Patient safety: learning the lessons in primary care

Abstract

Key messages

GPs are the champions of patient safety for their patients and have future possibility for driving patient safety across the entire health services. To fulfil this challenge clinicians need to consider how the techniques and tools widely applied in hospital care might best be used within primary care. This includes developing robust systems to effectively identify and capture information about safety events, procedures and collaborative activities to investigate and analyse safety event, and incentives and penalties for implementing safety improvements.

Why this matters to me

Patient safety should be at the forefront of health-care. Primary care clinicians have the opportunity to drive this agenda in the future.

Introduction

Patient safety has become an international health service phenomenon.¹ For nearly 20 years research in Australia, the US and the UK has shown that as many as one in ten hospital patients experience some form of adverse incident in the organisation and delivery of their care.^2–4 Over the last decade governments have invested in new agencies and systems to foster learning and improvement from these safety events. For the National Health Service (NHS) of England and Wales this could be seen with the creation of the National Patient Safety Agency which championed learning and safety across the health service.

Underlying the patient safety agenda is a purported sea-change in how safety events are understood and addressed. It is argued, for instance, that when mistakes and incidents occur there is too often a tendency to focus on the immediate event, especially mistaken or inappropriate clinical practice.⁵ Because clinicians believe they will be held responsible for these incidents there is a tendency for them to conceal information from their colleagues or managers. Accordingly it is often argued that a ‘culture of blame’ stymies learning and safety improvement within the NHS.^4,5

Yet research in other high-risk industries shows that in many instances mistakes, mishaps and failures result not from erroneous individual behaviour, but from an array of causal and contributory factors located ‘upstream’ within the wider organisation of work.^6,7 In the healthcare context, research points to risk factors found in communication pathways, teamwork arrangements, management priorities, organisational processes, occupational cultures and institutional influences.⁸

This ‘systems approach’ shows, for example, that clinical risks in the operating theatre are brought about by the complex inter-connection between other hospital departments such as surgical wards, sterile services and pathology services.⁹ Such research suggests that small delays and lapses in the coordination of clinical services can cause breakdowns, time pressures and uncertainties in the delivery of patient care. The systems approach provides a more nuanced lens for understanding the range of factors and chains of events that condition, exacerbate and enable mistakes in the delivery of frontline care. Through enabling us to recognise these wider factors it also encourages us to refrain from blaming those individuals at the ‘bluntend’ of care delivery and instead to look further a field for both the sources of risk and the opportunities for learning, innovation and improvement. It is in this drive to foster learning that the National Reporting and Learning System was introduced across the NHS to enable service providers to communicate their experiences of risk with the aim of sharing these lessons more widely and looking for more deeply embedded and systemic sources of risk.¹⁰

To date, however, much of the research has focused on the hospital sector to the neglect of primary and community service.¹¹ It is important to consider, however, that primary and community care providers also need to meet the challenge of patient safety. This is made more difficult, perhaps, given the complex and diverse needs of patients that can render diagnosis, treatment and referral uncertain and complicated. Take for example the difficulties of disentangling the array of experiences, symptoms and conditions presented by patients in the GP surgery about which doctors need to make timely and accurate diagnostic decisions about care needs and possible referrals. Here questions of safety are not isolated to the behaviour of the individual GP but relate to the wider configuration of services and resources. This might include, for example, access to appropriate diagnostic and treatments facilities; availability of electronic health records or other information communication technologies (ICT) systems; the ability to liaise with social care providers; and understanding of new therapies, interventions and care pathways provided in different secondary care providers. Consider the problems of hospital discharge and the planning of patient care and recovery back in the community. This requires GPs to have timely access to information related to ongoing treatments, changes in medication and the ability to coordinate care providers in domestic, community and social care organisations. As such, it is important to recognise that GPs work in equally, if not more, complex and fragmented settings that involve the interaction and collaboration of multiple agencies.

With current NHS reforms placing greater responsibility on GPs to commission high-quality care on behalf of their patients¹² there are also new challenges about how GPs can effectively learn the lessons for patient safety both in primary and hospital settings. More than ever GPs will have the responsibility but also power to drive the patient safety agenda. There is strong evidence that many GP practices engage in forms of significant event audit and case review, but how can these be developed and enhanced to ensure learning across primary and community care providers? More importantly, perhaps, how can GPs learn about the threats to patient safety that their patients might experience in hospital and use their new powers to ensure that safety is improved or their patients are referred elsewhere? Given the particular characteristics of primary care, this means recognising that some of the patient safety systems found hospital services might not be suitable or appropriate to needs and conditions of GPs. In thinking about these challenges three issues come to the fore. First, how can GPs identify and share the lessons for patient safety? Second, how can GPs analyse and learn from these events? And third, how can GPs use this knowledge and other resources at their disposable to enact safety improvements?

How can GPs identify and share the lessons for patient safety?

Clinicians working in primary and community settings, and participating in newly proposed consortia, need to establish robust and effective mechanisms for identifying and sharing the lessons for patient safety. These need to work in two ways.¹⁰ First, they need to be capable of capturing information about the threats to patient safety that relate to the delivery of care within and across primary and community care settings. This might include risks associated with diagnosis and decision-making, prescribing and dispensing or the provision of home or out-of-hours care. However, it is also essential that risks should be identified as arising from the interaction and coordination of different service providers and stakeholders located and involved within the organisation and delivery of primary care. Take, for example, stroke care and the complex risks associated with organising and coordinating medical and clinical care as well as specialist social and personal care.

In seeking to identify and understand the potential threats to patient safety in primary care, clinicians need to strike a balance between adopting standardised reporting and systems, as found in most NHS trusts, and developing more bespoke and localised techniques that make full use of available information sources found within and across primary and community settings. The key point is to avoid the allure of introducing expensive and often timely reporting systems that are widely shown to have limited effect¹³ and instead to review existing and missing sources of information with the aim of developing localised procedures that are tailored to and can enhance the ability of GPs to ‘know what is going on’ at the system level.

The second and related issue concerns those risks and patient safety events that originate in secondary and social care providers. Currently, NHS trusts are encouraged to use the National Reporting and Learning System which provides a procedural approach to capturing, analysing and using information related to patient safety. Although GPs and PCTs will often be provided with information related to ‘high-risk’ patient safety incidents as identified through this system, it is unusual for GPs to be provided with detailed or even summary information for all the incidents related to their patients. It is widely recognised that these reporting systems have limited efficacy and can struggle to stimulate learning,^13,14 but they still offer an important source of information that should be shared more widely with professionals working in different care settings. GPs might consider working more closely with hospital services to gain more appropriate and timely access to this information in ways that does not shift resources or responsibility to GPs. This might include monthly summaries of all incidents related to patients and certainly advanced notice of any significant event review or root cause analysis investigation related to a GP's patient. An additional but important source of information on the safety of secondary care also relates to patient and carer feedback on their experiences, which can provide a valuable first-hand account of the quality and safety of care. In short, GPs need to know more about the safety and quality of the care their patients receive in other care settings.

How can GPs better understand the threats to patient safety?

Once a safety event has come to light it is then important to see it as a learning opportunity and, as noted above, avoid the inclination to blame individual practitioners. It is at this point that the ‘systems approach’ comes to the fore, directing analysis to those underlying latent factors that shape clinical practice.⁵ Again, policy makers have looked to various industries for inspiration with approaches like root cause analysis (RCA) becoming mainstream for incident analysis in secondary care. RCA actually represents a collection of methods and tools, including time-line analysis, fish-bone diagrams, and error chains, that direct analysis to the risk factors located deep within the organisation of care.¹⁴ Although there are examples where these have been used to good effect, especially in the more high-profile cases of patient harm, a growing body of research suggests their use is variable and problematic. It is shown, for instance, that those leading investigations are often poorly supported and struggle to manage the powerful differentials between clinical groups.¹⁵ Moreover, is argued that too often investigations become dominated by the need to secure some form of closure and legitimacy in the wake of an incident rather than learning and change.¹⁶

For those working in primary care, however, the use of such techniques is complicated further. GPs sit at the interface between different care providers, almost like a central contact or referral point ensuring the continuity of care between a myriad of different processes. When patient safety incidents occur within and across these care settings GPs not only have the problem of indentifying them, but also in undertaking and leading investigations to determine their root causes. Although many hospital-based incidents also involve multiple agencies, in most cases investigations are lead by specialist risk managers who are able to review the activities of multiple hospital departments and wards when undertaking their investigation. Those in primary care, however, will often lack the formal and informal legitimacy to review processes and procedures located in other care settings, such as social care, pharmacies or indeed hospitals.

If GPs are to become more proactive and central to the promotion of patient safety it is therefore necessary that some common and agreed terms of practice are established that allow access to information and systems located in other care processes. Moreover, it is important to foster a collaborative and shared approach to learning whereby GPs working in different practices and with different sectors are recognised as equal partners in the learning process and not called to account for the actions or inactions in delivering patient safety. Techniques such as RCA might have the appearance of a police investigation, but it is important to avoid over-prescriptive use and instead to use them and other techniques as a more constructive dialogue between stakeholders around the opportunities for service improvement.

How can GPs influence patient safety outcomes?

The ultimate aim of any approach to patient safety is to learn the lessons and ensure the future safety of patient care. Whilst GPs can work to streamline and assure the quality of their own systems and procedures, it is clearly diffcult to engender change amongst other care providers. With the recent announcement of primary care consortia,¹² it can be expected that many of the oversight roles undertaken by PCTs, including patient safety, will be transferred to these new groups and possibly provided by third-party specialists. As such, these consortia should work to share the experiences of GPs across the wider network or group, especially as it relates to care provided by hospital or other community care providers. In turn, GPs can learn from the experiences of their peers and change their treatment or referral practices accordingly. In short, GPs need to work together to disseminate the findings of any incident and investigation to develop common standards of high-quality and safe patient care.

In thinking about these changes, GPs need to consider how they can use their growing financial powers as both incentives and penalties for patient safety. The Secretary of State raises the possibility of a post discharge warranty-style scheme,¹⁶ whereby emergency readmissions to hospital that result from inappropriate or poorly planned discharge should not involve additional payments. Commissioners might think of other ways of fostering safety improvements through, for example, reducing payments in the case of remedial care and extra bed days in the wake of hospital acquired infections or delay discharge. At its most extreme it might involve changing referrals patterns where there is consistent evidence of patient harm or where patients consistently experience poor levels of care.

Equally, financial rewards and extended commissioning arrangements might be secured where patients report high levels of satisfaction and where incidents of risk are lower than average in comparison to other providers. It is worth considering, however, that the use of such financial incentives might also run counter to the aspirations of learning. They might again reinforce the tendency to conceal evidence of patient safety and non-collaboration in incident investigations because of the fear of losing referral income. The stark realities of competitive commissioning and provision might therefore drive underground organisational learning, not through blame, but the fear of losing income. It might be necessary therefore to think more creatively about the use of new financial powers, and rather than using them in a rigid context of supply-and-demand, to think about rewarding and empowering other care professions and agencies for participating in the learning process.

Conclusion

In conclusion, GPs are set to receive greater responsibilities, especially financial, for ensuring the quality and safety of their patients' care. As such GPs need to become the champions of patient safety, not just in their own practice but across the range of health and social care providers. Whilst new financial powers can be used to encourage and discourage certain forms of care, caution should be taken in wielding these too much as they might undermine collaboration between care providers, which is integral if GPs want to be informed about patient safety events, understand their causes and ultimately reduced their reoccurrence. As such, it is important to recognise that care providers, working in different sectors, services and organisations, are involved in a collaborative effort and they need to be open with each other about their work.

GPs are often at the centre of these processes and provide that essential continuity of care. It is therefore appropriate that they take leadership for patient safety more widely within the NHS. As well as thinking about the role of individual GPs or practices, this now means thinking about how consortia might enable the sharing of resources and expertise for patient safety and foster a more collaborative approach. As PCTs are phased out many of their ‘backroom’ functions, including those for patient safety will be taken up by these newly formed groups. At this time it is important to ensure that safety, as well as cost-effectiveness, is built into the strategic plans and objectives for the future.