Risk management in general practice. Eric Bater 6 th November 2013. Aim of programme. to apply the principles of risk management to practical situations and relate these to personal experiences
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Risk management in general practice Eric Bater 6th November 2013
Aim of programme • to apply the principles of risk management to practical situations and relate these to personal experiences • to improve the quality of care by implementing initiatives to remedy deficiencies in the service provided.
Aim • To help reduce the risk of harm to patients, staff and visitors by improving safety and the quality of care in practice
Harvard Medical Practice StudyNew England Journal of Medicine 1991 • 3.7% patients suffered an adverse event • Of these 13% died • 58% events related to system errors
Summary of New Complaints Procedure (1998, 9/12 period)MDU experience • Failure or delay in diagnosis most common reason (28%) • 24% of complaints made after bereavement • Non-clinical issues accounted for 34% of complaints • 10% of complaints related to attitude • 93% settled at local resolution
MDU Settled Claims Against UK GPs • Failure to diagnose - 51% • Medication error - 26% • Pregnancy including labour - 13% • Minor surgical procedure - 7% • Other - 3%
MDU Claims Settled • Quality of medical care - 7% • Medical record issues - 60% • System failures- 33%
Clinical Governance • Clinical risk management • Complaints procedures • Adverse incident reporting • Clinical audit • Evidence- based practice • Whistle blowing • Performance review
Risk “The possibility of incurring misfortune or loss”
Living with risks Risk is part of everyday life • At home • When travelling • With patients You can minimise your risks by improving your systems
Making amends DH 2003 In general practice… • Average GP will provide about 200,000 consultations during their career • 25% of adverse events occur in primary care • And, it is estimated that 1% of GP consultations (one a week) are associated with a significant adverse outcome
Incident reports to the National Patient Safety Agency • 2600 reports from October 2006 to September 2007 from general practice: • 29% Medication errors • 14% Documentation • 11% Access/admission/transfer/discharge • 10% Consent/communication/ confidentiality 0.33% of all reports received NPSA National Reporting and Learning Data Summary Issue 7 December 2007
Top key risks in UK general practice • 95% Confidentiality • 92% Prescribing • 90% Health and safety • 85%Communication • 84% Record keeping • 84% Test results MPS Risk Consulting August 2006
Confidentiality Common issues: • Breaches of confidentiality in waiting rooms and reception areas • Staff contracts do not include a clause covering confidentiality post-employment • Not all patient-identifiable information is shredded • Patient medical records are not securely stored • Computers may be left on and unattended
Breach of confidentiality Can lead to: • Breakdown of practitioner/patient relationship • Lack of trust/confidence in other healthcare professionals • Failure to seek further treatment • Disciplinary action by GMC and employers
Prescribing Common issues: • No repeat prescribing protocol • No designated receptionist to record or generate repeat prescriptions • Reception staff are allowed to add medication to the computer • Medication reviews are undertaken on an ad hoc basis. • No system for recalling patients on long-term medication • Uncollected prescriptions are destroyed
Record keeping Common issues: • Illegible writing in the records • Letters scanned into wrong record • Telephone advice not always recorded • Medical records go missing • Home visits not always recorded on the computer
Test results Common issues: • No tracker system to ensure that patients are followed up • No system of knowing when all a patient’s test results have been returned • Test results not recorded onto the computer • Non-clinical staff allowed to inform patients of their result and treatment required
Infection control Common issues: • No infection control policy • Specimen handling • Hand washing issues
Hand washing For effective hand washing consider the following : • Liquid hand dispenser • Paper towels • Elbow/foot operated mixer taps • Alcohol based hand rub • No sink plug • Remove jewellery • Designated hand wash basin
What is clinical risk management? • Common sense • Identification, measurement and control of risk to avoid harm to patients and staff • Involves everyone • Relates to the whole package of care • Equates to good practice
RISK MANAGEMENT • A careful examination of what • could cause harm • its significance and • what precautions are needed to eliminate the risk or reduce it to an acceptable level
Risk Management Benefits • for patients • improved quality of care and service • enhanced patient safety • confidence in the service • for health care professionals • protection of confidence and reputation • quality procedures and staff involvement • decreased numbers of complaints and claims
The four principles of risk management • Identify the risks – what’s likely to go wrong? • Assess the risk – what are the chances of it going wrong, what could happen, does it matter? • Reduce/eliminate the risk – what can you do about it • Cost the risk – what are the costs of getting it right v. the cost of getting it wrong?
Risk Management Techniques • Complaint handling • Risk assessment • Staff awareness/training • Protocol and guidelines monitoring • Good medical records • Adverse incident reporting
Risk Areas • Staff - especially locums • Organisation • adequate staffing • regular guideline review • Communication • Consent • Record keeping
Clip 2 – Morning Surgery Identified Risks • Breaches of confidentiality – front desk/reception area etc. • Health and safety issue. • Lack of systems. • Phone call interruptions. • Verbal requirements regarding nurse visit. • Inappropriate roll/responsibilities of receptionist. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Clip 3 – Test Result / Minor Surgery Identified Risks • Dealing with smear results. • Aseptic techniques. • Lack of chaperones. • Unreasonable patient request. • Lack of informed consent. • Disposal of clinical waste/needles. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Clip 4 – Home Visit Identified Risks • Examination. • Response to collapsed patient. • Communication regarding hospital admission. • Communication with mother. • Dealing with request for repeat prescription. • Dealing with aggressive patient. What action do you suggest the practice takes in order to avoid/minimise these risks (in priority order)?
Aims of Assessment • Improve patient care • Ensure safe standards of practice • Ensure patient/staff safety and well being • Decrease the number of complaints and claims • Lessen the stress associated with litigation
The ‘three bucket’ model forassessing risky situations (Reason, 2004) 3 2 1 SELF CONTEXT TASK The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.
Reason’s Swiss cheese model James Reason’s ‘Swiss cheese model’