Examination of Witnesses (Question 600-621)
DR ALISON
HOLMES, PROFESSOR
MATT GRIFFITHS
AND PROFESSOR
ANEEZ ESMAIL
5 FEBRUARY 2009
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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