Transcript Significant Event Analysis in General Practice

Enhanced Significant Event
Analysis in General Practice
S E A
Adam Hay
Thursday 2nd October 2014
Why do an Enhanced SEA?
• Necessary part of GPST training
• SEA has developed from high risk organisation
• We make mistakes every day – why not learn
from them?
– 9 out of 10 medical consultation are based in
primary care
– 1-2% of these are estimated to have some level of
error occurring
Why change to the Enhanced SEA?
Why change to the Enhanced SEA?
• Criticisms of the old SEA
– Lead to a superficial description of the process
– No active action often taken
– SEA were often discussed informally
– SEA choice often “selective”
• Enhanced SEA aims to avoid all this and
– Encourage professional learning
– Improve patient care
– Discourage blame culture
Blame Culture & Traditional SEA
• A feeling of blame post-SEA could occur due
to:
– Hindsight bias
– The illusion of free will
– Fundamental attribution bias
– Just world hypothesis
Benefits of doing Enhanced SEA
• Enhanced SEA during GPST training is
intended to aid
– Understanding reasons for error occurring
– Improve the safety culture
– Enhance teamwork and communication
– Improve the healthcare system
– Attempt to aid predicting what might go wrong in
the future
How to choose a significant event
How to choose a significant event
• What makes an event significant?
– “Any event thought by anyone in the team to be
significant in the care of patients or the conduct
of the practice”
Pringle et al 1995
• What type of events are often seen?
– Near miss
– Adverse event
– Error
Types of Error
• Active error or passive error
• Can be:
– Slip
– Lapse
– Mistake
– Violation
How to record your Enhanced SEA
• Useful to complete the short e-learning module from NES
– http://www.nes.scot.nhs.uk/media/2408590/enhanced_significant_ev
ent_analysis_module_-_updated.pdf
– Or search “Enhanced SEA” on NES website
• You are advised to use the template available from NES website
http://www.nes.scot.nhs.uk/
Navigate:
>Education and training
>>By theme / initiative
>>>Patient Safety and Clinical Skills
>>>>Enhanced Significant Event Analysis
>>>>>The Guide Tools & Report Format
Steps in the Enhanced SEA Report
Section One
• Title page
• Describe what happened
• The impact or potential impact
Steps in the Enhanced SEA Report
Section Two
• Human and System factors
• How these factors combined to make the
event happen
• Did you identify these factors by yourself or
with the help of others
Human Factors
• “concerns understanding interactions among
humans and other elements of a system…”
• “also concerns applying theory, principles,
data and methods..in order to optimise
human well-being and overall system
performance”
(International Ergonomics Association)
Types of Human Factors to consider
• People Factors
– E.g. patients, interactions between staff
– Directly and possibly indirectly involved
• Activity Factors
– E.g. task complexity, lack of protocol or guidance
• Environment Factors
– E.g. physical environment, practice culture,
time/work load pressure, lighting, noise etc
Case Example for Human Factors
A Receptionist asked the duty GP to sign a repeat prescription for
Amitriptyline for a patient waiting at the desk.
The GP noticed the dose of Amitriptyline appeared incorrect and
checked the patient’s medical record. The GP discovered that
Amisulpride, rather than Amitryptiline, should have been prescribed.
She amended the prescription, explained the error to the patient, and
apologised.
Fortunately, the patient had not suffered any complications from the
wrong drug (and dose) and had not suffered a psychotic
exacerbation.
Possible Human and System Factors
PEOPLE
An administrative team member had entered the prescription incorrectly a few months before.
Amitriptyline is prescribed often, and has several indications, including chronic pain and irritable bowel syndrome.
Amisulpride is an antipsychotic drug and is very rarely prescribed.
Assumed from experience and deciphering of written note that is must be Amitriptyline.
Lacked sufficient clinical knowledge to realise a potential patient safety issue
A GP had signed the initial, wrong prescription.
Patient expectation of quick service.
ACTIVTY
The initial request for Amisulpride was a handwritten note and mostly illegible.
GPs often sign batches of prescriptions, without always checking for accuracy.
Flexible working to attempt satisfy patient need on the day.
ENVIRONMENT
Time and workload pressures
Distractions and noisy environment
Possible staff training on awareness of high risk medications
Availability of handwritten prescriptions
Safety system design issue with repeat prescribing signing by GPs
Steps in the Enhanced SEA Report
Section Three
• What lessons have been learned?
• What learning needs have you identified?
Steps in the Enhanced SEA Report
Section Four
• How have you minimised the chances of this
event happening again?
• Who is responsible for ensuring this?
Steps in the Enhanced SEA Report
Step Five
• Submit your Enhanced SEA for peer review
– [email protected]
Short Exercise on Human Factors
• Work in groups
• Consider
– What was the impact?
– Why did it happen?
• Consider in terms of Human Factors and System Factors
i.e. People, Activity, Environment
– What could be learnt from it?
– What changes could be implemented?
Case Study 1
Mr X’s son made an appointment with Dr G to complain about
the care of his father.
Mr X’s father had attended Dr G seven days previously, feeling
unwell, and Dr G had taken a blood test, and told the patient
he would phone him with the result. Four days after seeing
Dr G, Mr X had been admitted to hospital, where a blood test
demonstrated severe anaemia. The hospital staff said that
they could not find the original blood test taken by Dr G on
the hospital computer.
The son felt that action should have been taken sooner and
the blood result acted upon.
Unfortunately there was no record of the blood test having
gone to the laboratory or the result having been received by
the practice.
Case Study 2
Mr T arrives at the reception desk and begins to shout
at the receptionist demanding to see the doctor
because his prescription had been changed.
Mr T had taken his usual prescription to the pharmacist
who had dispensed a generic tablet instead of the
usual branded tablet. When Mr T queried this, the
pharmacist had told him that the practice had changed
the tablets as they were ‘cheaper’.
Mr T was irate and threw the tablets at the receptionist
narrowly missing her.
End.
Any questions?