The NHS aspires to provide the safest, most effective healthcare in the world. But every year a small number of patients are harmed, sometimes fatally, in incidents that could have been prevented, Anne Ward Platt explains

The majority of such incidents occur in secondary care, but a headline earlier this year ‘Anorexic died after errors at GP surgery’ was a stark reminder that patients can also be harmed, or even die, when things go wrong in general practice.[1] In this case, an abnormal blood result on a young woman requiring urgent attention was phoned through to the patient’s practice, but the information was not communicated or acted upon appropriately. Tragically, the young woman died without receiving the treatment indicated by the blood results.

It is in recognition of the fact that avoidable harm can and does occur in primary care that NHS England extended the National Reporting and Learning System (NRLS) to general practice. This system enables the reporting of patient safety incidents (including near misses) with the intention of identifying common themes, triggering safety alerts and disseminating learning.[2]

Any incident reporting system has to command the confidence of staff, otherwise it will not be used. But good quality investigations can help to increase confidence in incident reporting. Staff should feel that an investigation is not a process that is done to them, but one in which they participate, where their ideas are valued, and where the goal is to make sustainable improvements. The emphasis has to be on systems rather than people. Even human factors such as slips, lapses and distractions do not occur in isolation but as a result of workplace, system or environmental factors that can be addressed.  

The report of the Care Quality Commission (CQC) reviewing the first inspections of general practices in England found that strong management was essential to providing safe and effective healthcare.[3] And whether practices have adopted incident reporting as part of their safety culture is one of the areas scrutinised by the CQC when assessing a practice’s commitment to patient safety.

BOX 1 Resources in the RCGP Patient Safety Toolkit

• The Trigger Tool
• Primary Care SafeQuest
• Manchester Patient Safety Framework (MaPSaF)
• Prescribing Safety Indicators
• Patient Safety Questionnaire
• Concise Safe Systems Checklist
• Safety Checklist for General Practice
• Medicines Reconciliation Tool
• Significant Event Audit
• Additional Resources
• Background to the Toolkit

Practice managers therefore have a vital role in relation to patient safety through:

• Instilling and maintaining a culture of safety among all practice staff.
• Ensuring that administrative systems are robust and safe, so that important information about patients is not lost or delayed.
• Developing the recognition, reporting, investigation and analysis of safety incidents so that continuous improvement and learning take place, and the repetition of similar incidents becomes less likely.

Building a safety culture in a small organisation such as a practice is easier than in large institutions, since it is more straightforward to involve all staff. The goal is to ensure that minimising harm and improving quality are seen as everyone’s business and that all staff recognise they have a responsibility to take appropriate action if they notice a potential risk or are aware that something has gone wrong. 

A key step is to recognise the extent to which risk is present on a day-to-day basis. For example, in a recent study, almost one-fifth of general practice patients given prescriptions were found to be exposed to some degree of error, while one prescription in 550 contained a serious error.[4] Examples of other types of incidents and near misses are:

• Medication errors, including drug interactions.
• Missed or late diagnoses.
• Delayed referrals.
• Lost reports and results.
• Lost letters and discharge summaries from hospital.

Several resources are available to assist with patient safety training. Examples are the Patient Safety Toolkit from the Royal College of General Practitioners (RCGP) (see box 1) and the grading classification for incidents as defined by the NRLS (see box 2). There is also a generic root cause analysis tool (see Resources, below), for which staff need training.

Transparency in admitting errors and being open and honest with patients and their relatives is crucial to maintaining trust and is also shown to reduce the likelihood of complaints and claims. Aggrieved patients and families sometimes resort to litigation as a means of finding out the truth, especially if they feel there has been a cover-up.

Developments that will affect patient safety in general practice are ongoing. For example, the concept of ‘never events’, used in hospital practice.[5] A never event is one that:

• Is known to cause severe harm to a patient, or has the potential to do so; and,
• Is preventable by the healthcare professional, team, or organisation; and,
• Can be clearly and precisely defined; and,
• Can be detected; and,
• Is not the result of an unlawful act.[6]

The latest official list of never events covers 2015/16. Most of these, like wrong-site surgery, are unlikely to be relevant to general practice. However, some relate to any healthcare setting, for example: 

• Overdose of insulin due to abbreviations or incorrect device.
• Overdose of methotrexate for non-cancer treatment.

Do you consider the systems in your practice are sufficiently robust that wrong or excessive doses of these drugs could not happen?

BOX 2 Categories of harm

Definitions and examples of categories of harm, modified from the Guide for general practice staff on reporting patient safety incidents to the National Reporting and Learning System (NHS England) [2]

No harm – impact prevented

Example: A GP prescribes an inappropriate dose for a drug, which the community pharmacist picks up when dispensing the prescription.

Definition: Any unexpected or unintended incident that was noticed and halted or reversed before it was able to cause harm to a patient.

No harm – impact not prevented

Example: A patient is on medication that requires blood pressure monitoring. The hospital discharge letter does not mention this to the GP, which results in the patient not being followed up appropriately.  However it is noted when the patient visits the GP for a further prescription. The patient’s measurements are then found to be normal.

Definition: Any unexpected or unintended incident that did not lead to harm on this occasion.

Low

Example: A patient’s home visit is missed. The terminally ill patient required a pain assessment. This was picked up the following day, resulting in the patient continuing to be in pain until the medication was altered.

Definition: Any unexpected or unintended incident that required extra observation or minor treatment and caused minimal harm to one of more persons.

Moderate

Example: Continuing treatment with warfarin without monitoring clotting levels for a length of time, which results in an overdose and bleeding problems that require close monitoring and follow-up.

Definition: Any unexpected or unintended incident that resulted in further treatment, possible surgical intervention, cancelling of treatment or transfer to another area and caused short-term harm to one or more persons.

Severe

Example: The parents of a four-year-old child contact the GP out-of-hours service with a history of recurrence of a high temperature following the onset of a presumed middle ear infection five days ago. There is no face-to-face consultation and it is suggested that the child’s parents contact their own GP in the morning. On arrival at the surgery the following morning, the child is clearly very ill. The GP arranges immediate admission to hospital by ambulance where the child is diagnosed with sepsis and requires two days of high-dependency unit care before being transferred to the ward. After a further four days as an inpatient the child is discharged home with permanent effects on hearing.

Definition: Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.

Death

Example: A patient suffering from chest pain is asked to wait for a free slot in the GP surgery. As he feels difficulty in getting his breath, he goes for a walk, collapses and dies in the GP surgery’s car park.

Definition: Any unexpected or unintended incident that caused the death of one or more persons. The death must relate to the incident rather than to the natural course of the patient’s illness or condition.

Conclusion

As yet, there is no official list of never events specifically for general practice. As part of patient safety training, a useful exercise can be to consider which incidents might be classed as never events. As with other initiatives, anything that requires extra time, even temporarily, can conflict with the pressures of workloads in practices. But overwork is itself a patient safety issue, and one of the benefits of looking at quality and safety is that it is often possible to identify efficiencies that can mitigate the effects of increasing workload.[7]

Protecting patients from avoidable harm is integral to the delivery of effective healthcare and is a key priority for the NHS. Practices – and patients – have everything to gain from embedding a strong safety culture.

Resources

NHS England incident reporting e-form for general practices report.nrls.nhs.uk/GP_eForm

Generic tool for Root Cause Analysis investigation of incidents, 2010
http://www.nrls.npsa.nhs.uk/resources/?entryid45=75605

Royal College of General Practitioners. Patient Safety Tool for General Practice. rcgp.org.uk/clinical-and-research/toolkits/patient-safety.aspx

References

1. ‘Anorexic teenager died after errors at GP surgery.’ The Times, 22 June 2016.

2. NHS England. Guide for general practice staff on reporting patient safety incidents to the National Reporting and Learning System. NHS England Patient Safety Domain, 2015.

3. Care Quality Commission. The state of health care and adult social care in England 2014/5. London: Her Majesty’s Stationery Office, 2015.

4. Avery T, Barber N, Ghaleb M et al. Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study. A report for the GMC. General Medical Council 2012. gmc-uk.org/about/research/25043.asp

5. NHS England. Never Events list 2015-6. england.nhs.uk/patientsafety/never-events/# (accessed 5 November 2016).

6. de Wet C, O’Donnell C, Bowie P. Developing a preliminary ‘never event’ list for general practice using consensus-building methods. Br J Gen Pract 2014; DOI: 10.3399/bjgp14X677536

7. Royal College of General Practitioners. Patient safety implications of general practice workload. July 2015. rcgp.org.uk/policy/rcgp-policy-areas/fatigue-in-general-practice.aspx. (accessed 5 November 2016).