Transcript The NHS Care Records Service – Improving Patient Safety

Care Record Development Board
The NHS Care Records Service
– Improving Patient Safety
Mr. Ian Scott,
National Clinical Lead for Hospital
Doctors,
NHS Connecting for Health
Your Care, Your Record
Thursday 23rd November 2006
Care Record Development Board
TOPICS TO BE COVERED
• Introduction to NHS Connecting for
Health Safety approach
• Clinical reality presentation
• Human factors and safety
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Thursday 23rd November 2006
Care Record Development Board
PATIENT SAFETY
National Patient Safety Agency (NPSA)
have identified three principal areas for
concern:
• Right patient, right treatment
• Prescribing and dispensing medications
• Communication between health
professionals
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Thursday 23rd November 2006
Care Record Development Board
PASSIVE SAFETY
• Software has to do what it says on the tin
• Clinician safety training
• Close working with Software Houses
safety processes
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Thursday 23rd November 2006
Care Record Development Board
ACTIVE SAFETY
• Designing safe practice into software
• Do Once and Share
• E-pathway design
• E-prescribing
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Thursday 23rd November 2006
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IMPLEMENTATION SAFETY
• Recent experience has highlighted this
area of the programme
• Clinical Risk and Safety Board aware
• Establishing small group to share
experiences and promote good practice
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Thursday 23rd November 2006
Care Record Development Board
The NHS Care Records Service –
Improving Patient Safety
Maureen Baker CBE,
National Clinical Safety Officer,
NHS Connecting for Health
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SCENARIO – BILL’S STORY
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67 year old retired foundry worker
Artificial heart valve for many years
Takes Warfarin
Suffers from severe osteoarthritis
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SCENARIO - ARTHRITIS
• Has flare-ups of arthritis, painful and caused
difficulty walking
• Becomes housebound during flare-ups
• Flare-up week before Christmas
• Visited by locum GP at end of locum’s week
in practice
• It is a Friday
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SCENARIO – THE PRESCRIPTION
• Locum GP prescribed NSAID (Non
Steroidal Anti-Inflammatory Drug) for
arthritis
• Did not notice Bill taking Warfarin
• Prescription written on FP10 form in Bill’s
home
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Thursday 23rd November 2006
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SCENARIO – THE PHARMACY
• Bill’s wife brought prescription to pharmacy
• Exceptionally busy – just before Christmas
• Pharmacist dispensing prescription
interrupted by query from shop floor
• Did not therefore pick up Bill on Warfarin
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Thursday 23rd November 2006
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SCENARIO – THE HOSPITAL
• Normal Blood Testing Clinic delayed, as
Christmas
• He missed his previous clinic appointment
• Bill developed Gastro-Intestinal bleeding New
Year’s Day
• Brought to Accident & Emergency (A&E)
Department as emergency
• No record of NSAID on repeat prescription
• Bill was too ill to give accurate history
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Thursday 23rd November 2006
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SCENARIO – THE HANDOVER
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Bill’s condition critical
A&E busy (bank holiday)
Destined for Medical admission, but delayed
Regular observations not carried out while
still in A&E
• Bill’s family didn’t want to bother the staff – as
A&E is so busy
• Bill dies in A&E 3 hours after arrival
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Thursday 23rd November 2006
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HOW WOULD NATIONAL CARE
RECORD SERVICE HELP?
• INR (International Normalised Ratio)
Clinic
• GP clinic
• Pharmacy
• A&E Department
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Thursday 23rd November 2006
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INTERNATIONAL NORMALISED
RATIO (INR) CLINIC
• Knowledge about arthritis problems and
medications
• Reinforce warnings about drug
interactions – especially Warfarin with
arthritis medication
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Thursday 23rd November 2006
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GP CLINIC
• As now, information about other
healthcare episodes and medication
prescribed elsewhere
• Access to medication record from remote
sites?
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COMMUNITY PHARMACY
• Pharmacist will have access to medication
history
• Opportunities for comprehensive decision
support on pharmacy systems
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Thursday 23rd November 2006
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A&E DEPARTMENT
• Access to patient records from INR clinic
and from GP practice
• Access to medication history
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Thursday 23rd November 2006
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CONCLUSION
• Access to relevant information on patient
history whenever and wherever patient
presents
• Access to medication history
• Less reliance on patients/carers to provide
critical information
• Potential for major contribution to patient
safety
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Thursday 23rd November 2006
Care Record Development Board
The NHS Care Records Service –
Improving Patient Safety
Human Factors & Patient
Safety: System Issues
James Reason
Professor Emeritus
University of Manchester
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Thursday 23rd November 2006
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THE HUMAN FACTOR
• Errors dominate the risks to patient safety
(as in all hazardous systems).
• IT does not eliminate error, it relocates it
and can also change its form:
– Centralised mistakes rather than localised
slips and lapses
– A greater potential for rare but catastrophic
organisational accidents
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THE BATHTUB CURVE
.
Probability
of technical
and human
failures
• Change creates errors.
• Expect them.
• Don’t stigmatize them.
• Share them.
• Learn from them.
• Keep system transparent.
• Make it forgiving.
Age of system
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ELEMENTS OF AN ORGANIZATIONAL
ACCIDENT (SWISS CHEESE)
Some holes due
to active failures
Hazards
Other holes due to
latent ‘pathogens’
Victims
Successive layers of defences, barriers, & safeguards
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Thursday 23rd November 2006
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DEFENSIVE WEAKNESSES
• Active failures: errors and violations at the
‘sharp end’—often short-lived in their
consequences.
• Latent pathogens: seeded into the system
by designers, programmers, managers,
etc.—long-lasting in their effects, but
present now.
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SOME ‘BROAD BRUSH’ ISSUES
• What are the hazards?
• What defences exist to prevent these
hazards from harming patients?
• What are the possible scenarios of failure
(when hazards come into harmful contact
with patients)?
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Thursday 23rd November 2006
Care Record Development Board
TAKE-HOMES
• Radical changes require trial-and-error
learning.
• Errors and screw-ups are inevitable—but
they also mark the boundaries of acceptable
performance.
• The mental skills of error detection and error
correction are essential: become error-wise
and error-vigilant.
• Learn global rather than local lessons.
Your Care, Your Record
Thursday 23rd November 2006