I was speaking to a man recently who had worked all his life as a scaffolder. I asked him about advances in safety since the early days. He told me the story of when he worked on scaffolding 23 stories up on a building site in London many years ago. He seemed proud of the raw bravery you had to have in those days, but in hindsight he can’t believe the risks they took at work every single day. One day his foreman called him to join him on some work on the next floor. For some reason he didn’t go immediately and just a few minutes later his shocked workmate informed him that tragically the foreman had just walked over some loose boards and fallen 24 stories to his death. The scaffolder spoke about the incident as if it was yesterday and he still wonders why he hadn’t died that day. Safety regulations on building sites have dramatically reduced deaths and workmen these days wouldn’t dream of taking those risks. In the case of the health service, we as health professionals are not taking risks with our own safety but with that of our patients. So reducing risk – ‘first do no harm’ – should always be at the core of our professional integrity. In today’s uneasy climate it doesn’t take much to bring the great weight of ‘quality inspectors’ and intense media attention to bear on a hospital and its services. At the moment this level of scrutiny is still quite infrequent, and people may get the impression that patient safety is not embedded into routine practice. It is high time that we all started to reflect on what we are doing to improve patient safety and let people know what we’re doing. High risk specialties involving high risk surgery or obstetrics are well used to reporting deaths to confidential enquiry programmes such as ‘CEPOD’. In some cases, particularly in the U.S., these statistics are available to the public and not anonymised. In lower risk specialties such as Rheumatology the measures of safety and quality are harder to measure. The safety measures listed below are gradually being incorporated into routine practice. Here is a provisional list of some of the measures we currently use in our Rheumatology unit to promote patient safety:
- We report serious drug adverse effects using the ‘Yellow card’ post marketing surveillance run by MRHA. This is a voluntary reporting scheme: some report more than others, but it can help to pick up problems that haven’t surfaced in the drug’s development. We also contribute to a national ‘risk registry’ for the newer biologic drugs (BSRBR).
- Morbidity reporting for infusion reactions. In the past year we noticed quite a high incidence of allergic reactions in our unit to Iron Dextran infusions: following discussions with specialists and pharmacists we have changed to another preparation with a lower risk of reaction. None of the reactions were serious, but it is still a patient safety issue.
- Clinical Incident reports – actual harm or near misses. Our hospital has a database for this and the risk management team rate incidents as green/yellow/red by risk level. We contribute to this, mainly for the more serious incidents. These incident reports are looked at centrally and there isn’t normally much discussion at a local level. It is therefore difficult sometimes to see whether anything changes when problems are identified.
- In our unit, we have started holding regular ‘Mortality and Morbidity’ multidisciplinary meetings – using a clear unambiguous format. These meetings take place once a month and take a few hours to prepare and write up.
- Multidisciplinary clinical discussions about unusual imaging reports or difficult diagnostic or treatment decisions. We have a good meeting with radiologists to discuss x-rays and scans, but we could probably do better in discussing difficult cases with our peers. It is very difficult to find a time when all clinicians are free.
- We use (and helped to develop) agreed regional shared care guidelines for ‘disease modifying drugs’ which used to be thought of as drugs with a lot of side effects. We record in the notes that these have been issued with every prescription and we check that monitoring is carried out when patients attend clinics. In our system the General Practitioner or Family doctor has responsibility for monitoring blood tests. We try to record telephone calls for advice, but this is an area we can improve on, perhaps by using email more often. We also standardise patient information about these drugs – we give out booklets but make sure that the patient understands the most important issues.
- We are responsible for monitoring blood tests for patients on biologics drugs – our pharmacist and specialist nurses take responsibility for this and use an agreed protocol.
- When we conduct research, we adhere to ‘good clinical practice’ standards and the international statement of Helsinki. We are also regularly monitored by the Trust’s R&D department and have to provide annual reports. Each study has to have prior approval by a regional (and very detailed) ethics review body.
- We have a discussion of major drug safety alerts or other safety alerts at our monthly multidisciplinary meeting.
- We carry out regular audits – for instance, this year we looked at the accuracy of Methotrexate prescriptions in patients admitted to hospital. This has led to several proposals to help ensure that mistakes are reduced/identified before a patient can come to harm.
- Each doctor who works in the unit has to undergo an annual appraisal. For consultants, this includes a review of statistics including mortality & a comparison with peers. There is also a discussion about any complaints, incidents or legal cases. Each doctor has to sign a probity and health statement. Every five years a doctor in the UK now has to undergo revalidation. This assessment has to include two confidential surveys about the performance of that particular doctor – one from patients and the other from health professionals with whom they work.
This is not an exhaustive list, and it doesn’t mean that there aren’t areas in which we need to improve. For instance, we don’t yet use a clinical database, and we don’t have any link to the patient’s prescription list held by their GP. We don’t participate in a peer review programme – this doesn’t yet exist in our region. These are significant developments that may contribute to patient safety – but they have to be properly resourced and supported by our hospital’s management.