Patient Safety. Royal College of General Practitioners Curriculum Statement 3.2

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1 Roya Coege of Genera Practitioners Curricuum Statement 3.2 Patient Safety One in a series of curricuum statements produced by the Roya Coege of Genera Practitioners: 1 Being a Genera Practitioner 2 The Genera Practice Consutation 3 Persona and Professiona Responsibiities 3.1 Cinica Governance 3.2 Patient Safety 3.3 Cinica Ethics and Vaues-Based Practice 3.4 Promoting Equaity and Vauing Diversity 3.5 Evidence-Based Practice 3.6 Research and Academic Activity 3.7 Teaching, Mentoring and Cinica Supervision 4 Management 4.1 Management in Primary Care 4.2 Information Management and Technoogy 5 Heathy Peope: promoting heath and preventing disease 6 Genetics in Primary Care 7 Care of Acutey I Peope 8 Care of Chidren and Young Peope 9 Care of Oder Aduts 10 Gender-Specific Heath Issues 10.1 Women s Heath 10.2 Men s Heath 11 Sexua Heath 12 Care of Peope with Cancer & Paiative Care 13 Care of Peope with Menta Heath Probems 14 Care of Peope with Learning Disabiities 15 Cinica Management 15.1 Cardiovascuar Probems 15.2 Digestive Probems 15.3 Drug and Acoho Probems 15.4 ENT and Facia Probems 15.5 Eye Probems 15.6 Metaboic Probems 15.7 Neuroogica Probems 15.8 Respiratory Probems 15.9 Rheumatoogy and Conditions of the Muscuoskeeta System (incuding Trauma) Skin Probems Roya Coege of Genera Practitioners, Bow Churchyard, London EC4M 9DQ Phone: , Fax:

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3 Contents Acknowedgements 5 Key messages 5 Introduction 6 Rationae for this curricuum statement 6 UK heath priorities 6 Learning Outcomes 7 Primary care management 7 Person-centred care 7 Specific probem-soving skis 8 A comprehensive approach 8 Community orientation 8 A hoistic approach 8 Contextua aspects 9 Attitudina aspects 9 Scientific aspects 9 Further Reading 10 Exampes of reevant texts 10 Web resources 10 Promoting Learning about Patient Safety 12 Work-based earning in primary care 12 Work-based earning in secondary care 12 Non-work-based earning 12 Learning with other heathcare professionas 12 References 13

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5 Acknowedgements This RCGP curricuum statement on patient safety was deveoped in partnership with the Nationa Patient Safety Agency (NPSA). It has drawn on various nationa guideines and poicies, current research evidence and the cinica experience of practising genera practitioners. The Roya Coege of Genera Practitioners woud ike to express its thanks to these individuas. Authors: Dr Maureen Baker & Dr Christine Johnson Contributors: Dr Amar Rughani, NPSA Editors: Dr Mike Deighan & Professor Steve Fied Guardian: Dr Maureen Baker Created: December 2005 Date of this update: June 2011 Version number: 1.2 Previous versions: 1.0 issued January 2006, corrected and re-issued February 2007; 1.1 issued February 2009 Key messages Patient safety concerns everyone in the NHS, and is equay important for genera practitioners whether working as an independent contractor or for a Primary Care Organisation. Tacking patient safety coectivey and in a systematic way can have a positive impact on the quaity and efficiency of patient care. Safety in heath care is a reativey young fied internationay and, as such, it wi be some time before we understand its fu potentia. It is ikey that further training throughout a doctor s career wi be required. Genera practitioners are we paced to be active members of the heathcare team and positivey infuence the safety cuture within the practice and the deveopment of the practice as a earning organisation. The knowedge and appication of risk assessment toos must become part of genera practitioners skis and, whatever change occurs in their environment, they shoud assess the effects of change and pan accordingy. Patient Safety v. 1.2, Jun 11 5

6 Introduction Rationae for this curricuum statement The Department of Heath pubication An Organisation with a Memory 1 mobiised the patient safety movement in the NHS. It drew attention to the scae and pattern of potentiay avoidabe patient safety incidents and the devastating consequences these can have on patients, their famiy and the heathcare staff invoved. (A patient safety incident (PSI) is defined as any unintended or unexpected incident that coud have or did ead to harm to one or more patients receiving NHS-funded care.) 2 This report aso acknowedged that there has been itte systematic earning from PSIs. It proposed soutions based on deveoping a cuture of openness, reporting and safety consciousness. One of the key areas identified was A much wider appreciation of the vaue of the systems approach in preventing, anaysing and earning from patient safety incidents. 2 Buiding a Safer NHS for Patients 3 required the NHS to estabish agreed definitions of incidents for the purposes of reporting and recommended the estabishment of the Nationa Patient Safety Agency to instigate a nationa (Engand and Waes) system for reporting, and earning from, patient safety incidents. The Nationa Audit Office Report (A Safer Pace for Patients: earning to improve patient safety, November 2005) 4 acknowedges that 90% of patient contact with the NHS is in primary care services. It particuary identifies the need for progress in enhancing organisationa earning and reporting to improve patient safety at both oca and nationa eve. The report states that it is imperative that patient safety becomes a core part of professiona training, incuding heping cinica staff understand their responsibiity for patient safety. It aso recommends that the Department of Heath needs to buid on its work with the Roya Coeges to better embed patient safety training in curricua. Lasty, the need to engage with patients in identifying patient safety issues and designing soutions is emphasised. Doctors are aready famiiar with the precepts upon which patient safety is based sometimes described as the circe of safety buit upon the audit cyce. This is then framed within a new cuture that requires a deeper understanding and respect for the patient s agenda couped with the communication skis, teamworking and sef-awareness to put patient safety into action. UK heath priorities Huge numbers of peope are treated and cared for in British genera practice every working day and safety incidents of both cinica and non-cinica types occur. In primary care, medication errors are particuary important. For exampe, every day amost 1 miion peope visit their GP; 1.5 miion prescriptions are dispensed (650 miion prescriptions per year). Amongst a this compex activity things sometimes go wrong and patients are harmed as a resut. With the voume of patients invoved, this means that the number of PSIs from genera practice is considerabe. When patients move between primary and secondary care the potentia for patient safety probems increases. Studies have aso shown that the best way of reducing error rates is to target the underying systems faiures, rather than take action against individua members of staff. 6 RCGP Curricuum Statement 3.2

7 Learning Outcomes The foowing earning objectives reate specificay to patient safety. This RCGP curricuum statement shoud be used in conjunction with the core curricuum statement 1, Being a Genera Practitioner, and the other cinicay orientated statements. Speciaty registrars (GP) shoud achieve these earning objectives during their GP training programme. Primary care management Participate in meetings run by the practice that iustrate how a practice can start to buid and enhance a safety cuture. Describe how organisations and individuas can earn to be vigiant for PSIs. Know how organisations and individuas can earn to improve systems by anaysing patient safety incidents and near misses Describe how the anaysis of patient safety incidents can enhance rather than undermine professiona integrity and performance Contribute to the reguar significant event audit (SEA) meetings and observe the benefits of a mutidiscipinary team. Be aware of the existing training toos avaiabe for SEAs from the defence associations 5,6 and NPSA. 7 Participate in and write up an SEA from a patient seen during the genera practice period of training. Refect on the earning and consider whether reporting ocay or nationay woud be appropriate. Demonstrate the measures that the organisation takes to ensure that reports are deat with fairy and that the appropriate earning and action takes pace. Describe the eements that contribute to an appropriate infrastructure for risk management, such as: the essentia features of a practice that create a cuture that is open and fair; poicies that commit the organisation to being open about serious incidents that invove permanent harm or death; poicies that state the actions that staff shoud take foowing an incident; individua roes and accountabiity; the mechanism of investigation; support that shoud be given to patients, famiy and staff; staff training. Describe how changes in the IT structure of the NHS wi impact upon the possibiity for both reducing and increasing the chance of PSIs. Person-centred care Communicate openy, isten and take patients concerns seriousy. Consider patient issues when refecting on consutation experiences. Be aware of current cinica governance guideines that impact on patient safety within a practice. Be prepared to consider the Being Open Poicy 8 as advised by the NPSA when a PSI has occurred or coud have potentiay occurred. Patient Safety v. 1.2, Jun 11 7

8 Te patients and their famiies as soon as possibe when incidents occur and do so fuy, honesty and compassionatey. Specific probem-soving skis List and identify the systems and processes that are in pace in practices to manage risk in a primary care setting and compare these with coeagues in other practices. Know how to assess the organisation s reporting and earning cuture. Demonstrate awareness of evidence-based toos to identify and assess risk. Give exampes, from a persona educationa portfoio throughout your current training, that show an understanding of the benefits and disadvantages of such toos. 2,5 Describe the criteria for when the organisation shoud undertake a root cause anaysis or significant event audit. These criteria shoud incude a incidents that have ed to permanent harm or death. Demonstrate an awareness of the imitations of your own skis in risk management and iustrate that you understand when the skis of coeagues trained more extensivey in risk management shoud be caed upon. A comprehensive approach Demonstrate an awareness of the a-encompassing approach to patient safety; for exampe, by keeping a og diary of consecutive consutations for at east one day per month and comment on any actua or potentia PSIs within those consutations. Describe the risks to patient safety by considering an iness pathway/journey in which a variety of heathcare professionas have been invoved. In particuar, to refect on the interface issues arising from the current mutitude of such providers and be abe to comment on the ways in which, as a GP, you can work to minimise these. 9 Describe the structures and processes for managing cinica and non-cinica risk, and how these are integrated with patient and staff safety, compaints, cinica negigence and financia and environmenta risk. Community orientation Demonstrate the abiity to invove and communicate with patients and the pubic by practising the Being Open approach. 8 Be abe to make contact with the oca patient representative body (Heathwatch or equivaent) and be aware of the current pattern of patient comments. Describe the ways in which genera practice and community pharmacy can minimise the potentia for PSIs. Describe how patient groups may be put at increased risk of mishap by virtue of their particuar characteristics, such as anguage, iteracy, cuture and heath beiefs. The atter may be manifest through the patient s abiity and wiingness to work in partnership with the doctor in the management of the probem. Iustrate an awareness of the potentia benefits for patient safety of good working reationships with coeagues from ongstanding community services. Describe any new roes that have emerged in the community setting (e.g. community matrons) and give exampes of how these new roes have impacted on patient safety. 10 A hoistic approach Describe how the essons of patient safety can be appied prospectivey to doctor patient interactions, especiay through the identification and discussion of risk. Describe the oca cinica governance arrangements. 11 Describe and show usage of the various options for reporting PSIs both ocay and nationay. 1 8 RCGP Curricuum Statement 3.2

9 Comment on the participation of whoe teams in significant event audit 2 within the practice and give reasons for incusion or excusion of different team members. If reevant to the training practice, hep faciitate the impementation of soutions to prevent harm, by embedding any essons earnt in the practice processes and systems. Describe how to share essons from the anaysis of PSIs within the team. Identify which other eements of patient services may be affected in future and share earning more widey on the basis of this. Contextua aspects Identify how, as a speciaty registrar (GP) within the team environment of genera practice, his or her experiences gained in undergraduate and eary postgraduate education can be shared with coeagues. Recognise that the forma Patient Safety Agenda 1 is reativey recent and sti changing so may be unfamiiar to weestabished coeagues in primary care. Describe the impact of the working environment on the care the doctor provides and the ikeihood of adverse incidents as a resut of this. Comment on the use of situationa awareness theories. i Attitudina aspects Demonstrate a preparedness to admit when an error has occurred, apoogise for faiings in the deivery of care and to communicate this openy to patients and their famiies, reassuring them that the appropriate essons have been earned. 8 Discuss exampes that describe a cear appreciation of how a change in the behaviour and/or systems can infuence patient safety. Describe experiences gained from discussing with coeagues in different practices how high-quaity mutiprofessiona working can benefit patient safety. Consider the steps needed to faciitate such co-working. 2 Hep to shape an organisationa cuture that prioritises safety and quaity through openness, honesty, shared earning and continua incrementa improvement. Scientific aspects Describe the toos that can be appied in risk management and patient safety issues accessibe from sites such as medica indemnity sites. 5,6 Describe the basic principes of human error. 12,13 Describe the basic principes of risk assessment. 2 Demonstrate how to compie a simpe risk matrix. 2 i For exampe, the three bucket mode proposed by James Reason ( where each bucket is variaby fied according to the context, the domestic feeings of the doctor and the compexity of the task. Patient Safety v. 1.2, Jun 11 9

10 Further Reading Exampes of reevant texts Seven Steps to Patient Safety for Primary Care. The fu reference guide (September 2005) is avaiabe at or ca Web resources Genera Medica Counci Principes of Prescribing; Who can prescribe; Prescribing safey; Guidance on prescribing medicines; Specia Circumstances; Unicensed medicines; Off icence medicines; Information for patients on icensing of medicines; Responsibiity for prescribing for outpatients; Issuing repeat prescriptions; Remote prescribing by internet or teephone; Working in private cinics; Other sources of guidance on Prescribing. The Care Quaity Commission The Care Quaity Commission is an independent body, set up to reguate care provided by the NHS, oca authorities, private companies and vountary organisations. NHS Evidence This is a service that enabes access to authoritative cinica and non-cinica evidence and best practice through a web-based porta. It heps peope from across the NHS, pubic heath and socia care sectors to make better decisions as a resut. NHS Evidence is managed by the Nationa Institute for Heath and Cinica Exceence (NICE). The Nationa Patient Safety Agency The Nationa Patient Safety Agency (NPSA) aims to improve the safety and quaity of care through reporting, anaysing and earning from adverse incidents and near misses invoving NHS patients. Seven Steps to Patient Safety in Primary Care ists actions that primary care organisations, staff and teams can take to improve patient safety ocay and hep meet their cinica governance targets RCGP Curricuum Statement 3.2

11 The Nationa Prescribing Centre The Nationa Prescribing Centre is a heath service organisation, formed in Apri 1996 by the Department of Heath. Its aim is to promote and support high quaity, cost-effective prescribing and medicines management across the NHS, to hep improve patient care and service deivery. Patient Safety v. 1.2, Jun 11 11

12 Promoting Learning about Patient Safety Work-based earning in primary care Being part of a mutidiscipinary team is a particuar feature of primary care. Understanding the infuence of being a doctor in that team and the effect on the cuture and systems within the practice is important. It is aso usefu to observe and be aware of the differing eves of infuence arising from the different roes such as partner, sessiona doctor and ocum. Experience of seeing significant event audit as a too for refection and ceebration of good care as we as a method to ook at patient safety incidents is a particuar feature of primary care teams. The observation of systems deveoped by each practice to manage its repeat prescribing system and decisions about how much risk to toerate in this process and how changes over time have been infuenced by the Nationa Prescribing Centre guidance and is unique to primary care. Likewise, understanding the processes that occur during a consutation when a decision to seek advice from a referra is considered, as we as the practica systems in pace to achieve it, are ideay expored within the primary care setting. Refecting on cases that iustrate a deay in diagnosis using toos such as SEA can hep understanding of the compex process of diagnosis both within the primary and secondary care setting. Work-based earning in secondary care The cinica governance and risk management structures are different in secondary care. Understanding this is important to fuy appreciate how to maximise the benefits for patients. Root Cause Anaysis (RCA) is the standard risk too used in secondary care and famiiarity with its appication can be best observed in this setting. Likewise the particuar roe of risk managers in secondary care trusts is best appreciated in this environment. The primary/secondary care interface is especiay vunerabe to patient safety events. Observing and understanding how different systems and processes infuence this can particuary be appreciated during a secondary care-based experience. Non-work-based earning There are many web-based sites that offer educationa modues in patient safety (see above) as we as providing access to reevant toos such as the NPSA toos IPSEL (Induction to Patient Safety e-learning), RCA tookit and the Incident Decision Tree. In addition, there is the DH vincristine video or the Deivering Patient Safety DVDs. Learning with other heathcare professionas Primary care teams are highy sophisticated mutiprofessiona groups. The opportunity to participate in shared earning with such coeagues has particuary expanded given the extended roes seen foowing the pharmacy contract of 2005 and the extension of non-medica prescribing and the emergence of coeagues working with ong-term conditions, such as community matrons, nurse practitioners and medica care practitioners. The variety of modes for out-of-hours deivery of care has aso faciitated many opportunities for shared 12 RCGP Curricuum Statement 3.2

13 earning with emergency care practitioners, paramedics, accident and emergency units, crisis menta heath teams and wak-in centres. Patient Safety v. 1.2, Jun 11 13

14 References 1 DEPARTMENT OF HEALTH. An Organisation with a Memory London: The Stationery Office, NATIONAL PATIENT SAFETY AGENCY. Seven Steps to Patient Safety for Primary Care London: NPSA, DEPARTMENT OF HEALTH. Buiding a Safer NHS for Patients London: Department of Heath, NATIONAL AUDIT OFFICE REPORT. A Safer Pace for Patients: earning to improve patient safety London: The Stationery Office, MEDICAL DEFENCE UNION, [accessed January 2007] 6 MEDICAL PROTECTION SOCIETY, [accessed January 2007] 7NATIONAL PATIENT SAFETY AGENCY, 8 NATIONAL PATIENT SAFETY AGENCY. Being Open Poicy, 2005, [accessed January 2007] 9 DEPARTMENT OF HEALTH. Commissioning a Patient Led NHS London: DH, DEPARTMENT OF HEALTH. Community matron poicy in Department of Heath NHS Improvement Pan 2004: putting peope at the heart of pubic services London: DH, DEPARTMENT OF HEALTH. A First Cass Service: quaity in the new NHS London: The Stationery Office, REASON J (ed.). Human Error Cambridge: Cambridge University Press, REASON J. Human Error: modes and management BMJ 2000; 320(7237): RCGP Curricuum Statement 3.2

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