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
experiences

to improve the quality of care by implementing
initiatives to remedy deficiencies in the service
provided.
Aim

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
complaints

10% of complaints related to attitude

93% settled at local resolution
MDU Settled Claims Against
UK GPs

Failure to diagnose
- 51%

Medication error

Pregnancy including labour
- 13%

Minor surgical procedure
- 7%

Other
- 26%
- 3%
MDU Claims Settled

Quality of medical care -
7%

Medical record issues -
60%

System failures-
33%
Clinical Governance

Clinical risk management

Complaints procedures

Adverse incident reporting

Clinical audit

Evidence- based practice

Whistle blowing

Performance review
Risk
“The possibility of incurring misfortune or
loss”
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
Agency

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
practice






95% Confidentiality
92% Prescribing
90% Health and safety
85%Communication
84% Record keeping
84% Test results
MPS Risk Consulting August 2006
Confidentiality
Common issues:

Breaches of confidentiality in waiting rooms and reception
areas

Staff contracts do not include a clause covering confidentiality
post-employment

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
Prescribing
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
returned

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
RISK MANAGEMENT
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
management
1.
Identify the risks – what’s likely to go wrong?
2.
Assess the risk – what are the chances of it going
wrong, what could happen, does it matter?
3.
Reduce/eliminate the risk – what can you do about it
4.
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

Organisation
adequate staffing
 regular guideline review


Communication

Consent

Record keeping
Clip 2 – Morning Surgery
Identified Risks
Breaches
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
Dealing
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
Examination.
Response
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)
3
2
1
SELF
CONTEXT
TASK
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
experience
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,
temperature
Workspace
working environment,
writing space,
Team and support
leadership, stability and
familiarity, trust
Organisation and
management
safety culture, culture,
targets and workload
Task Bucket
Errors
omission errors, primary
goal achieved before all
steps complete, lack of
cues from previous steps
Task
complexity
Novel task
calculations
Process
task overlap, multi-tasking
unfamiliar or rare events
Reason’s Swiss cheese model
Jamesmodel
Reason’s ‘Swiss cheese model’
Reason’s Swiss cheese
Department of Consumer
and Employment Protection
Resources Safety