Improving Patient Safety: Error Reporting and Risk Management

Aim: To optimise the safe use of medicines and reduce avoidable harm to patients.

Objectives:

1. To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018)
2. To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter).
3. To ensure practices responded to patient safety alerts from the MHRA in a timely manner.

These are in line with NICE guidance NG5 which recommends:

• Organisations should ensure that robust and transparent processes are in place to identify, report, prioritise, investigate and learn from medicines related patient safety incidents, in line with national patient safety reporting systems – for example, the National Reporting and Learning System.
• Organisations should consider using multiple methods to identify medicines related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning.
• Organisations should ensure that national medicines safety guidance, such as patient safety alerts, are actioned within a specified or locally agreed timeframe.

Background: NHS England (NHSE) Primary Care Incident Report 01 Jan - 31 Dec 2015 released in May 2016 showed that 49% of 171 incidents reported were medication related. Thirty seven incidents were reported from North Central and East London of which none came from City and Hackney practices.

The medicines management team (MMT) did not consider zero reported incidents from City and Hackney practices to accurately reflect practice. Therefore the need was identified to raise awareness of the benefits of learning through reporting medication related incidents and the subsequent benefits to improving patient safety and avoiding harm from use of medicines. Stakeholders were engaged through commissioning intention events (patients); prescribing programme board meetings (discussions with secondary and primary care prescribers and pharmacy teams, public health and a patient representative) as well as GP consortia meetings. City and Hackney CCG commissions care for a diverse population of approximately 320,000 patients. There are 43 GP practices and 1 major secondary care provider.

Buy-in from stakeholders was gained through activities outlined previously i.e. promotion at CCG commissioning events, discussions at Prescribing Programme Board meetings and GP consortia meetings.

Practice Support Pharmacists were used as change management champions at the practice level to support patient review and encourage practices to report incidents as well as discussing and documenting learning gained from the incidents and relevant actions required to avoid repeats.

The two areas of error reporting and managing risks from MHRA safety alerts were included in the annual QIPP as part of the clinical commissioning and engagement contract. Practices were incentivised to share at least 4 medication related errors/near misses with the CCG via NRLS as well as prompt review and submission of action taken in response to 4 MHRA patient safety alerts.

The project met its aim and objectives. There was an increase in error reporting. The initial report from NHSE covering 01 Jan to 31 Dec 2015 showed ZERO (0) incidents from City and Hackney Practices out of 171 primary care incidents reported that year.

From data shared with the CCG MMT between April 2017 and March 2018, there were 108 reported incidents from City and Hackney practices, of which NINETY-SIX (96) were medication related. Practices were only required to share at least four incidents with the CCG therefore the total number of reports is presumably higher.

Themes were identified with regular sharing of learning through the monthly MMT newsletter 'Prescribing Matters'. Practices are more attentive and responsive to MHRA patient safety alerts. All 43 practices responded to at least ONE MHRA patient safety alert with documentation of review and action taken. 90% of practices shared at least one medication related incident with the CCG via NRLS.

We believe encouraging and investigating error reports (without apportioning blame) as well as sharing the learning at a wider CCG level contributes to reduction of avoidable harm and improves patient safety. GP practices can gain valuable CPD points as part of working towards the QIPP as well as provide evidence towards CQC inspections. The CPD benefits and evidence for CQC inspections must be highlighted.

Practices need to be assured error reporting is not about apportioning blame but a vital useful learning tool to improve patient safety and optimise the use of medicines. Practices benefit from the support of pharmacists working at the practice level to help with patient review, error reporting and addressing MHRA patient safety alerts promptly.

Incentivising practices (however small) can help to encourage identification and reporting of medication related incidents. If these measures are introduced as part of QIPP or local prescribing incentive scheme, it is important to consider what is being asked of practices (e.g. quantity) is reasonable alongside other workload. Ensure the process is as seamless as possible e.g. practices were encouraged to report directly to the NRLS but to enable sharing of the record with the CCG (just a tick of a box on the system) i.e. there was no duplication of effort to notify the CCG.