�Attending this learning session

�Being a part of safety in practice so far

�Submission of monthly audit data – 10th of each monthplease

�Fruitful and promising start to the year

� Aim of SiP Initiative is to enhance the qualityimprovement capability of general practices acrossAuckland through a specific focus on patient safety.

� 2014/15 23 practices, 2015/16 32 practices� 2016/17 - 42 enrolled practices working together

� Data collected so far reflects that our objective ofimproving patient safety and quality of care is being met.

• Try to have a crystal-clear picture of where you’re going

• Make sure your people, processes, and strategies are in alignment to get you there

• Go for it

1. If the patient is eligible for a CVDRA recall to bein place, is there a recall?

2. Was the most recent recall acted upon/labforms given?

3. If lab tests were completed, was a CVDRAcompleted?

4. Was a clinical decision made as a result of theCVDRA?

5. Have the required actions beencompleted/significant risk factors addressed?

6. Has documented smoking cessation advicebeen offered at every opportunity in the last yearfor all smokers?

Approach So Far Has Been To Provide Practices With QualityImprovement Support And Facilitation To Assist With:-

• Up-skilling teams in improvement methodology

• Identification of current systems, processes and behaviours

• Data analysis

• Redesign of practice systems and processes

• PDSA testing of small change with the SiP care bundle audit

tools

• Simple checklist used to screen medical records for potential harm.

• They facilitate the structured, focused and rapid review of a sample of medical

records.

• ‘Triggers’ are ‘flags’ for patient harm. They act as a prompt to the reviewer to search

the record in more depth for a potential unintended consequence of treatment.

• The focus is on identifying avoidable harm, not error.

• It is therefore about the systems of care, not the individuals who deliver the

care.

• The scale and type of harm that is detected is variable and dependant on a

number of factors.

• Benchmarking and comparisons between two different practice teams is

therefore unreliable, unhelpful and to be avoided.

Error – the failure of a planned action to be completed asintended; (commission or omission) that caused, or contributedto the cause of, the unintended injury.

Adverse event – unintended consequence of medical care,whether preventable or not.

Harm – unintended physical injury resulting from, orcontributed to, by medical care that requires additionalmonitoring or treatment or that results in death.

• >2 consultations with a prescribing practitioner in thesame general practice within 7 days

• New diagnosis of cancer within 3 months

• New Allergy/Adverse reaction added to PMS

• Death within the review period

• Reduction in medication dose

• Out of hours / A&E attendance within the review period

• Hospital discharge

• Hb < 100

• eGFR <35

• Cessation of medications.

HOW TO USE IT?

• Practices identify cohorts of patients (usually high risk) .

• Each quarter, a maximum of 25 records is randomly selected from aselected cohort.

• Each time the Trigger Tool is applied, the same cohort can bereviewed or a different cohort selected.

• Once the allocated 20 minutes for each record is reached go on tothe next record.

• The record review is completed either when 5 harms are found, or 2hours have been spent on the review, whichever comes first.

• Identified harms are documented and classified.

• Opportunities for improvement are identified and prioriti sed.

• Trigger tool is better at detecting acts of commission which lead toerror and harm though omission of care should also be documented.

• Consistency is essential to obtain reliable data over time.

�Before you start this process, it is suggested to have a pract icemeeting to introduce the concept and discuss what is involve d andhow you plan to approach it.

�How frequently will you undertake reviews.

�Who will be involved.

�How you will share the findings.

�How you will prioritize and plan any improvements as a result of the review.

�Reassure team members that the purpose is for system improvement and learning,not accountability.

�Clarify issues relating to how you will manage identification of events where seriousharm has occurred.

�There needs to be an agreed process for managing this which may involve opendisclosure with patients.

�This activity is a Quality Improvement activity and could be described as a type ofaudit. This is not research and ethics approval is not required.

DEFINE THE COHORT

� Patients’ susceptibility to patient safety incidents vary widelyand are influenced by many factors, including age, frequencyof consultation, co-morbidities and the number and types ofprescribed medications.

� There is no single ‘right’ group to choose.

� The following are examples/ideas only to get you started.Each practice should determine the cohort they wish toreview.

• Group 1: At risk individualsResidential Care / HouseboundAged 75 years or older and on 6 or more medicationsRecent or multiple hospital admissionsPalliative careRecent deaths

• Group 2: Patients with one or more long term conditionsChronic kidney disease and on NSAIDSCOPDDiabetesHeart FailureCVD: Stroke / TIA

• Group 3: Patients on one or more high risk medicationsInsulinOpiatesWarfarinNSAIDsDiuretics x 2

• Combinations of groups may be selectedE.g Residential care patients prescribed NSAIDs or Patients with heart failure prescribed

2 or more high risk medications.

SEVERITY SCALE

PREVENTABILITY

SCALE

COMMISSION & OMISSION

CASE SCENARIO 1

A 17 year old female patient presents with fever, no cough and asore throat. The examination discovers purulent tonsillitis, temp38.7 and enlarged tender nodes. GP diagnoses bacterialtonsillitis, takes swab then recollects patient is allergic topenicillin and prescribes Erythromycin 800mg bd. Patient fullyrecovers.

During trigger tools process the GP realizes Penicillin Allergy notdocumented and updates the PMS.

Did Harm Occur – NO

Potential for Harm - YES

CASE SCENARIO 2

A 17 year old female patient presents with fever ,no cough and a sore throat. Theexamination discovers purulent tonsillitis, temp 38.7 and enlarged tender nodes.

No penicillin allergy.

The GP takes a swab and starts Phenoxymethyl penicillin1000mg bd. The patient recovers from tonsillitis but returns 7days later with vaginal thrush. The Swab confirmed streptonsillitis.

Did harm occur –YES – thrush in response to penicillin

Severity Scale – 2 – Mild Harm/inconvenience

Preventability Scale – 2 – Not preventable and originated in thispractice – OR if has had thrush before GP could have givenempirical thrush treatment so Potentially preventable i.e. 3

CASE SCENARIO 3

A 17 year old female patient presents with fever ,no cough and a sore throat.The examination discovers purulent tonsillitis, temp 38.7 and enlarged tendernodes. No penicillin allergy. The GP takes a swab and starts amoxicillin 500mgtds.

The patient represents 3 days later feeling worse with wide spread itchymorbilliform rash. The GP notes an arc of haemorrhage on the soft palate. Theswab result finds no strep isolated. Diagnosis is likely Epstein Barr virusinfection with hypersensitivity reaction to amoxicillin.

Did harm occur- YES – patient had an EBV infection and developedhypersensitivity reaction to inappropriate amoxicillin prescribing.

Severity Scale – 3 – Moderate Harm

Preventability Scale – 3 – Potentially preventable and originated in thispractice - presentation fitted with EBV, amoxil unnecessarily broad spectrum.

ACTIONS

� Acknowledge the detected levels of harm, irrespective ofwhether errors have occurred.

� In those instances where an error occurred it may benecessary to apologize to affected patients.

� With regard to those patients where harm was detected -there may still be an opportunity to intervene to preventfurther progression or alleviate complications.

� It may be possible through early, targeted intervention toprevent similar harm to other patients.

LEARNING EXAMPLES

• Detected a female patient with severe migraine attacksthought to be complicated by the combined hormonalcontraceptive pill

• Found a case of Warfarin and Aspirin being co-prescribedinappropriately

• Temporary INR increase to >5 after prescription of oralantibiotic for suspected UTI.

Co-Design FrameworkFive Key Steps

� Engage with patients

� Capture the experience – Questionnaire or Interview

� Understand the experience

� Identify opportunities and improve the experience

� Measure the experience

CAPTURE THE EXPERIENCE

Experience Questionnaire

Gathering people's feelings and/or emotions at cert ain points of the process

Can be used for patients and staff

• Step 1. – Map the touch points of an experience with the patient’s perspective

• Step 2. – Choose which emotion words you would like to include for each touch point

• Step 3. – Distribute to patients, explain how theinf ormation will be used focus on improving the experience

• Step 4. – Allow time to complete the questionnaire

Medication Reconciliation Room 102

Cervical Screening Room 103/104

COPD Room 105

Opioids + Warfarin Room 106

Results Handling & CVDRA Lecture Theatre

Almost there….

Co-Design FrameworkFive Key Steps

� Engage with patients

� Capture the experience –Questionnaire or Interview

� Understand the experience

� Identify opportunities and improve the experience

� Measure the experience

NEXT STEPS• Continue Monthly Audits – 10th of every

month, please don’t erase the data fromthe month before

• Undertake Trigger Tool

• Undertake Safety Climate Survey

• Incorporate Patient Experience

• Continued input from IA, PHO facilitatorand Clinical Lead.

• Help Evaluate SiP

• Learning Session 3 –30th March 2016