Changing times, changing dangers

With new practices come new risks. Julie Wilson analysed data from hundreds of risk assessments to tell you how to future-proof your practice

Remember your childhood? What were our parents’ concerns? They certainly weren’t worrying about the risk posed by the technological advances of today; for example, who is your teenage daughter chatting to online and what sites is she accessing? Risks are constantly changing; we can’t ever eradicate them, but we can try to manage them by following the right practices.

General practice is risky: it is busy, demanding, stressful and diverse. A well-designed system will include error traps that will prevent errors resulting in adverse events. Having robust and effective systems can reduce the likelihood of things going wrong and reduce avoidable patient harm.

For these reasons much of the risk management activity MPS Educational Services is focused on improving systems within general practice. In 2008, Your Practice identified the most common risks in general practice based on hundreds of Clinical Risk Self-Assessments (CRSA). Last year, 130 CRSAs were carried out across the UK. An analysis of the results showed that, while the same risks were evident, new ones were commonplace. The new risks are discussed below.

1. Automated blood pressure screening

At many practices, patients are invited to have their blood pressure taken unsupervised, using an automated machine. There is often a lack of follow-up of patients with raised blood pressure, with the risk of morbidity and mortality.

Advice

Any approach that gets patients to become involved in their care should be encouraged, but there are hazards to be aware of:

  • Give clear instructions. 
  • The machine should be regularly cleaned, maintained and calibrated.
  • Any readings should be logged in the patient records. Relying on the patient telling the receptionist may not be sufficient – is it possible for the machine to produce a personalised written print-out?
  • There is a risk that patients may use the machine, have an abnormal reading and not attend for follow-up. Procedures should be in place to deal with patients whose readings give immediate cause for concern and to follow-up those who need less urgent intervention. 
  • The blood pressure reading must be assessed in the context of the patient’s other risk factors by an appropriate clinician.

For more information, read: Turnbull, S. et al. Patient monitoring of blood pressure in general practice, British Journal of General Practice (2003).

2. Community hospitals

Practices are becoming increasingly involved in activities outside their normal day-to-day practice, such as taking responsibility for patients in a community hospital. There were cases where little information was available to GPs who were caring for patients that were unknown to their practice. GPs reported that they were concerned about the inappropriate referral of some of the patients to the hospital.

Advice

  • Discuss concerns with the PCT. 
  • Read guidance provided by the British Geriatric Society Intermediate Care: Guidance for Commissioners and Providers of Health and Social Care.

3. Texting patients

Many practices are signing up to text messaging services to inform patients of appointments, flu vaccinations, etc, but not obtaining the appropriate consent from the patient. It is often assumed that because they have the patient’s telephone number, that would suffice.

We found that some practices have the mother’s mobile telephone number on a child’s medical records. This is reasonable up to a point, but what if the appointment is for a 14-year-old who has not told her mother that she has an appointment? Practices risk breaching the child’s confidentiality.

Advice

While the use of text messages can offer greater convenience and flexibility for patients and doctors, it is essential for practices to review the systems in place and make sure they are secure and compliant with the relevant legislation and guidance.

Remember: 

  • Patients should not be contacted by text unless they have provided their consent.
  • “Text-speak” should be avoided.
  • Children have the right to confidentiality. Texting is not an appropriate way of conveying sensitive information.

For more information, read the MPS factsheet on Communicating with Patients by Text (2009).

4. HCA’s role

Over the years health care assistants have taken on more responsibility. At several practices, HCAs are responsible for the monitoring and dosing of warfarin using a computer decision support system. During the CRSAs, concern was expressed about the delegation of this task to the HCA and indemnity cover.

Advice

MPS’s position regarding HCAs is that MPS supports “reasonable delegation” within the field of the HCAs expertise, as long as the HCA is fully trained and competent, and follows a robust protocol. MPS would expect that training had been validated locally or nationally.

However, MPS does have concerns about the extended role of the HCA, and in particular, warfarin monitoring, where the HCA is making therapeutic decisions. If a claim were made following a wrong dose being given, the GP is of course vicariously liable for the acts and omissions of the HCA.

The RCN have produced a useful guide, Health Care Assistants and Assistant Practitioners Delegation and Accountability (2008).

5. Prescribing to new patients

At some practices, new patient medication requests are passed to a prescription clerk, who adds them to the computer. The prescription is then generated without the patient having seen the doctor for a review of their medication.

This procedure carries significant risk as the patient receives a prescription signed by their new GP who has not undertaken a review of the new-patient medications. The doctor is putting himself and the patient at risk by prescribing, to an unknown patient, drugs that another doctor has prescribed.

Advice

  • Best practice indicates that all medication added to the prescription list should be done by the GP after an appropriate review.
  • The GMC advises that a doctor must only prescribe drugs when they have an adequate knowledge of the patient’s health, and are satisfied that they serve the patient’s needs (Good Medical Practice).
  • If medication is added to the computer or changed by administration staff, it must be closely checked by the doctor afterwards.
  • Ensure that all the details are correct and that they have been added to the correct patient record. 
  • On a busy day it is all too easy for a doctor to sign a prescription without fully checking the appropriateness and indication for that prescription – the person signing the prescription carries the legal responsibility for it.

6. Responding to test results

Many practices failed to take action in response to normal or abnormal test results.

Advice

  • Practices should not solely rely on a patient to phone in for a result for an action to occur. The responsibility for actioning results lies with the practice.
  • Practices should make every effort to contact the patient to ensure that the appropriate action is carried out. Record all attempts to contact the patient. 
  • Normal results may also require action; for example, stopping iron after a normal ferritin result. 
  • If a hospital has asked a GP to follow-up results, whether copied or not, the GP should ensure that the results are obtained and the appropriate action taken.

7. Pharmacists ordering prescriptions

Practices expressed concerns about pharmacists ordering repeat prescriptions automatically for patients, regardless of whether or not the patient needed them. In a system at a practice where local pharmacists initiate repeat prescriptions automatically it may result in:

  • Patients receiving larger quantities of medication than they need, with cost and waste implications.
  • Patients who are elderly or demented may be confused about how to take rapidly accumulating quantities of medication, risking overdose, underdose and general confusion about their medications. GPs will be familiar with the chaos associated with a draw full of mixed-date medications found on elderly house visits.
  • The reviewing doctor ay misinterpret the apparent regular ordering of medicines by the reviewing doctor and give dangerously misleading clinical cues.

Advice

  • Develop and agree with pharmacists and the PCT a protocol to make sure only those medications required by the patient are dispensed. 
  • Checking with the PCT that the system where pharmacists are allowed to initiate repeat prescriptions is an agreed system between the pharmacist, PCT and the practice. Pharmacists may be putting themselves in a vulnerable position as there is a chance that this system could be misinterpreted.

Examination for obese patients

Staff at one practice identified a risk regarding obese patients being examined and treated on an examination couch exceeding the weight limit for that couch. The manufacturers stated the couch was for weight up to and not above 150kg.

Advice

  • Practices could investigate alternative couches for obese patients. 
  • Consider alternative locations of care, for example, at their home.

Overcoming risk

Managing risk is a continuous process of evaluation, action and re-evaluation rather than a one-off event. Risk management should be a dynamic process, proactive involving all members of the practice team.

About the author: Julie Wilson leads a team of trained facilitators who conduct CRSAs across the UK. They are offered to MPS members as a benefit of membership. For more information please contact Neil Hepworth on 0113 2410624.

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