Paul Bowie

The preliminary development and testing of a global trigger tool to detect error and patient harm in primary-care records

Background: A multi-method strategy has been proposed to understand and improve the safety of primary care. The trigger tool is a relatively new method that has shown promise in American and secondary healthcare settings. It involves the focused review of a random sample of patient records using a series of “triggers” that alert reviewers to potential errors and previously undetected adverse events. Aim: To develop and test a global trigger tool to detect errors and adverse events in primary-care records. Method: Trigger tool development was informed by previous research and content validated by expert opinion. The tool was applied by trained reviewers who worked in pairs to conduct focused audits of 100 randomly selected electronic patient records in each of five urban general practices in central Scotland. Results: Review of 500 records revealed 2251 consultations and 730 triggers. An adverse event was found in 47 records (9.4%), indicating that harm occurred at a rate of one event per 48 consultations. Of these, 27 were judged to be preventable (42%). A further 17 records (3.4%) contained evidence of a potential adverse event. Harm severity was low to moderate for most patients (82.9%). Error and harm rates were higher in those aged ⩾60 years, and most were medication-related (59%). Conclusions: The trigger tool was successful in identifying undetected patient harm in primary-care records and may be the most reliable method for achieving this. However, the feasibility of its routine application is open to question. The tool may have greater utility as a research rather than an audit technique. Further testing in larger, representative study samples is required.

A qualitative study of why general practitioners may participate in significant event analysis and educational peer assessment

Objectives: To explore the influences and perceived benefits behind general practitioners’ willingness to participate in significant event analysis (SEA) and educational peer assessment. Design: Qualitative analysis of focus group transcripts. Setting: Greater Glasgow Primary Care Trust. Participants: Two focus group sessions involving 21 principals in general practice (GPs). Main outcome measures: GPs’ perceptions of the reasons for and benefits of participating in SEA and associated educational peer assessment. Results: Pressure from accreditation bodies and regulatory authorities makes SEA compulsory for most participants who believe more in-depth event analyses are undertaken as a result. Some believed SEA was not an onerous activity while others argued that this depended on the complexity of the event. SEA that is linked to a complaint investigation may provide credible evidence to patients that their complaint is taken seriously. Writing up an event analysis is viewed as an educational process and may act as a form of personal catharsis for some. Event analyses are submitted for peer assessment for educational reward but are highly selective because of concerns about confidentiality, litigation, or professional embarrassment. Most participants disregard the opportunities to learn from “positive” significant events in favour of problem ones. Peer assessment is valued because there is a perception that it enhances knowledge of the SEA technique and the validity of event analyses, which participants find reassuring. Conclusions: This small study reports mainly positive feedback from a select group of GPs on the merits of SEA and peer assessment.

Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes

BackgroundRoot cause analysis (RCA) originated in the manufacturing engineering sector but has been adapted for routine use in healthcare to investigate patient safety incidents and facilitate organizational learning. Despite the limitations of the RCA evidence base, healthcare authorities and decision makers in NHS Scotland – similar to those internationally - have invested heavily in developing training programmes to build local capacity and capability, and this is a cornerstone of many organizational policies for investigating safety-critical issues. However, to our knowledge there has been no systematic attempt to follow-up and evaluate post-training experiences of RCA-trained staff in Scotland. Given the significant investment in people, time and funding we aimed to capture and learn from the reported experiences, benefits and attitudes of RCA-trained staff and the perceived impact on healthcare systems and safety.MethodsWe adapted a questionnaire used in a published Australian research study to undertake a cross sectional online survey of health care professionals (e.g. nursing & midwifery, medical doctors and pharmacists) formally trained in RCA by a single territorial health board region in NHS Scotland.ResultsA total of 228/469 of invited staff completed the survey (48%). A majority of respondents had yet to participate in a post-training RCA investigation (n=127, 55.7%). Of RCA-experience staff, 71 had assumed a lead investigator role (70.3%) on one or more occasions. A clear majority indicated that their improvement recommendations were generally or partly implemented (82%). The top three barriers to RCA success were cited as: lack of time (54.6%), unwilling colleagues (34%) and inter-professional differences (31%). Differences in agreement levels between RCA-experienced and inexperienced respondents were noted on whether a follow-up session would be beneficial after conducting RCA (65.3% v 39.4%) and if peer feedback on RCA reports would be of educational value (83.2% v 37.0%). Comparisons with the previous research highlighted significant differences such as less reported difficulties within RCA teams (P<0.001) and a greater proportion of respondents taking on RCA leadership roles in this study (P<0.001).ConclusionThis study adds to our knowledge and understanding of the need to improve the effectiveness of RCA training and frontline practices in healthcare settings. The overall evidence points to a potential organisational learning need to provide RCA-trained staff with continuous development opportunities and performance feedback. Healthcare authorities may wish to look more critically at whom they train in RCA, and how this is delivered and supported educationally to maximize cost-benefits, organizational learning and safer patient care.

Can we quantify harm in general practice records? An assessment of precision and power using computer simulation

BackgroundEstimating harm rates for specific patient populations and detecting significant changes in them over time are essential if patient safety in general practice is to be improved. Clinical record review (CRR) is arguably the most suitable method for these purposes, but the optimal values and combinations of its parameters (such as numbers of records and practices) remain unknown. Our aims were to: 1. Determine and quantify CRR parameters; 2. Assess the precision and power of feasible CRR scenarios; and 3. Quantify the minimum requirements for adequate precision and acceptable power.MethodWe explored precision and power of CRR scenarios using Monte Carlo simulation. A range of parameter values were combined in 864 different CRR scenarios, with 1000 random data sets generated for each, and harm rates were estimated and tested for change over time by fitting a generalised linear model with a Poisson response.ResultsCRR scenarios with ≥100 detected harm incidents had harm rate estimates with acceptable precision. Harm reductions of 20% or ≥50% were detected with adequate power by those CRR scenarios with at least 100 and 500 harm incidents respectively. The number of detected harm incidents was dependent on the baseline harm rate multiplied by: the period of time reviewed in each record; number of records reviewed per practice; number of practices who reviewed records; and the number of times each record was reviewed.ConclusionWe developed a simple formula to calculate the minimum values of CRR parameters required to achieve adequate precision and acceptable power when monitoring harm rates. Our findings have practical implications for health care decision-makers, leaders and researchers aiming to measure and reduce harm at regional or national level.

Awareness and analysis of a significant event by general practitioners: a cross sectional survey

Objectives: To determine the extent to which general practitioners (GPs) were aware of a recent significant event and whether a structured analysis of this event was undertaken to minimise the perceived risk of recurrence. Design: Cross sectional survey using a postal questionnaire. Setting: Greater Glasgow primary care trust. Participants: 466 principals in general practice from 188 surgeries. Main outcome measures: GPs’ self-reported personal and practice characteristics, awareness of a recent significant event, participation in the structured analysis of the identified significant event, perceived chance of recurrence, forums for discussing and analysing significant events, and levels of primary care team involvement. Results: Four hundred and sixty six GPs (76%) responded to the survey. GPs from single handed practices were less likely to respond than those in multi-partner training and non-training practices. 401 (86%) reported being aware of a recent significant event; lack of awareness was clearly associated with GPs from non-training practices. 219 (55%) had performed all the necessary stages of a structured analysis (as determined by the authors) of the significant event. GPs from training practices were more likely to report participation in the structured analysis of the recent event, to perceive the chance of this event recurring as “nil” or “very low”, and to report significant event discussions taking place. Conclusions: Most GPs were aware of a recent significant event and participated in the structured analysis of this event. The wider primary care team participated in the analysis process where GPs considered this involvement relevant. There is variation in the depth of and approach to significant event analysis within general practice, which may have implications for the application of the technique as part of the NHS quality agenda.

A research agenda on patient safety in primary care. Recommendations by the LINNEAUS collaboration on patient safety in primary care.

ABSTRACT Background: Healthcare can cause avoidable serious harm to patients. Primary care is not an exception, and the relative lack of research in this area lends urgency to a better understanding of patient safety, the future research agenda and the development of primary care oriented safety programmes. Objective: To outline a research agenda for patient safety improvement in primary care in Europe and beyond. Methods: The LINNEAUS collaboration partners analysed existing research on epidemiology and classification of errors, diagnostic and medication errors, safety culture, and learning for and improving patient safety. We discussed ideas for future research in several meetings, workshops and congresses with LINNEAUS collaboration partners, practising GPs, researchers in this field, and policy makers. Results: This paper summarizes and integrates the outcomes of the LINNEAUS collaboration on patient safety in primary care. It proposes a research agenda on improvement strategies for patient safety in primary care. In addition, it provides background information to help to connect research in this field with practicing GPs and other healthcare workers in primary care. Conclusion: Future research studies should target specific primary care domains, using prospective methods and innovative methods such as patient involvement.

Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study

Background and aims: There is variation in the identification, analysis and reporting of significant events in general practice. Consistency is desired to optimise learning from, and reporting of, patient safety incidents. We examined levels of agreement among different groups of general practitioners (GPs) on the grading, analysis and reporting of selected significant event scenarios. Method: Cross-sectional postal questionnaire survey of 162 GPs split into five professional groups in the west of Scotland. Differences in grading severity and willingness to formally analyse and report seven significant event scenarios were examined using analysis of variance (ANOVA). Differences in proportions were calculated together with 95% confidence intervals. Results: 122 GPs responded (77%). No difference was found in the grading severity of significant events by GP groups. Increased grading severity was linked to the willingness of GP groups to analyse and report that event (p<0.05). A preference to anonymously report all event scenarios to a national educational body was reported (p<0.05). The majority of respondents were not willing to involve patients in relevant event analyses (83–100%). Conclusions: The strong levels of agreement suggest that GPs can prioritise relevant significant events for formal analysis and reporting. Focused guidance should be developed to encourage their engagement with the patient safety agenda, optimise learning from safety-relevant events and increase reporting opportunities. Exploration is required of the reasons why GPs may prefer an educational body as a potential reporting source or may be unwilling to include patients in relevant event analyses.

Acceptability and educational impact of a peer feedback model for significant event analysis

Context  A model of independent, external review of significant event analysis by trained peers was introduced by NHS Scotland in 1998 to support the learning needs of general practitioners (GPs). Engagement with this feedback model has increased over time, but participants’ views and experiences are largely unknown and there is limited evidence of its educational impact. This is important if external feedback is to play a potential role in appraisal and future revalidation.

Blood sampling - two sides to the story

This study aimed to investigate why there is variability in taking blood. A multi method Pilot study was completed in four National Health Service Scotland hospitals. Human Factors/Ergonomics principles were applied to analyse data from 50 observations, 15 interviews and 12-months of incident data from all Scottish hospitals. The Functional Resonance Analysis Method (FRAM) was used to understand why variability may influence blood sampling functions. The analysis of the 61 pre blood transfusion sampling incidents highlighted limitations in the data collected to understand factors influencing performance. FRAM highlighted how variability in the sequence of blood sampling functions and the number of practitioners involved in a single blood sampling activity was influenced by the working environment, equipment, clinical context, work demands and staff resources. This pilot study proposes a realistic view of why blood sampling activities vary and proposes the need to consider the systems resilience in future safety management strategies.

Combining QOF data with the care bundle approach may provide a more meaningful measure of quality in general practice

BackgroundA significant minority of patients do not receive all the evidence-based care recommended for their conditions. Health care quality may be improved by reducing this observed variation. Composite measures offer a different patient-centred perspective on quality and are utilized in acute hospitals via the ‘care bundle’ concept as indicators of the reliability of specific (evidence-based) care delivery tasks and improved outcomes. A care bundle consists of a number of time-specific interventions that should be delivered to every patient every time. We aimed to apply the care bundle concept to selected QOF data to measure the quality of evidence-based care provision.MethodsCare bundles and components were selected from QOF indicators according to defined criteria. Five clinical conditions were suitable for care bundles: Secondary Prevention of Coronary Heart Disease (CHD), Stroke & Transient Ischaemic Attack (TIA), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus (DM). Each bundle has 3-8 components. A retrospective audit was undertaken in a convenience sample of nine general medical practices in the West of Scotland. Collected data included delivery (or not) of individual bundle components to all patients included on specific disease registers. Practice level and overall compliance with bundles and components were calculated in SPSS and expressed as a percentage.ResultsNine practices (64.3%) with a combined patient population of 56,948 were able to provide data in the format requested. Overall compliance with developed QOF-based care bundles (composite measures) was as follows: CHD 64.0%, range 35.0-71.9%; Stroke/TIA 74.1%, range 51.6-82.8%; CKD 69.0%, range 64.0-81.4%; and COPD 82.0%, range 47.9-95.8%; and DM 58.4%, range 50.3-65.2%.ConclusionsIn this small study compliance with individual QOF-based care bundle components was high, but overall (‘all or nothing’) compliance was substantially lower. Care bundles may provide a more informed measure of care quality than existing methods. However, the acceptability, feasibility and potential impact on clinical outcomes are unknown.