff participated in a Staff survey. This measured the patient safety culture of the practice. During the CRA an educational session was held for all staff at the practice providing an explanation of risk management and its importance, and discussions of risks that the practice think could occur.
The CRSA fundamentally and permanently changed our approach to patients and patient care. “ALL CHANGED, CHANGED UTTERLY” We commissioned the MPS to undertake a clinical risk assessment of our practice. That CRSA fundamentally changed our approach to patients. We got a fabulous report totalling some 60 pages. There was a page telling us how good we were...... Then.....59 pages of improvements!
I think Humpty Dumpty is actually a wonderful metaphor for patient safety. It touches on all the salient facets: What was he doing on the wall in the first place? Were all options other than climbing the wall fully explored? Who authorised him to climb on the wall. How did Humpty actually get up on the wall. Can someone else get up & fall? Did Humpty provide informed consent? Were all reasonable precautions taken to ensure he would not fall. Were all reasonable precautions taken to ensure if he fell he wouldn’t be seriously injured. When he fell & was tragically (!) injured were strenuous efforts made to “put him together again” Did the King take action to ensure this could never happen again?
Following our CRSA our practice set out to build a safety culture. The entire practice team is involved at most meetings ie administration staff, nurses, GPs, GP registrar, dietician, physiotherapist, medical students & local pharmacists. We think having med students is valuable for all. All staff are encouraged to report both positive and negative incidents. This is facilitated by regular meetings at which audits and SEs are analysed in a supportive learning environment. Some of the changes we implemented following our CRSA include: Audit of patients taking toxic medication eg methortexate/lithium. Changed the practice computer system to an accredited system. Developed a chaperone policy. Implemented electronic messaging to reduce the interruptions of GPs during consultations. Introduced a repeat prescribing system. A practice website. ‘Flu pandemic plan. System to notify all staff of patient deaths. The list goes on & on……….. I regret that time doesn’t permit me to elaborate on each of these. However I have chosen those areas with greatest potential for patient harm, In which we undertook change, with substantial improvement in quality of care.
We started Significant Event Audit: Examples of events subjected to forensic examination include: A young woman on “the pill” had a “saddle embolus” & was fortunate not to have died. PAUSE An MRI brain report on my patient which never reached the practice-delaying diagnosis of a brain tumour, PAUSE Management of cardiac arrest managed in a patient’s home. PAUSE Administration of incorrect vaccine to a child. PAUSE. ……….. It was very challenging initially. That put the TERRIBLE in the title of this slide.
Having given you an OVERVIEW of what our CRSA involved, before , during & after I now will give 2-3 (time permitting) recent examples.......from my own practice.... May I emphasise these are real cases, from my practice. They are not fictitious. To this day I wish one of them didn’t happen.............. Childhood vax. Fax & breast cancer Methotrexate audit
A GP in my practice gave an incorrect baby vaccine. While discussing this another GP “fessed up” that a similar error occurred. A third GP told me in confidence that he had almost done the same. Three errors, previously unrecognised. This was about 4y ago, when the vaccine schedule was changing. The appropriate vax depended on the childs DOB. We had a lot of different vax in the fridge & all similar packaging. We were always under time pressure. Parents often used the vax consult for a full clinical consultation. RISK ASSESSMENT IS ABOUT CHANGE: DESIGNING SAFE PROCESSES OF CARE. WHAT CHANGES DID WE MAKE: We bought a new fridge & Ordered addition shelves, one vax per shelf. We designed a parent vaccine leaflet. We gave this at the two week check, and re-iterated advice at 6 week check; Vax is complex, easy to make mistake. One consult for vax only. No other topics. We got our Admin team to say this to parents when making vax appts. Parents accept this readily. Outcome: no vaccine error in past 4y. But takes co-ordinated practice wide approach, involving all stakeholders; parent, admin, nurse & GP. THIS STORY HAS A HAPPY ENDING.
The CRSA was the catalyst for this 2008 audit.I first audited our Methotrexate monitoring in 2008. The results still embarrass me. We repeated this audit in 2012, but involved all 3 practices in Glanmire. We adopted the April 2012 IMB recommendations as the “gold standard” IMB 2012 guidelines; specify tablet strength / Specify day of week / Educate patient about s-s toxicity : not unduly onerous ! We went much further than IMB recommendations; Vaccination uptake, smart use of existing IT, Designed a patient held “ALERT” card etc. Unexpected finding; excessive blood testing curtailed; reduce practice workload, more convenient for patients, reduce laboratory costs./maintain quality. We are chasing a “virtuous cycle” where the standards expected are constantly under review. We cannot afford to stand still. THIS STORY HAS A HAPPY ENDING- We won QIP award 2013, and our quality of care is demonstrably improved.
TAKE HOME MESSAGE: I ask myself this every time I write a prescription for Methotrexate, Lithium or potentially toxic medication. You need to be lucky, Each & every single time you sign a methotrexate prescription. CLINT EASTWOOD in film “Dirty Harry”
Upon receipt of the CRSA report for our practice in 2008 I stopped sending faxes. The Playboy of the Western World has a tragic ending. I have two stories to tell you here today. One has a happy ending. Earlier this year the local primary school phoned me. They had received a fax destined for me! A radiology facility (which remains nameless) inadvertently dialled the incorrect number & the school secretary got the fax. They posted it on to me .................but imagine if it was an abnormal result?? The final true story still haunts me. A colleague of mine saw a shy reserved woman with a breast mass. A referral was faxed to the local breast clinic. Everyone happy with this? Hands up if you are unhappy........... Four months later the woman, now pregnant, attended the same GP. Still happy? You see where this is going. The woman mentioned in passing, that she never got an appointment in the breast clinic.......... I’m going to finish on this story. At first sight it seems like the GP is the culprit. Or is it a badly designed system. Maybe the letter was faxed or maybe it was never faxed at all. . Maybe the fax was out of paper, or the printout fell down back of machine, or was inadvertently shredded.........or maybe it was faxed to the wrong number...... Is the few hours saved in referral worth the clearly documented hazards? WHY ARE WE STILL SENDING FAXES. Why are our national bodies encouraging & promoting referral by fax? Today I ask all our leaders present the minister, HIQA, HSE & ICGP to STOP faxing..........THIS IS A ZERO COST PATIENT SAFETY INITIATIVE. That woman could be your mother, wife, sister or daughter.................. It could be you.
Finally & to summarise: The ancient Greeks recognised the potential for physicians to harm patients. Today we know that 5-10% of patients entering hospital suffer PREVENTABLE HARM. We commissioned the MPS to undertake a clinical risk assessment of our practice. The CRSA fundamentally and permanently changed our approach to patients, and patient care. All staff members feel valued. We are enthusiastic regarding risk management and patient safety and are proud of our achievements and the quality of care provided for patients. Significant events are reported frequently by all staff without fear of retribution & automatically trigger reflection, analysis, sharing, learning & change. We now have a ZERO TOLERANCE approach to errors, & ruthlessly pursue them, examine & analyse them, and then we actively design safer systems. “ALL CHANGED, CHANGED UTTERLY, A TERRIBLE BEAUTY IS BORN”
Dr. Diarmuid Quinlan, MPS GP Glanmire
Medical Protection Society
‘Clinical Risk Self Assessment
- Its role in General Practice’
National Primary Care Conference 2013
Dr Diarmuid Quinlan
“Methotrexate; We can do
Multi practice audit
“Compliance with 2012 IMB guidelines”
• Blood tests
0% ------- 65%
• “Pop up alerts”
• Flu Vaccine
Ask yourself one question:
"Do I feel lucky?" ......Well do ya....Doctor?
Is Ireland the
“All changed, changed utterly:
A terrible beauty is born”
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