Writer and editor
Medical Protection Society
Sara has written about medicolegal issues for nearly four years. Working for MPS, she edits Your Practice magazine and Sessional GP. Sara also writes for Casebook, MPS’s signature journal, and has recently written about child protection issues and chaperones
Health and safety and communication were among the top five high-risk areas identified in clinical risk self-assessments (CRSAs) conducted by MPS of 126 general practices in 2009. An analysis revealed that all practices had risks around health and safety, and 93% had risks around communication. These high risks represent common challenges shared by busy modern practices – so it is vital that all practices confront them.
Health and safety pitfalls
The top 10 health and safety risks are listed in Box 1 and explored below. Box 2 presents a case study typical to general practice.
Health and safety legislation compliance
Recent legislative changes, such as the Health and Safety (Offences) Act (2008), mean that there may be greater penalties imposed and a broadening of the range of offences for practices who fail to comply with the Health and Safety at Work Act (1974).
Practice responsibilities vary according to who owns the building. For example, the provision of fire equipment and fire policies could be the responsibility of the primary care trust (PCT) or health board, if the latter own the building. Practice managers are advised to clarify with owners of the premises what health and safety areas the practice is responsible for. If the practice owns the building, then the responsibility for health and safety lies with the practice.
Insufficient security measures
The MPS risk assessment analysis revealed that 79% of practices had risks associated with personal safety and security (see Box 1), eg:
- Consulting rooms unlocked when not in use.
- No plan of what to do if a panic button is activated.
- During extended opening hours there may be only one receptionist and one doctor in the practice, eg, the front door not being locked, so patients could wander into other unused areas of the building.
- Lone worker risk assessments not being completed and staff training needs not being addressed.
To mitigate these risks practices may:
- Consider installing combination locks on consulting room doors.
- Draw up an action plan following the activation of panic alarms, linking to the local police station if possible. All staff should be aware of this.
- Review security issues at the practice in relation to extended opening hours. Draw up a protocol.
- When a limited number of staff are on duty, lock areas not in use, eg, nursing and consulting room corridors.
- Consider the safety of the receptionist who may be working alone during the extended hours. Consider locking the front door, as access to the practice is by pre-arranged appointment only; the patient can be asked to ring the bell for entry to the practice.
- Consider the use of CCTV.
- Conduct lone-worker risk assessments and consider the training required by staff to help them manage violence and aggression. Under the Health and Safety at Work Act (1974), it is the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all employees.
- Provide staff training in conflict resolution and how to deal with aggressive patients.
Control of Substances Hazardous to Health (COSHH)
Many practices were unclear whether they had undertaken a formal COSHH assessment. This should cover biological agents, the safe disposal of waste and the need for personal protective clothing/equipment, and be carried out in accordance with COSHH Regulations (2002).
Latex gloves used routinely
Some practices still provide latex gloves – where this is the case, practices should review their glove policy, taking into account the risks for staff associated with the ongoing exposure to latex. All circumstances where staff are exposed to latex should be considered when completing COSHH assessments.
No manual handling assessments
The risk of injury is reduced by training staff in manual handing, yet not all practices had such training in place. Practices that undertake this must do it in accordance with the Manual Handling Regulations Act (1992, revised 2002).
No designated first aider
Many practices did not have a designated first aider. Practices must appoint a designated first aider and provide first aid training, equipment and facilities to enable first aid to be given to employees if they are injured or become ill at work (Health and Safety Regulations 1981).
No clear fire policy
Risks identified around fire safety included not having a written fire policy, no fire equipment checks, fire exits not marked and/or obstructed, and the practice team being unfamiliar with the evacuation plans. Managers should contact the local fire service and ask them to help devise a fire evacuation plan. Staff should then be made aware of it, so that they know what to do in the event of a fire.
Storage of sharps boxes and clinical bins
Sharps and waste storage was found to be inadequate in 41% of practices; many did not have a sharps/needlestick injury policy. This should be regularly reviewed and adhered to by all staff. All sharp containers and clinical waste bins should be stored out of reach of children.
Effective communication is fundamental to the delivery of safe patient care. The top communication risks are listed in Box 3 and explored below; Box 4 presents a case study highlighting a risk.
Limited practice information
Fifty-nine percent of practices had issues relating to their practice leaflet or website, which should contain information on the practice’s policy on consent, confidentiality, compliance with data protection, chaperones, how a patient can make a complaint, etc. Practices should cater for patients with special requirements, such as non-English speakers, especially in ethnically diverse areas. The needs of visually and hearing impaired patients should also be adequately met.
Practice internal messaging system
Fifty-eight percent of practices had issues relating to the mechanism for sharing information. This included not having a recordable system for passing internal messages – MPS observed several practices still using post-it notes and paper to pass on messages. To mitigate these risks, practices are advised to use an electronic computer messaging system that provides an audit trail of messages.
Issues of other healthcare providers
The results showed that poor communication from the primary care team was evident in 38% of practices and a further 36% experienced poor communication from secondary care.
Problems can arise within a practice because of a breakdown in communication within the practice and outside, eg, specialists, district nurses, etc. Having clear communication systems in place can avoid this. It is also important to ensure that communication from attached staff is documented in the patient’s record.
Interruptions during surgery
Just under a third of practices had risks around interruptions from other clinicians, administrative staff and patients in the treatment area. Interruptions can lead to entries being added incorrectly, if at all, or a breach of confidentiality. A cultural change in the practice should discourage interruptions by fellow staff, but patients need to be educated not to interrupt practitioners as it can lead to mistakes.
Managing risk in practice
General practices are busy environments, where there is the possibility of human and systems errors, so risk will never be completely eliminated. However, by identifying and addressing the risks, this will mitigate them for the future and enable practices to deliver a safer service.