The Welsh ‘code-breaker’ making our visits to the GP safer
It’s 8.25am and you’re sitting on a row of seats in a busy room, waiting for your 10 minute slot to see your GP.
Behind the doors, just off the waiting area, are doctors who can help diagnose your symptoms, maybe prescribe you medication or even refer you to a specialist, if you need further tests.
You’re there to get better and you have hope that you’ll come away with a solution to your problem. However, for many people it doesn’t work out that way.
In fact you could be the one person out of the 33 in that waiting room who will experience what’s called a ‘patient safety incident’ today; a medical error that could, or does, lead to a harmful outcome.
Here we speak to Professor Andy Carson-Stevens, an award-winning Welsh researcher and GP who aims to spot and eliminate these errors through a whole new language of codes.
Professor Carson-Stevens’ work is not only helping to improve patient safety here in Wales but also around the world.
The scale of the problem
“You talk to any professional working in the primary care setting, whether as a GP or a practice nurse, and patient safety is their ultimate priority,” said Andy, lead for patient safety research at the Wales Centre for Primary and Emergency Care Research (PRIME), one of Health and Care Research Wales’ funded centres. “No-one goes to work to cause harm.”
While patient safety incidents can include errors like being prescribed the wrong type or dose of drug, or mis-diagnosis of symptoms, the most common issues arise because of the very systems designed to manage our care.
“More often than not it’s not about the doctor getting it wrong,” explained Andy. “It’s more likely to be the complex systems that allow patients to be harmed.
“So, it’s about the doctor realising that a patient needs a referral to a cancer specialist and because there are three or four ways a referral can be dictated, then written up and eventually sent from his or her practice, there are many opportunities for delay.
“I think we just need to disentangle the chaos so that we have confidence in our own internal processes, so that everyone knows and feels confident, not least patients, that there’s a reliable process.”
In 2008, the ‘1000 Lives Campaign’ launched in Wales aiming to save lives and prevent patients coming to avoidable harm in hospitals.
“In some ways it’s staggering that we’ve had a decade of research in to hospital safety, focusing on a smaller volume of patients, and all of a sudden it’s like we’ve woken up and realised, ‘hold on a minute, we’re delivering masses of care over here in primary care settings and it could very well be having the same kind of burden on health and wellbeing’.”
The PISA care model
One of the first steps to improving safety is to make sure all errors, or patient safety incidents, are recorded so they can be analysed for any patterns and lessons learnt, to hopefully stop them happening again in the future.
However, views on what is and isn’t a reportable error varies between GPs and practices. To tackle this and get a common understanding of how to identify, record and learn from an incident, Andy and his team have created the Primary Care Patient Safety (PISA) Learning for Care Improvement Model.
“Evidence is hard to ignore,” added Andy. “You can say to someone ‘look this particular error has happened 37 times, do you really think it’s a coincidence?’ Then they realise.”
Making sense of the data
Thousands of patient safety incident records are logged in the National Reporting and Learning System; a huge database made up of files sent in from every NHS organisation in England and Wales.
“About six years ago, I and a group of colleagues were challenged to make sense of those reports and data,” recalled Andy.
Andy accepted the challenge and cracked the case.
“It turns out that if you give each type of incident a code, essentially codes mean something and when you have a series of codes you can take a really complicated long story and represent it with four or five buzz words.
“We developed a library of words so doctors and nurses can pick a code to describe what happened, why it happened and also what the outcomes were for patients. And those three things were more than enough for us to be able to identify patterns and to start looking for priorities.”
The ‘real’ people behind the numbers
While Andy is focused on the numbers and the patterns emerging from the data, his research partner Antony Chuter provides a lay perspective on the research.
“From the harrowing stories we read through, we have to create aggregates of data,” said Andy.
“When we’re aggregating stories to numbers Antony will never let us forget that there are real people behind those numbers every time.”
“The work I’ve been doing with Andy in Wales around safety is just so important to patients, the public and carers, to know the health system is safe,” said Antony.
“There are some very challenging topics and it’s important that we do this research to prevent these things happening again in the future.”
Wales and the world
In 2018, Andy won the Yvonne Carter Award for Outstanding New Researcher. Through this prestigious award Andy is now working with researchers in Turkey, helping them to apply his patient safety ‘codes’ to their own medical errors.
“You don’t necessarily have to speak the same language, you can communicate in codes about what happened and why. It sounds a bit geeky but actually I see that as an opportunity to maximise the insight on human error. We’ll be able to have conversations about safety in the same way they do in the airline industry, when an accident investigation occurs.
“They may come up with solutions in Turkey that we really need to learn from in Wales or elsewhere. So, the sooner we can coordinate that, build the infrastructure to compare, contrast and look for the guiding lights that emerge from structured data, the better.”
First published: @ResearchWales Issue 5, December 2018