Avoiding harm in primary care

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Mitchell Allison
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1 Avoiding harm in primary care Liz Price senior risk adviser

2 Session content Claims of negligence What are they? duty of care liability / causation timescales defence What are the common causes? analysis themes case studies How can you mitigate the risks? risk assessment systems human factors

3 What are negligence claims? Three tests the claimant must establish: 1. A duty of care 2. Negligence (Bolam test) 3. That the negligent act or omission caused harm Three year window * Other case law (Bolitho test) Records

4 GP claims: patterns of risk Prescribing Communication Clinical treatment Missed or delayed diagnosis

5 Missed or delayed diagnosis Actioning letters/results 11% Acting on patient concerns 5% Record-keeping 36% Inadequate exam/more tests indicated 21% Failure to refer 27%

6 Risk assessment via process mapping Step 1 Identify the hazards (what can go wrong?) Step 2 Step 3 Decide who might be harmed and how Evaluate the identified risks (how bad are they, how often will they occur?) Decide on the precautions. Step 4 Record findings and proposed actions. Identify who will lead and set an implementation date. Step 5 Review the assessment and update if necessary

7 Case Study Delayed Diagnosis

8 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Patient responsibility? Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods

9 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Should GP1 have followed this up? No red flags: - capacity - chaotic lifestyle - clinical history Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

10 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods If red flags present: - safety net with pt - note pt informed - diarise follow-up Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

11 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Should the bloods have been returned to GP1? - continuity can mitigate risk Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

12 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Reasons for processing error: - lapse in concentration - lack of protected time - would your system allow this? Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

13 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Receptionist - reassured patient (no action necessary) - compounded the error Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

14 Patient 52 year old man complaining of fatigue Consultation 1 Seen by GP1 who notes TATT and requests a blood screen for fatigue The patient never makes an appointment for the PN to have the bloods Criticism of GP2 (advice, management of condition) and practice systems Outcome Allegation of negligence (after myocardial infarction) due to delay in diagnosis of diabetes Consultation 2/ results Patient makes an appt with the PN six months later Bloods taken, results returned to GP2 GP2 reviews, files with no action including: a fasting blood glucose of 15.1mmol/L Patient calls for results and informed: nothing untoward to report

15 Diagnosis Key lessons Better, more adequate records Fuller examination Watch out for red-flag symptoms Less reliance on other clinicians opinions Knowledge and training deficits need to be identified More robust results handling *** Adequate information in referrals More robust referral processes *** Act on patient concerns ***

16 Results Risks 6 Actions Taken 5 Actions Ordered 4 Results Seen 3 Results Returned 2 Tests Done 1 Tests Ordered

17 Referral processes Map out your referral process Consider locum interface Consider standards (quality, timescales for turnaround) Computer generated referrals are checked Urgent / routine referral pathways are understood The audit trail should contain: Decision-making Generation Sending Receipt (where available) Patient communication is adequate: Patients well informed of the process? Patient expectations set and safety nets documented? Failures result in SEA

18 Prescribing contraindications prescribing practices prescription error known allergy discharge medication review

19 Medication Review Long term medication Medicines on repeat Poor systems for ongoing acute requests Failure to monitor concordance Failure to conduct routine testing Failure to recall the patient (defaults) Often more opportunities to reverse an error Often more opportunities to mitigate the impact Alerts / systems of recall are essential to manage risk

20 Systems for defaulters Clinician responsibilities GMC you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients needs and any risks arising from the medicines. Patients should not be surprised by admin contacts Robustness of recall What does a robust system look like in practice?

21 Prescription Errors to err is human Systems can compound the risk drop down lists, alphabetical, range of medicine options Lets look at a case example

22 Pain Clinic 60 year old male, Rx request to GP To provide (1) Morphine 10mg (modified release) 2bd and (2) Oramorph 10mg/5ml oral solution 5mls qds prn Practice Patient seen by GP later that day, medicines review undertaken, Rx provided to inc. Morphine 100mg 2bd Given by pharmacy and taken by patient at 22:00 Outcome Allegation of negligence that GP failed to prescribe correct dose leading to hospital admission and PTSD A+E Ambulance called at 05:00, patient admitted with respiratory failure and acute renal failure, transferred to HDU 3 days later, discharged after 10 days

23 Discharge Interface between providers (secondary to primary ++) An estimated 30-70% of patients experience an error Medicines reconciliation Clinical check always recommended (once it becomes a repeat ) (deletions, substitutions, additions) Vulnerable groups more at risk elderly, chaotic, children, multiple serious morbidities, multiple medications, serious acute medical problems Lets look at a case example

24 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

25 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Contradictory discharge instructions 3/12.6/12 Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

26 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Patient communication unclear verbal instructions Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at

27 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Prescribing GP assumed pt. would return for more in two weeks Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

28 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Reviewing GP assumed H had provided Rx and follow-up instructions Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

29 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. OoH/ Third GP no check of previous history before Rx Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

30 Practice 32 year old female, h/o recurrent UTIs referred to urology Outpatients investigation normal, discharge instructions: please give Nitrofurantoin 50mg, 4 daily for 2 weeks, followed by 50mg at night for 3 months. No follow up. Patient responsibility? Outcome Allegation of negligence that antibiotic not prescribed for correct period resulting in recurring UTI Practice Patient provided with Rx for 60 capsules Discharge letter received stating: We have provided the patient with a prescription for prophylactic Nitrofurantoin which she should continue for 12 months (marked as no action required) Patient does not request a repeat Treated for 2 further separate UTIs

31 Known allergy Coding errors (free text) lack of system alert Almost always no patient check (a safety net advised by GMC) Lack of knowledge (names misleading for patients) Human factors contribute Unpleasant rash anaphylactic shock Pharmacy relationship

32 Contraindications Coding errors (free text) lack of system alert again! System alerts many legitimately overridden Common patterns of risk Drug-Drug // Condition-Drugs Warfarin and non-steroidal anti-inflammatories such as Diclofenac Chronic asthma and beta-blockers such as Propranolol

Prescribing Key lessons Take care when using drop down lists of medications When adding medicines select appropriate review periods Take notice of review alerts and act on them Take notice of alerts

33 Prescribing Key lessons Take care when using drop down lists of medications When adding medicines select appropriate review periods Take notice of review alerts and act on them Take notice of alerts and warnings from the system Ensure you review all discharge notifications and take action / diarise action as appropriate Ensure patient instructions are clear Reconcile old and new medicines, ensuring a clinical check is in place Code allergies and conditions consistently and accurately

34 Communication Key risks Delay across the clinical team Failure across the clinical team Failures between clinical and non-clinical teams Failures in communication with the patient

35 Communication Case examples Failure to safety net with admin staff (risks, expectations, feedback) Failure to transfer patient to hospital quickly Failure to appropriately communicate patient results to attached staff

Communication Key lessons Ensure you have robust procedures to transfer information *** Document discussions about patient management Make sure patients (and

36 Communication Key lessons Ensure you have robust procedures to transfer information *** Document discussions about patient management Make sure patients (and receptionists) are informed of any red flag symptoms which would alter management of symptoms Ensure you safety net and document instructions to patients/ carers

37 Mitigating risks Increase awareness of these risks within your team Ensure patient communication is clear (and documented) Robust call systems for testing and medicines review Escalation should be on a case-by-case basis If recall by practice, note why within appointment (DNAs / Cancellations) Undertake risk management of your practice systems Workflow processes checklist Referring patients checklist Results handling checklist Access to clinicians exercise Recognise human factors risks Mitigate using systems (protected time / reduced interruptions) Failures result in SEA

38 Further resources

Medication Safety. Patient Safety. Setting Direction Julie Simmons, Medication Safety Pharmacist January 2016

Medication Safety. Patient Safety. Setting Direction Julie Simmons, Medication Safety Pharmacist January 2016 Medication Safety Patient Safety Setting Direction Julie Simmons, Medication Safety Pharmacist January 2016 1 The patient journey Admission Ward Transfer Ward stay Discharge Medication storage and supply