Patient safety toolkit
| Site: | Royal College of General Practitioners - Online Learning Environment |
| Course: | Clinical toolkits |
| Book: | Patient safety toolkit |
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| Date: | Wednesday, 24 April 2024, 4:46 AM |
Description
This toolkit is intended to aid the assessment of different aspects of patient safety with a view to making improvements.
Patient safety is the prevention of errors and adverse effects for patients associated with health care. Health care has become more complex, requiring greater use of new technologies, medicines and treatments. Health services are more frequently treating older and sicker patients presenting with significant co-morbidities that demand increasingly difficult decision making with regards to health care priorities.
The Patient Safety Toolkit
The Patient Safety Toolkit plays an important role in preventing patients from being harmed. This toolkit allows your practice to look at different aspects of patient safety with a view to making improvements. It covers the following areas of general practice: safe systems, safety culture, communication, patient reported problems, diagnostic safety, prescribing safety.
The Patient Safety Toolkit is designed to be used by any general practice in the UK. These resources can be used flexibly, either as standalone materials or as part of an integrated package for patient safety.
New for 2017: RCGP Reporting and learning from patient safety incidents in general practice - a practical guide [PDF].
Disclaimer
This toolkit is intended to aid the assessment of different aspects of patient safety with a view to making improvements. Using it will not, on its own, ensure you are compliant with health and safety legislation. Practices should evaluate their own level of compliance with the law and seek competent advice if appropriate.
The Trigger Tool
The aim of the Trigger Tool is to reduce the number of events that could cause avoidable harm. Adapted from the NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) Trigger Tool, this is used as a routine tool to screen for patient harm or patient safety incidents (PSIs).
Alternatively, it can be used more specifically to discover PSIs or harm in a particular area of perceived risk. Your practice may choose its own particular topic for audit (for example, patients over the age of 75 years), which can then be repeated regularly by one or more doctors in each practice.
The Trigger Tool is an efficient way of performing a case note review to highlight any potential area of poor patient safety. It is important that any significant PSI or harm events are evaluated and, where appropriate, action is taken to reduce future risk. Actions to achieve this might include conventional audit, significant event audit, practice meetings specifically to discuss the results, drafting of new guidelines or a change of procedure within your practice.
Prescribing Safety Indicators
A list of Prescribing Safety Indicators
Prescribing Safety Indicators describe scenarios in which there is potentially inappropriate (and unsafe) prescribing. A set of these indicators has been developed for use in general practices following a project commissioned by the RCGP. Your practice may now use these indicators to develop your own computer searches to identify patients at risk. The most up-to-date list of these indicators can be found on the BJGP website.
- Download latest list of indicators from the BJGP website
- Download Prescribing Safety Indicators for Spotlight Project [PDF]
A tool to identify patients with potentially unsafe prescribing and monitoring
This tool is a set of automated indicators developed to assess prescribing safety. It is based on the prescribing safety indicators used in the PINCER trial. This trial showed an improvement in prescribing safety when pharmacists worked with GPs using the indicators. The package uses CHART (Care and Health Analysis in Real Time) software to extract data about those patients who may be at risk of medication-related injury.
Patient Safety Questionnaire
Patient Reported Experiences and Outcomes of Safety in Primary Care, or PREOS-PC, is a questionnaire for patients that is designed to assess their experiences with respect to patient safety in your practice.
Your practice will use this questionnaire to collect information about your patients’ experiences, and any outcomes of patient safety problems in primary care.
These results will provide a direct benefit to your patients and strengthen the patient-centred focus of health care.
Concise Safe Systems Checklist
The Concise Safe Systems Checklist allows practices to think about those background systems which are important for patient safety, but are often overlooked. It is deliberately designed not to include items already covered by legislation or mandatory requirements.
This checklist is designed to be quick and simple to use by your practice manager or a senior clinician.
Safety Checklist for General Practice
This checklist identifies hazards across the wider work systems that may threaten patient safety, as well as those hazards that have an impact on the health, safety and well-being of all involved.
It can be seen as a traditional checklist, but it also has a global monitoring role. It provides clarification of specific safety issues already covered by legislation and mandatory requirements. This checklist is designed to be used every four months.
The Safety Checklist for general practice is designed by NHS Education for Scotland in partnership with Health Improvement Scotland.
Medicines Reconciliation Tool
Patients are vulnerable during changes in care level particularly with respect to medication errors.
This Medicines Reconciliation Tool, which is adapted from the NHS Education for Scotland (NES) and Healthcare Improvement Scotland (HIS) tool, assesses the safety of the interface between primary and secondary care in terms of the general practice role in medication reconciliation following any patient’s discharge from hospital.
The audit of at least 20 patients aged 65 years and over following hospital discharge, helps to assess how promptly and how accurately medication changes suggested by the hospital have been made. It also assesses the extent to which changes have been discussed with patients.
This tool deliberately focuses on vulnerable patients who are likely to need alterations to medication when their care level changes, where it is easy for mistakes to be made.
Significant Event Audit
This guidance enables primary care teams to conduct an effective Significant Event Audit (SEA) with the aim of improving care for all patients.
SEA ensures that primary care teams learn from patient safety incidents and ‘near misses’ by highlighting both strengths and weaknesses in the care provided.
The guidance can help primary care teams to develop a structured and effective SEA process. Also, a link is provided for reporting safety incidents in England.
For practices in England, it is good practice to report to the National Reporting and Learning System (NRLS) any patient safety incidents that could have or did harm a patient receiving NHS funded care so they can be learnt from and any necessary action can be taken to prevent similar incidents from occurring in the future.
- Reporting a patient safety incident in England - a specific form is available from reports from general practices.
To our knowledge, the other countries in the UK do not have national reporting systems for patient safety incidents in primary care, but it is worth checking if local systems are in place.
Additional Resources
This guide will aid GPs and their teams to maximise opportunities for learning from patient safety incidents. The guide provides guidance on sharing learning via organisational or national reporting systems, and outlines a process for learning from patient safety incidents.
The National Institute for Health Research School for Primary Care Research is a partnership between nine leading academic centres for primary care research in England. The school's main aim is to increase the evidence base for primary care practice, through high quality research and strategic leadership.
NHS Education for Scotland is a special health board supporting NHS services in Scotland by delivering education and training for those who work in NHS Scotland. Its vision is for 'Quality Education for a Healthier Scotland' and its mission is to provide educational solutions that support excellence in healthcare for the people of Scotland.
HIS is the national healthcare improvement organisation for Scotland and part of NHS Scotland. Health Improvement Scotland works with staff who provide care in hospitals, GP practices, clinics, NHS boards and with patients, carers, communities and the public. HIS plays an important role in helping others put into place the improvements to patient care that matter most to health care providers.
The CQC produce guidelines and targets regarding quality. Many of these have a safety component as well. It is the independent regulator of health and social care in England.
PRIMIS promotes patient care by using general practice data to improve quality and accessibility, supporting access to patient data, and transforming data into information.
Reporting safety incidents from general practices in England
Patient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving NHS funded healthcare. In England general practitioners can report these incidents electronically. It is recommend that the ‘e-form icon’ is downloaded to desktops (a simple drag and drop process) for quick access to the new GP e-form. A guide to completing the form is available.
Quality Improvement
To access shared learning networks to assist you in applying practical QI methodologies to better treat this clinical area, join our QI Ready platform.
Patient safety priorities in primary care
The PatIent SAfety (PISA) research group at Cardiff University have carried out a series of national-level analyses of patient safety incidents reported from general practice and wider primary care.
In their published reports, the PISA group have summarised the patient safety priorities that you can explore, or investigate further, in your system (GP practice, cluster, PCN, CCG) as well as potential solutions to mitigating risk and improving safety for patients.
Major studies completed, include:
- Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice – published in the NIHR HS&DR journal
- Patient safety incidents involving sick children in primary care in England and Wales: A mixed methods analysis – published in PLOS Medicine
- Safety incidents involving children in general practice– published in Pediatrics
- Harms from discharge to primary care: Mixed methods analysis of incident reports – published in British Journal of General Practice
- Nature of blame in patient safety incident reports: Mixed methods analysis of a national database – published in Annals of Family Medicine
- Paediatric immunization-related safety incidents in primary care: A mixed methods analysis of a national database– published in Vaccine
- Sources of unsafe primary care for older adults: A mixed-methods analysis of patient safety incident reports – published in Age and Ageing
- Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database – published in Palliative Medicine
- Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents – published in Palliative Medicine
- Patient safety incidents in primary care dentistry in England and Wales: A mixed-methods study – published in the Journal of Patient Safety
- Patient safety incidents in advance care plans for serious illness: a mixed methods analysis – published in BMJ Supportive and Palliative Care
- Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports– published in Archives of Disease in Childhood.
- A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales – published in Addiction.
Background to the Toolkit
Purpose
The identification and reduction of avoidable harm is a major priority for the NHS. There has been widespread attention to this issue in secondary care. Now primary care is increasingly coming under the spotlight. With funding from the NIHR School for Primary Care Research a team of researchers has developed a Patient Safety Toolkit for general practice. This developmental work involved experts from Nottingham, Manchester, Keele, Southampton, Birmingham, Oxford, Exeter and Bristol, with user and public involvement throughout the project.
With funding from the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, and developed in partnership with the Clinical Innovation and Research Centre, the toolkit is now available on the RCGP website. General practices can use the various tools to identify a wide range of patient safety issues and make improvements to help prevent patients from being harmed.
Acknowledgements
We would like to thank the following people for their contribution to this project:
Project Steering Group
- University of Nottingham (Professor Tony Avery, Kate Marsden, Dr Rachel Spencer, Dr Brian Bell, Dr Sarah Rodgers)
- University of Manchester (Professor Stephen Campbell, Professor Aneez Esmail, Dr Katherine Perryman, Dr David Reeves)
- University of Birmingham (Professor Paramjit Gill, Professor Shiela Greenfield, Dr Ian Litchfield, Dr Lucy Doos)
- University of Exeter (Professor Jose Valderas)
- University of Keele (Professor Umesh Kadam, Dr Mark Porcheret
- University of Southampton (Jane Barnett, Professor Michael Moore, Professor Paul Little)
- University of Oxford (Dr Ignacio Riccabello, Dr Jeffrey Aronson, Dr Daniel Lasserson)
- University of Durham (Dr Sarah Slight)
- University of Edinburgh (Professor Aziz Sheikh)
- University of Bristol (Professor Sarah Purdy)
- GP (Dr Manny Samra)
- PPI representative (Antony Chuter)
International Experts Group
- Professor Mike Pringle, President of the RCGP
- Professor Bruce Guthrie, University of Dundee, Scotland
- Dr Neil Houston, Clinical Lead for the Scottish Safety Improvement in Primary Care Collaborative
- Professor Tom Fahey, Royal College of Surgeons in Ireland
- Paul Bowie, Programme Director (Safety & Improvement) at NHS Education for Scotland
- Sathya Naidoo, Associate Postgraduate Dean, Health Education East Midlands
- Gordon Schiff, Associate Director at Center for Patient Safety Research and Practice, Brigham & Women’s Hospital, Boston, USA
- Jurate Svarcaite, Head of Pharmaceutical Care Department at UAB Nemuno vaistine, Lithuania
- Andreas Soennichsen, Chair of General Medicine and Family Medicine at the University of Witten / Herdecke, Germany
- Michel Wensing Professor of Implementation Science, Institute for Quality of Healthcare, Radboud University, Nederlands
This toolkit was developed as part of the Patient Safety Spotlight Project, which was a one year collaboration between the NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre and the RCGP from 2015-16. This report reviews the project’s impact and legacy. [PDF]
Incident Reporting
- There is a national reporting system designed for use by general practitioners, practice nurses and general practice staff to report patient safety incidents to the National Reporting and Learning System.
- The NHS Patient Safety Strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.
- Central alerting system, system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care.
- Patient safety improvement programmes collectively form the largest safety initiative in the history of the NHS. They support a culture of safety, continuous learning and sustainable improvement across the healthcare system.
- As the guardians of patient data, making sure it is protected and handled securely, NHS Digital provides guidance to the health and care sector on keeping patient data safe.