Risk management in general practice

Risk management in
general practice
Eric Bater
6th November 2013
Aim of programme
to apply the principles of risk management to
practical situations and relate these to personal
to improve the quality of care by implementing
initiatives to remedy deficiencies in the service
To help reduce the risk of harm to
patients, staff and visitors by improving
safety and the quality of care in practice
Harvard Medical Practice Study
New England Journal of Medicine 1991
 3.7%
 Of
patients suffered an adverse event
these 13% died
 58%
events related to system errors
Summary of New Complaints Procedure
(1998, 9/12 period)
MDU experience
Failure or delay in diagnosis most common
reason (28%)
24% of complaints made after bereavement
Non-clinical issues accounted for 34% of
10% of complaints related to attitude
93% settled at local resolution
MDU Settled Claims Against
Failure to diagnose
- 51%
Medication error
Pregnancy including labour
- 13%
Minor surgical procedure
- 7%
- 26%
- 3%
MDU Claims Settled
Quality of medical care -
Medical record issues -
System failures-
Clinical Governance
Clinical risk management
Complaints procedures
Adverse incident reporting
Clinical audit
Evidence- based practice
Whistle blowing
Performance review
“The possibility of incurring misfortune or
Living with risks
Risk is part of everyday life
At home
When travelling
With patients
You can minimise your risks by improving
your systems
In general practice…
Average GP will provide about 200,000 consultations during their career
25% of adverse events occur in primary care
And, it is estimated that 1% of GP consultations (one a week) are associated
with a significant adverse outcome
Making amends DH 2003
Incident reports to the
National Patient Safety
2600 reports from October 2006 to September 2007 from general practice:
29% Medication errors
14% Documentation
11% Access/admission/transfer/discharge
10% Consent/communication/ confidentiality
0.33% of all reports received
NPSA National Reporting and Learning Data Summary
Issue 7 December 2007
Top key risks in UK general
95% Confidentiality
92% Prescribing
90% Health and safety
84% Record keeping
84% Test results
MPS Risk Consulting August 2006
Common issues:
Breaches of confidentiality in waiting rooms and reception
Staff contracts do not include a clause covering confidentiality
Not all patient-identifiable information is shredded
Patient medical records are not securely stored
Computers may be left on and unattended
Breach of confidentiality
Can lead to:
Breakdown of practitioner/patient relationship
Lack of trust/confidence in other healthcare professionals
Failure to seek further treatment
Disciplinary action by GMC and employers
Common issues:
No repeat prescribing protocol
No designated receptionist to record or generate repeat prescriptions
Reception staff are allowed to add medication to the computer
Medication reviews are undertaken on an ad hoc basis.
No system for recalling patients on long-term medication
Uncollected prescriptions are destroyed
Record keeping
Common issues:
Illegible writing in the records
Letters scanned into wrong record
Telephone advice not always recorded
Medical records go missing
Home visits not always recorded on the computer
Test results
Common issues:
No tracker system to ensure that patients are followed up
No system of knowing when all a patient’s test results have been
Test results not recorded onto the computer
Non-clinical staff allowed to inform patients of their result and
treatment required
Infection control
Common issues:
No infection control policy
Specimen handling
Hand washing issues
Hand washing
For effective hand washing consider the
following :
 Liquid hand dispenser
 Paper towels
 Elbow/foot operated mixer taps
 Alcohol based hand rub
 No sink plug
 Remove jewellery
 Designated hand wash basin
What is clinical risk management?
Common sense
Identification, measurement and control of risk to
avoid harm to patients and staff
Involves everyone
Relates to the whole package of care
Equates to good practice
A careful examination of what
1. could cause harm
2. its significance and
3. what precautions are needed to eliminate the risk
or reduce it to an acceptable level
Risk Management Benefits
for patients
improved quality of care and service
enhanced patient safety
confidence in the service
for health care professionals
protection of confidence and reputation
quality procedures and staff involvement
decreased numbers of complaints and claims
The four principles of risk
Identify the risks – what’s likely to go wrong?
Assess the risk – what are the chances of it going
wrong, what could happen, does it matter?
Reduce/eliminate the risk – what can you do about it
Cost the risk – what are the costs of getting it right v.
the cost of getting it wrong?
Risk Management Techniques
Complaint handling
Risk assessment
Staff awareness/training
Protocol and guidelines monitoring
Good medical records
Adverse incident reporting
Risk Areas
Staff - especially locums
adequate staffing
 regular guideline review
Record keeping
Clip 2 – Morning Surgery
Identified Risks
of confidentiality – front desk/reception
Health and safety issue.
Lack of systems.
Phone call interruptions.
Verbal requirements regarding nurse visit.
Inappropriate roll/responsibilities of receptionist.
area etc.
What action do you suggest the practice takes in order to avoid/minimise
these risks (in priority order)?
Clip 3 – Test Result / Minor Surgery
Identified Risks
with smear results.
Aseptic techniques.
Lack of chaperones.
Unreasonable patient request.
Lack of informed consent.
Disposal of clinical waste/needles.
What action do you suggest the practice takes in order to avoid/minimise
these risks (in priority order)?
Clip 4 – Home Visit
Identified Risks
to collapsed patient.
Communication regarding hospital admission.
Communication with mother.
Dealing with request for repeat prescription.
Dealing with aggressive patient.
What action do you suggest the practice takes in order to avoid/minimise
these risks (in priority order)?
Aims of Assessment
Improve patient care
Ensure safe standards of practice
Ensure patient/staff safety and well being
Decrease the number of complaints and claims
Lessen the stress associated with litigation
The ‘three bucket’ model for
assessing risky situations
(Reason, 2004)
The fuller your buckets, the more likely something will go wrong, but
your buckets are never empty.
Self Bucket
Level of knowledge
newly qualified
Level of skill
competence and
involuntary automaticity,
under/over confidence
Level of experience
Current capacity to do
the task
fatigue, time of day,
negative life events
Context Bucket
Equipment and devices
usability, not available
Physical environment
lighting, noise,
working environment,
writing space,
Team and support
leadership, stability and
familiarity, trust
Organisation and
safety culture, culture,
targets and workload
Task Bucket
omission errors, primary
goal achieved before all
steps complete, lack of
cues from previous steps
Novel task
task overlap, multi-tasking
unfamiliar or rare events
Reason’s Swiss cheese model
Reason’s ‘Swiss cheese model’
Reason’s Swiss cheese
Department of Consumer
and Employment Protection
Resources Safety

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