Patient Safety - Health Committee Contents

Examination of Witnesses (Question 600-621)



  Q600  Dr Naysmith: You do not think it is a problem.

  Professor Esmail: I think there is a problem, but I think that things that have happened change hugely. Take a simple example of urinary tract infection, I would imagine if you did an audit of urinary tract infection prescribing in general practice you will find that the vast majority are prescribed for three days, prescribed one antibiotic, trimetheprin, which is used in 90% of cases, and will then follow it up if it is not. If you had looked at that eight years ago you would have found a totally different pattern. I think if you looked at diagnosis of upper respiratory infections you would find that there is a lot less prescribing for sore throats, and so on. I do not have it at my fingertips, but I would like to see that data.

  Q601  Dr Naysmith: It still goes on, based on some of the conversations I have with GPs, some of whom I know quite well. Let us move on. Do you think that primary care trusts acting as commissioners play enough role in ensuring safe practice in primary care particularly?

  Professor Esmail: I think primary care trusts are only beginning to wake up to the idea of the importance of their role and what they can do as commissioners, especially in terms of improving patient safety in primary care, and I think they are actually scratching around to try and find out what that role entails because they have only come to it very recently. So I think there is going to be a lot of feeling to see what is going to be acceptable and what is not going to be acceptable. What will not work is if they say to doctors, "You must do X, Y and Z", because from my experience as a researcher am guilty of it, I think up simple solutions and say, "If only everyone did this we would solve the problem", and I know it does not work that way. I think that commissioners are going to have to be careful about what they target, in terms of the way they want to change things, and then work together with people to do that.

  Q602  Dr Naysmith: Can you include examples of commissioning changing practice?

  Professor Esmail: Not yet. This is a very new area and I am working together with our local PCT, and I know there are examples in Wales and there are one or two PCTs that are beginning to work on this, so we really are talking about a handful of examples at the moment. They are doing things like saying, "All right, can we, for example, begin to try and understand how big a problem it is?", and they are using things like the global trigger tool, which is doing a systematic audit of notes in certain areas to find out how big a problem that is. The significant event audit tool kit, for example, will enable PCTs to say: can we have a look at these and see what lessons can be learnt across the board? I think prescribing is going to be a constant area they will be looking at.

  Q603  Dr Naysmith: It is work in progress?

  Professor Esmail: Very much so.

  Q604  Dr Naysmith: It is simply worth pursuing.

  Professor Esmail: Definitely, and I think they are all looking around, and I know this because I am getting more requests to speak on how to work with PCTs, so I think this is work in progress. I think they can flex their muscles and play a very important role, but they have got to built up those relationships in order to do that change.

  Q605  Dr Naysmith: Can I move on to question of revalidation and the need for GPs to register with the Care and Quality Commission. Do you think that will affect patient safety, do you think it will help, or do you think it will produce a burden on the system, an unnecessary burden, bringing in the practice of too much bureaucracy?

  Professor Esmail: I am sure the intention of the policy-makers is that it will help. I think the outcome will be that it will probably provide a burden and, again, we will have to work through what is going to be suggested and what it will involve. I think potentially revalidation, as an example, will become a very powerful instrument for monitoring individual care and, if it is applied effectively, I think it will be a huge tool for improvement across spectrum, so I have high hopes for revalidation, but I hope it does not become burdensome, that it becomes part of quality improvement rather than about regulation. I think will be a great problem if it does become that.

  Chairman: We are with you now, Professor Griffiths. We are running late but we have a number of questions for you.

  Q606  Dr Stoate: We have heard this morning that there clearly is a problem with prescribing and medicines management affecting patient safety, but do we have any idea of the scale of the problem?

  Professor Griffiths: Yes, there is some evidence out there. The NPSA did a report: Safety and Doses. It is a really, really good read and should have been a good read for all practitioners. Unfortunately, it has gone to clinical governance managers and senior managers and I do not think it has hit the practitioners that it should have, because there is a lot of evidence in there and a lot of incidents that are raised. In there is a study by Pirmohamed et al of about 19,000 patients which showed that about 6.5% of all hospital admissions were down to a direct result of medication incidents or harm, about 9% were preventable, and about 63% were probably preventable. That is a smallish study, 19,000 patients, but there are studies from the US that mirror this, and although it is a different health economy, there are transferable pieces of research that do come across that mirror that we are causing harm with medicines.

  Q607  Dr Stoate: Do you think there is enough evidence or do you think we need a lot more?

  Professor Griffiths: I think we probably need to go back and redo similar research, so that we can see, like for like, if we are getting any better. The NPSA report showed 60,000 medication incidents over an 18-month period through the NRLS and it basically cost the NHS around £750 million, let alone the suffering that it caused to patients.

  Q608  Dr Stoate: Clearly it is something we need to address. Just to pick up on something Professor Esmail has already said, what about doing more research in general practice? Is there a significant gap there?

  Professor Griffiths: In the report into NRLS, about 80% of the report came from secondary care, even though there are two million prescriptions per day in the NHS and the vast majority of transactions occur in primary care. Although the vast number is in primary care, therefore, there is still vast under-reporting. There are several reasons why there is under-reporting. To some degree, with the old paper reporting forms people felt disenfranchised with the system, that if they did something nothing was going to be done about it. I put in reports about assaults when I was in practice in casualty and nothing ever seemed to change. There is this disenfranchisement that practitioners have: If they are going to put in a report, what is going to happen? I think that the newer forms, the Datex, the computer reporting, although they can take a little while to work through you can copy certain managers in, so you can make sure that it gets to the people who hopefully will make the decisions to action the incidents.

  Q609  Dr Stoate: What do we do with the problems we do not know about? Okay, we can do significant events. I think most GPs are reporting significant events. It is easy to do so, and most practices now are having quarterly meetings on significant events, so it is a problem that is being dealt with. What about the problems that GPs are not aware of? For example, in many prescription areas or other areas they have no clue that they have made an error, so how do we get evidence on that?

  Professor Griffiths: Particularly in primary care, a prescription may go out and it may not even be picked up that there is an incident. In secondary care it tends to be a bit tighter, in terms of there are more links in the chain that you have to go through for the process of dispensing medicine. In primary care it can go straight from the doctor to their own dispensing pharmacy, which does not have a pharmacist but a dispensing technician, and then it goes out to the patient, so there are less links in that safety chain.

  Q610  Dr Stoate: If, for example, a GP has made a wrong diagnosis and given the wrong medicine, that does not necessarily do the patient any harm, so the patient does not come back and complain of side effects but nevertheless a mistake has been made. How do we even begin to address that?

  Professor Griffiths: There has been opening up of reporting through the NRLS, and through yellow card reporting—which is slightly different: it is about adverse drug reactions.

  Q611  Dr Stoate: That is only takes up adverse effects. I am talking about a patient who has simply been given the wrong medicine, nothing whatever to do with their diagnosis. The patient takes that medicine for two months, just as instructed, but it is completely the wrong medicine. If no harm happens to that patient, it is a fairly significant event but there is no way of knowing about it.

  Professor Griffiths: I understand what you are saying, but I was trying to say that the reporting system, through yellow card reporting and NRLS, is open to patients if they know about it. The problem—

  Q612  Dr Stoate: How would they know about it?

  Professor Griffiths: This is it. How would the doctor know about it?

  Q613  Dr Stoate: That is my question. Is there any way we could improve education and training to try to reduce this?

  Professor Griffiths: At the moment there is not a system in place that will necessarily pick up all of those incidents. There are specialist pharmacists that will look at prescribing patterns within PCTs. Like Professor Esmail said, there is PACT data, prescribing data, for practitioners which can be assessed and can be peer reviewed, and so you can see certain things there, but without looking at each individual case and reviewing each individual case it is very difficult to say that was inappropriate. There are two million prescriptions a day.

  Q614  Dr Stoate: Do you see a case for more automation and expert systems?

  Professor Griffiths: Yes. We have PACT data in primary care. Secondary care lacks prescribing data considerably. Everything goes on the medication administration review charts. They are paper based or cardboard drug charts, which, as soon as the patient is discharged, go into the medical notes and they get archived and library services take them off and put them away. The problem with that is that it is very hard to audit individual practitioners where you have a paper system, half of which is archived away. Electronic prescribing in secondary care will make a big difference in terms of audit and in terms of a review of prescribing patterns which is not there at the moment.

  Q615  Dr Stoate: I would like to see, and I do not know whether you agree with me, is effectively NICE guidelines and NICE data being built into a GP expert system. If you, for example, typed in a diagnosis of hypotension, up would come NICE guidelines which I believe would make it less easy to make a significant prescribing error. Do you think there is a place for that?

  Professor Griffiths: I think there is. I think there are very good systems out there at the moment. Clinical knowledge summaries does a lot of guiding practitioners. I also agree there has to be some flexibility in the system because of co-morbidities, age, different things, but there is a lot of decision support software out there. I have been looking at e-prescribing recently within the Trust I am working in, and the problem with some decision support software is that practitioners can get turned off by it. They do not want to see pop-ups all the time. If you get a pop-up repeatedly coming up for something that is very, very routine, then you can start to ignore those warning pop-ups. There is a potential that they can be overused, in which case you get a sort of burn out for the practitioner.

  Q616  Charlotte Atkins: Dr Howard Stoate raised issues around non reporting of incidents but is the National Reporting and Learning System Data being used to help in terms of management of safety?

  Professor Griffiths: Yes, to some degree. Things like this report came as a result of that. The National Patient Safety Agency again does use the reporting where it sees significant incidents in terms of putting out the rapid response reports which are really, really helpful. Although we get the information in, there are feedback reports, quarterly data summaries, organisation level patient safety reports and bulletins which not very many practitioners would probably access. I think patient safety is taken extremely seriously in the NHS, but because there are so many facets to it, practitioners sometimes get overkill in terms of how many emails they receive, how many memos they receive. Pressure care, skin care, child protection, vulnerable adult protection, fire, infection control, you name it, everyone is looking after their own particular area. I am just as guilty in that with anything to do with medicine safety within my trust it is a case of "he who shouts loudest". You try to get your messages out about your particular area and I think that is probably the case. Although the NRLS can get messages out, I think that sometimes practitioners can get swamped by the amount of messages coming to them from different directorates saying, "You must do this for child protection" or "You must do this for infection control" and from me saying, "You must do this from the medicines management point of view."

  Q617  Charlotte Atkins: Is the whole process of reporting this used as a learning experience, the fact that they have to report issues around safety? Obviously there is no point in just collecting the data if it is not used to improve the experience for the patient.

  Professor Griffiths: They are used. As I said, that is why it was a shame that this did not go out as widely as I would have liked it to. I think it should be a "must read". There are lots of anecdotes in here. Okay, there is evidence as well, but some of the stories, being anecdotal, hit home. Practitioners can think, "Oh, there but for the grace of God go I." There are ten-times dose incidents in here. They happen time and time again internationally. There are cases of medicines that are meant to be oral going down intravenous lines. We had the famous case of vincristine being given intrathecally. It has happened worldwide 20 or 30 times in the last ten years. It is still happening. Vincristine is being given intrathecally around the world, even though we brought in measures in the UK. When you read these sorts of shock horror stories, the fact is that if you are going to give someone some oral medication and you think it is going down a PEG tube, you will check it is a PEG tube and not an intravenous catheter. These things bring home incidents to practitioners because they can put it into some sort of context to do with their own practice.

  Q618  Charlotte Atkins: Does it mean that those particular incidents are not repeated but other similar sorts of problems arise? Is there any real evidence that the reporting of these incidents is leading to an improvement in practice and in systems?

  Professor Griffiths: Yes, I genuinely believe that there is. There are issues in here about issues for medicines. We have just brought in a new policy into our trust where if Parkinson's disease patients or epileptic patients do not receive medicines, if they have their medicines omitted for one reason or another, because the drug is not in stock, for example, patients can come to harm. In the case of Parkinson's disease, for example, the average patient spends an extra five days in hospital because we do not get their medicines to them on time. Nurses generally are extremely strict on admission units and they will not give a medicine until it is prescribed. If someone has been delayed in the admission period, then they will not give a medicine because it has not been prescribed by the hospital doctor. We have brought in a policy, as a result of looking at medication omissions, to try to ensure that these patients do get their medicines in on time. If we stiffen a Parkinson's patient up by not giving them their medication on time, it can delay the whole hospital process and they suffer as a result. We are tackling things. There is allergy information in here—one of the other recommendations. We are making sure that we are trying to adhere to all the allergy advice, ensuring that we have other things in place. Another common issue is that sometimes patients have a penicillin allergy and it has been documented but they are prescribed a penicillin-type medication. Because it is branded and not down as a penicillin, they can then sometimes get administered that penicillin medication, so we are trying to tighten there so we have workshops around the hospital, seminars, as well as posters, warnings, stickers on boxes where they contain penicillin. We are actioning it and I do think it does make a difference.

  Charlotte Atkins: Thank you.

  Q619  Dr Naysmith: Professor Griffiths, if clinicians continue to practise unsafely in their use of medications, at what stage does that become an issue for managers and regulators?

  Professor Griffiths: Practitioners are working on safety. It is obviously a big concern. The Fitness to Practise Report of the Nursing & Midwifery Council last year showed 14,087 potential new cases. 9.87% were down to maladministration of drugs and 7.75% were down to unsafe practice. The NMC have very, very strict guidelines. Their primary purpose is to protect members of the public. We have very strict medicine standards. They were guidelines and they were made standards. We have strengthened language in there, so that and "should" has been replaced with a "must". We also have very good standards on prescribing. They are very comprehensive. Generally, if nurses are referred to the NMC they tend to be referred by colleagues. Again, we have quite an open process where nurses will refer other colleagues to the NMC. There is an article in yesterday's Nursing Standard which I wrote about medicine storage and security. It basically encourages people if they see poor practice to report to the Nursing & Midwifery Council. I do think it is something we do as a profession pretty well. There are about 30 people doing my role around the country, senior nurses in medicines, and we do a whole host of different things but one of the things is to audit, to look at competencies. We do calculations and assessments of skills around the administration of medicines. At the moment I have 4,500 nurses that have that every year, but we are also going on to e-learning and competencies for our prescribers as well.

  Q620  Dr Naysmith: In terms of reporting, there must be a balance. We were talking about a fair blame culture and the self-reporting of adverse incidents and so forth earlier with Professor Esmail. At what point does unsafe practice become a disciplinary matter? Colleagues reporting colleagues will eventually lead to a disciplinary matter.

  Professor Griffiths: I think there needs to be a balance and it tends to come down to the individual manager.

  Q621  Dr Naysmith: Should it depend on the individual manager or not?

  Professor Griffiths: I think it should do because there are sometimes extenuating circumstances. Fair blame should be just that: it should be fair. I do not think it should be a scapegoat system. If we go to a scapegoat system completely, I think you will see a huge drop off in the amount of reported incidents, and I think there is a fine balance to be had. In terms of the formalising of the process, at the moment Datex and other type of incident reporting does not require any names. Again they have tried to meet this balance. I am not sure if that is necessarily the right thing. If it is a fair blame, you can be open about it and put names in. I still think it needs to be documented just to see if there are patterns occurring if practitioners move from one place to another. There is a fine balance between where you would have anonymous reporting and where you have named reporting but I think that it has to be balance, as I have said, with the fact that people are not made scapegoats out of and punished unfairly.

  Chairman: We are nearly running as late as your train, Professor Griffiths, in this session. If any of you have observations coming out of this session or any further observations, we would be more than happy to take them by email or on paper or whatever. Thank you very much indeed for coming along and helping us with this inquiry.

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