How to improve patient safety

Improved adverse incident reporting will improve patient safety, says Dr Karen Roberts of the MDU

Adverse incident reporting can help practices improve patient safety by identifying risks. Reporting incidents nationally can also help organisations like the National Patient Safety Agency (NPSA) identify the types and causes of safety problems and develop practical solutions at a national level to prevent harm to patients.

GMC requirement
The Medical Defence Union (MDU) has long encouraged its members to use adverse incident reporting systems to try to improve patient safety and the standard of medical care provided to patients. Implementing such systems could help you to collect useful evidence of reflective practice for the appraisal and revalidation process.

Culture of non-reporting
Although over 90 per cent of GPs are analysing and learning from adverse events in their own practice, only four per cent routinely report adverse incidents to the NPSA, according to a National Audit Office report published earlier this year.

Last year, the NPSA revealed that just 0.4 per cent of 526,000 individual reports received in the 12 months to March 2006 came from general practice. The majority were from acute trusts, which the NPSA points out have a well-established and active reporting culture. So why are there fewer national reports of adverse incidents from primary care? As well as a lack of a culture of reporting, which the NPSA identified, there may also be a reluctance by individuals to report if they feel they could be unfairly criticised.

All practice staff should be made aware of the importance of reporting an adverse incident in a non-judgmental way that allows vital information to be passed on without fear of being criticised for doing so. Staff should also receive training in how to recognise an incident that needs reporting.

Another element in the reporting of events from primary care may be if it is not clear whose responsibility it is to report an incident to the NPSA. While anyone can report an incident anonymously to the NPSA, you might find it helpful to identify one person in the practice to be responsible for their adverse incident reporting system. 

Medication errors
Almost a quarter of primary care incidents in the NPSA research centred on medication errors and other themes included problems with documentation including patient records and identification errors.

There are some similarities with the MDU’s own research into adverse incidents reported by GP members to our medico-legal advice line. Over a recent six-month period, 500 such calls were received — 100 of these cases were analysed and of the 48 that occurred in primary care, the most commonly reported reasons for the events were medication errors, including vaccine errors, and delayed diagnosis.

Case study
A typical example is as follows: a practice nurse was running a busy immunisation clinic. The clinic was overbooked and a child was slotted in at short notice.

The nurse checked the records and administered the MMR vaccine, explaining to the mother that she was giving the child the next immunisation that was due.

An hour later the nurse saw another child with the same surname and explained to the mother that her child was due to be given a HiB/MenC vaccine. The mother said she was sure the child had already been given that immunisation. The nurse realised to her dismay that the records of the two children had been mixed up and that she had given the earlier child the MMR in error, instead of the HiB/MenC vaccine. She retrieved the correct records and administered the correct vaccine to the second child, apologising to the mother for the identification error. The nurse spoke with one of the GPs to report the vaccination error and an arrangement was made to contact the mother of the first child to explain the mistake.

The incident was analysed as part of the practice’s adverse incident system and the practice made a number of changes to its systems, including a change in the way the clinics were run to try to space appointments appropriately. They reviewed their system for flagging records of patients with similar names. The practice immunisation protocol was revised to ensure that adequate information was given to a patient or parent prior to administration of vaccines.

Dr Roberts is an MDU medico-legal adviser 

Learning points

Look at adverse incident reporting as a reflective process 

  1. It is a GMC requirement for doctors to take part in adverse incident reporting.
  2. Reporting adverse events can provide useful evidence of reflective practice for the appraisal and revalidation process.
  3. Reporting adverse events to a national body, such as the NPSA, can help it identify significant national trends which solutions may then be found for.
  4. Report adverse incidents in a non-judgmental way that allows vital information to be passed on without fear of being criticised.
  5. Staff should be trained in how to recognise an incident that needs reporting.
  6. Identify one person in the practice who should be responsible for the adverse incident reporting system.

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