Patient safety - are we doing enough?
Date sent: Tuesday 7 April 2015
Email sent by Wessex LMCs, on Thursday, 2 Apr 2015
Openness and honesty – a professionals duty of candour
Following the Mid Staffordshire enquiry, there was significant publicity to the appalling events of poor care that was provided to the patients in the hospital. What was also highlighted was the healthcare professionals were aware of this going on.
The duty of candour is now a statutory obligation for all NHS bodies including general practice.
Following the Francis enquiry it has been reinforce that all health care professionals must be open and honest with patients, particularly when thing go wrong.
This relates to our special relationship with patients, being the “family doctor” and providing holistic care. In addition the introduction of significant event reviews over 10 years ago has contributed to developing an more open culture within a practice in terms of discussing and learning from adverse events.
But have we gone far enough?
Although general practice is generally very good at internal practice reviews of significant events, we report far less externally than other parts of the NHS.
Medical errors in general practice occur 5 – 80 times per 100,000 consultations yet prescription and prescribing errors occur in 11% of all prescriptions.
GMC Guidance states in Para 49:
You should also:
a. check that all serious patient safety incidents are reported to the National Reporting and Learning System (in England and Wales), especially if such incidents are not automatically reported through clinical governance arrangements where you work.
How many GPs have reported an event to the National Reporting and Learning system?
In fact haw many of you have even heard of this organisation?
The probability is that if an adverse event occurs in one practice it could occur or probably has occurred in many other. So could we learn from each other?
General practice patient safety reporting form launched
A new eform has been launched to enable general practice staff to quickly and easily report patient safety incidents to the National Reporting and Learning System (NRLS) – the national patient safety incident database.
Reports of harm or near misses to the NRLS provide NHS England with important insight of incidents from across the country. This enables risks to be identified and appropriate action to be taken to prevent incidents – such as the cascading of patient safety alerts, developing learning resources and holding workshops for NHS staff.
Incident reporting is also important at a local level because it helps the healthcare system to learn what can be done locally to keep patients safe from avoidable harm.
With 360 million consultations each year, general practice is the most common place for patient interaction with the health service.
Despite this, the number of safety incidents reported to the NRLS from primary care remains low compared to the almost 1.5 million reports each year from hospital-based care. This makes it difficult to develop appropriate and relevant support and learning resources for practice staff.
The new GP e-form, which has been developed in consultation with general practice staff, the form is simple and quick to complete.
Practices can choose to include their practice code or can submit a report entirely anonymously. Patient identifiable information is also not required.
GPs can also gain Continuing Professional Development (CPD) credits by submitting incident reports via the GP e-form.
Upon submission of the incident report there is the option to request a bounce back email with a Significant Event Audit template which can be used for CPD, Appraisal and Revalidation.
This can also provide evidence of patient safety activity during CQC inspections.
To access the e-form please click here.
It is recommend that the ‘e-form icon’ is downloaded to desktops (a simple drag and drop process) for quick access to the new GP eform.
See the Patient Safety in General Practice pages to download a guide to the new form, please click here.
I have downloaded this Icon on all PCs in my practice.
There is also a range of other supporting materials on our GP patient safety web page, please click here.
It would be great to share our learning by using the new and improved system and once again show how general practice in Wessex embraces initiatives that improve quality, help patients and are simple and practical to use.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)