Training

"In safer hands, exploring the anatomy of risk in primary care”. 4th September 2003

Introduction
The day was intended to increase the awareness of risk in primary care. It was jointly organised by the National patient Safety Agency (NPSA) and the Quality unit at the RCGP.

There was a combination of brief presentations, group work and displays by interested organisations.

Points of Interest
Critical case analysis

• Breadth - looking for common messages in large samples of cases
• Depth - going for a limited number but really going for the root causes
• Looking for system failures rather than blame
• Reporting methods – e-record
• Confidentiality and confidence in those looking at the reports
• Feedback – how do you prevent the same things happening again?
• Root cause analysis – structure for looking at problems
• Support for those reporting – cathartic experience.

System change
The customer

• Dissatisfied customers tell 25 others
• Good management of complaints and when things go wrong is the key.

Root cause analysis
Steve Rogers had looked into a few cases where things had gone wrong. He had interviewed all those concerned and tried to understand why there were problems. A structure to this such as root cause analysis can help to clarify the process.It is interesting that at the base of the problems is very often the stretching of the system to the point where it is no longer safe. Clearly things like communication feature highly but a 5 minute phone call times 12 is an hour plus recording these calls. There is the temptation to try and do more and more and to constantly push the system harder. To balance this there needs to be feedback of a negative type saying that actually not doing things properly is costing lives and money. – interesting theoretical area.

Reporting and analysing errors
Dr Esmail looked at methods of reporting errors and analysing them. Systems to email mistakes are being tried out and software to identify common features. One problem is “who is responsible?” The legal responsibility immediately impinges on attempts to really understand things rather than blaming a person.

Analysis so far indicated that Errors where cause
2/3 by process failures and
1/3 by knowledge or skill failures.

Many people reported as feeling better after they had spoken of something that had gone wrong.

Points of interest
1. What to do with the report
2. How to classify them
3. How best to learn from them

Cause of Complaints
Dr Helen Goodwin reported on research into complaints.

• Australian system – 76% of events were preventable
• Can be resolved locally – 83%
• Trigger events for complaints – death, emotional, cancer
• Communication failures caused 31% of complaints
• Escalating complaints for out of hours work

Developing a safety culture
I went to two workshops one on “an Open & Fair Culture” and the other on “Developing a Safety Culture”.

There were then some finishing talks on the plans for the future including the NPSA programme for training groups of people in each trust on the application of these ideas.

Conclusions
The day was very interesting and I agreed with most of the material and ideas that were presented. The problems as I see it relate to applying these ideas of openness in an organisation that is riddled with blame and financially driven targets. If we are able to get round the problems then such things as :-

• Critical Case Analysis
• Near Miss Reporting
• Root Cause Analysis
• System Development
• Risk Prevention Systems
• Audit & Benchmarking

Would be well worth doing.
It looks as though PCTs will need to be seriously looking at these areas in the very near future. I fear that the NHS thinking does not take on board the whole package but this would mean junking some of their dearly held beliefs.