Creating a patient safety culture

Healthcare is not without risks and incidents will occur. Julie Price, a registered nurse and Clinical Risk Manager at the Medical Protection Society, advises on how creating a patient safety culture can help to minimise the risks.

In the 2012 Olympics, Team GB gained success in many events including cycling and rowing; these were excellent examples of teams working together for a common goal. So, how does a general practice team become successful? Practices may have fantastic individuals, but to achieve a safe and efficient practice they must have a culture of safety within the team. This article will explore the concept of a patient safety culture alongside some practical tools for practice nurses.

WHAT IS A SAFETY CULTURE?

Working in general practice is not without risks; however, nurses have a vital role to play in minimising those risks by helping to create a culture of safety. This means ensuring systems and processes are robust and that when things do go wrong, lessons are learnt and appropriate actions taken.

The Nursing and Midwifery Council's (NMC) code of conduct identifies patient safety as an essential part of nursing care. Nurses have a responsibility to be vigilant about risk, and to help keep everyone safe in the places they receive healthcare.¹

Background to a safety culture

It is increasingly recognised that safety within a healthcare organisation is dependent upon its safety culture; a concept that was first coined after the nuclear power industry in the aftermath of the Chernobyl accident in 1986. The Chernobyl plant exploded on 26 April 1986, following an error during the testing of a reactor, discharging a radioactive cloud and contaminating much of Europe — an estimated 15,000-30,000 people died in the aftermath.²

Of course, first thoughts are to blame the plant operators — they made a mistake — but as with most disasters when things go wrong it is rarely because of a single isolated event. Errors and incidents occur within a system and usually there is a sequence of events that occur before an accident happens. In the Chernobyl accident investigators found that the disaster was the product of a flawed Soviet reactor design coupled with serious mistakes made by the plant operators. It was a direct consequence of a lack of any safety culture.

Similarly, in an analysis of a number of high profile investigations into catastrophic healthcare incidents, lessons were learned on how to develop safer systems for patients.³ The failures that can occur include:

• Communication breakdown
• Safety procedures not practised
• Poor supervision
• Poor maintenance procedures
• Inexperienced staff
• Poor organisational learning
• Human factors such as fatigue, distraction or stress

HOW TO DEVELOP A SAFETY CULTURE

Being open and fair when an adverse incident happens means sharing information openly with patients and their families. This should be balanced with fair treatment for staff. Learning from other industries can be translated into the context of healthcare and a safety culture in primary care should possess the following characteristics:

• Individuals have a constant awareness of the potential for things to go wrong
• A culture that is open and fair and encourages people to speak up about mistakes
• Both the individual and organisation are able to acknowledge mistakes, learn from them and take action to put them right
• It influences the overall vision, mission and goals of the team or organisation, as well as the daily activities.⁴

In this approach to patient safety you should acknowledge that the causes of a patient safety incident cannot simply be linked to the actions of the individual staff member or members involved, but to the system in which they are working.

Capturing the patient experience

Developing a safety culture within the practice can enhance the patient experience. On return from a holiday, travellers are often encouraged to provide feedback on the service, yet until April this year, when patients are admitted to hospital for medical treatment feedback was not routinely sought.

The 'Friends and Family' test aims to change this. All patients will be asked a simple question to identify if they would recommend a particular A&E department or ward to their friends and family.⁵ The results of the test will be used to improve the experience of patients by providing timely feedback alongside other sources of patient feedback and highlight areas for action. Although initially introduced in secondary care, it has been suggested that this will be introduced into primary care in the near future. In the meantime, patients are encouraged to use websites such as NHS Choices to post comments about their experiences. This is an invaluable tool for practices and should be used to engage with patients and make improvements where necessary.

MEASURING THE CULTURE

MPS has developed a validated tool for general practices to assess the opinion of the clinical and non clinical staff towards the patient safety culture within an organisation. It consists of a 23-question survey, which is sent to all staff working for the practice prior to an MPS Clinical Risk Self Assessment (CRSA).⁶ This anonymous dataset enables practices to benchmark their safety culture with other practices and target areas for improvement, and has been used in over 600 practices, with over 16,000 forms completed, across UK and Ireland.

The survey consists of statements across four core dimensions of patient safety:

• Leadership and teamwork
• Communication
• Reporting and learning
• Resources and training

LEADERSHIP AND TEAMWORK

It is essential to have effective leadership and management of the practice, to motivate staff and develop effective team work. Working effectively as part of a team within a general practice setting is vital to delivering high quality care to patients.

In 2012, the NMC and the General Medical Council (GMC) jointly outlined how high quality, safe patient care also involves teamwork, communication and leadership. As well as a culture where health professionals can discuss patient safety and issues openly with peers, senior clinicians, nurses and midwives, healthcare managers and with patients themselves.⁷

COMMUNICATION

Poor communication can be a key contributory factor when things go wrong. Consider starting the day with a briefing or 'huddle' to discuss the following questions:

• Is anyone away?
• What are we doing today?
• Do we have what we need?
• What are the barriers or constraints?

REPORTING AND LEARNING

Many practices partake in significant event audits; however, in MPS's experience, the clinically significant events are usually reported by clinicians and not all staff report incidents or near misses. All practice staff should be made aware of the purpose of the incident reporting system and how it works.

RESOURCES AND TRAINING

Having access to the right equipment and resources is vital in ensuring patient safety; it is important to ensure the practice has a medical devices inventory and that all medical equipment is maintained and fit for purpose.

Practice teams must also ensure that they have an effective staff training programme in place that's supported by staff appraisals.

CONCLUSION

The correlation between safety culture and patient safety is dynamic and complex. Healthcare is not without risks and errors and incidents will occur; general practice should work to minimise those risks by ensuring systems are robust and when things do go wrong, lessons are learnt and appropriate actions taken. By developing a team approach to patient safety, practice nurses can assist in the process of ensuring a safety culture of their practice and thus improve the quality of care provided.

REFERENCES

1. Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives, London: NMC.

http://www.nmc-uk.org/Publications/Standards/

2. World Nuclear Association Chernobyl Accident 1986

http://www.world-nuclear.org/info/chernobyl/inf07.html

3. Norris, B (2009) Human factors and safe patient care. Journal of Nursing Management, Vol 17, pg 203-211.

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2009.00975.x/abstract

4. National Patient Safety Agency (2006) Seven Steps to patient safety in primary care

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59804

5. Department of Health (2013) The NHS Friends and family test. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/141446/Friends-and-Family-Test-Publication-Guidance-v2-FOR-PUBLIC_E2_80_A6.pdf.pdf

6. Medical Protection Society Clinical Risk Self Assessment.

http://www.medicalprotection.org/uk/education-and-events/clinical-risk-self-assessments-for-GPs

7.Nursing and Midwifery Council and General Medical Council (2012) Joint statement on professional values

http://www.nmc-uk.org/Press-and-media/Latest-news/NMC-and-GMC-release-joint-

statement-on-professional-values/?dm_i=129A,YIU0,666Z27,2VWXJ,1