Your Care, Your Record

1
The NHS Care Records Service Improving Patient
Safety

• Mr. Ian Scott,
• National Clinical Lead for Hospital Doctors,
• NHS Connecting for Health

2
TOPICS TO BE COVERED

• Introduction to NHS Connecting for Health Safety
  approach
• Clinical reality presentation
• Human factors and safety

3
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

4
PASSIVE SAFETY

• Software has to do what it says on the tin
• Clinician safety training
• Close working with Software Houses safety
  processes

5
ACTIVE SAFETY

• Designing safe practice into software
• Do Once and Share
• E-pathway design
• E-prescribing

6
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

7
The NHS Care Records Service Improving Patient
Safety

• Maureen Baker CBE,
• National Clinical Safety Officer,
• NHS Connecting for Health

8
SCENARIO BILLS STORY

• 67 year old retired foundry worker
• Artificial heart valve for many years
• Takes Warfarin
• Suffers from severe osteoarthritis

9
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 locums week in
  practice
• It is a Friday

10
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 Bills home

11
SCENARIO THE PHARMACY

• Bills 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

12
SCENARIO THE HOSPITAL

• Normal Blood Testing Clinic delayed, as Christmas
• He missed his previous clinic appointment
• Bill developed Gastro-Intestinal bleeding New
  Years Day
• Brought to Accident Emergency (AE) Department
  as emergency
• No record of NSAID on repeat prescription
• Bill was too ill to give accurate history

13
SCENARIO THE HANDOVER

• Bills condition critical
• AE busy (bank holiday)
• Destined for Medical admission, but delayed
• Regular observations not carried out while still
  in AE
• Bills family didnt want to bother the staff
  as AE is so busy
• Bill dies in AE 3 hours after arrival

14
HOW WOULD NATIONAL CARE RECORD SERVICE HELP?

• INR (International Normalised Ratio) Clinic
• GP clinic
• Pharmacy
• AE Department

15
INTERNATIONAL NORMALISED RATIO (INR) CLINIC

• Knowledge about arthritis problems and
  medications
• Reinforce warnings about drug interactions
  especially Warfarin with arthritis medication

16
GP CLINIC

• As now, information about other healthcare
  episodes and medication prescribed elsewhere
• Access to medication record from remote sites?

17
COMMUNITY PHARMACY

• Pharmacist will have access to medication history
• Opportunities for comprehensive decision support
  on pharmacy systems

18
AE DEPARTMENT

• Access to patient records from INR clinic and
  from GP practice
• Access to medication history

19
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

20
The NHS Care Records Service Improving Patient
Safety
Human Factors Patient Safety System Issues

• James Reason
• Professor Emeritus
• University of Manchester

21
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

22
THE BATHTUB CURVE

• .

• Change creates errors.
• Expect them.
• Dont stigmatize them.
• Share them.
• Learn from them.
• Keep system transparent.
• Make it forgiving.

Probability of technical and human failures
Age of system
23
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
24
DEFENSIVE WEAKNESSES

• Active failures errors and violations at the
  sharp endoften short-lived in their
  consequences.
• Latent pathogens seeded into the system by
  designers, programmers, managers,
  etc.long-lasting in their effects, but present
  now.

25
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)?

26
TAKE-HOMES

• Radical changes require trial-and-error learning.
• Errors and screw-ups are inevitablebut 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.