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Learning Briefing 2: A Safety Checklist for Early GP Specialty Training2

Driving Improvements in Healthcare: Implementation Evidence

© NHS Education for Scotland 2017.

You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

Dr Nancy El-Farargy: [email protected]

IntroductionA safety checklist has been tested and developed for use within the first 12 weeks of GP Specialty Training [1]. 14 themes and 47 related patient safety items have been developed, and adherence to the checklist could ensure that safety critical topics are addressed and adequately covered during the initial training period.

The checklist can be used by Educational Supervisors to assist in the delivery of safety-critical educational issues. It has also been adapted into a self-assessment tool for use by GP trainees.

Patient Safety in ContextPatient safety is a current worldwide priority [2, 3],and research to support the area has increased in recent times [4, 5]. Within primary care there is a large body of research relating to levels of harm and adverse events [6, 7], and for the post-graduate training environment, the following issues may further compromise patient safety:

Other patient safety critical issues could include the quality of the learning environment, safety cultures, workloads and time management. In addition, whilst Educational Supervisors highlight the importance of technical skills, conscientiousness, and honesty as core attributes of a safe practitioner, they may not be recognised in core safety skills training or continuing professional development [13].

Given the potential variations on safety-critical training provision, there is a risk that patient safety can be compromised, and that quality of care issues could arise.

Failures or inadequacies around the supervision process [8]

Feedback processes [9] and responding appropriately to the needs of trainees seeking professional guidance [10]

Issues around feedback in drug prescribing performance [11] (as well as other cited factors such as communication and workloads [12])

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Patient Safety and the GP Specialty Training CurriculumThe Royal College of General Practitioners (RCGP) is responsible for the content of GP specialty training. Of specific interest, Professional Module 2.02 outlines 12 key areas in ‘Patient Safety and Quality of Care’ [14] (Table 1).

Item Knowledge and Skills Guide Core Competence

Brief Description

1 Fitness to practiseTaking action to protect patients, and developing professional values, behaviours and personal resilience. Gains insights into own performance and conduct.

2 Maintaining an ethical approach Practising ethically, with integrity and with respect for diversity.

3 Communication and consultation

Using recognised consultation techniques, establishing patient partnerships, and managing consultations.

4 Data gathering and interpretation

Interpreting patient’s narrative and adopting a proficient approach to clinical examination.

5 Making decisions Taking conscious structured approaches to decision making during consultation and wider areas.

6 Clinical management Recognising and managing common medical conditions in generalist care; including safe prescribing and medicines management.

7 Managing medical complexity

Managing care beyond straightforward problems; including the management of co-morbidity, poly-pharmacy, uncertainty and risk.

8 Working with colleagues and in teams Working effectively with other professionals to ensure good patient care.

9 Maintaining performance, learning and teaching Maintaining performance and effective CPD for oneself and others.

10Organisational management and leadership

Understanding organisations and systems for the benefit of patient care. This also includes developing relevant business and financial skills.

11 Practising holistically and promoting health

Promoting physical, psychological, socioeconomic and cultural dimensions of health. This includes preventative medicine, self-management and care planning with patients and carers.

12 Community orientationUnderstanding the need to build community engagement and resilience; including global and multi-cultural aspects of evidence-based, sustainable healthcare.

Table 1: The Knowledge and Skills Guide for the RCGP Professional module in ‘Patient Safety and Quality of Care’ [14]. 4

Whilst guidelines on the GPST curriculum are presented, individual GP Educational Supervisors are largely free to determine how the RCGP Curriculum is delivered, and how learning needs are identified and acted upon during the training period.

It may also be worthy to note that Educational (and Clinical) Supervisors have related standards for ensuring safe and effective patient care through training [15].

Compliance Checklist in Healthcare

Due to potential lapses in human memory and awareness, the use of procedural checklists could compensate and mitigate any potential errors, and support more reliable performance [16, 17]. Compliance checklists are common for preventing error and have been widely used in fields such as commercial aviation and petro-chemical industries. Whilst the use of checklists is now common in surgery [18] and anaesthesia [19], they are increasingly being used in other areas, such as on the ward, intensive care and other medical procedures [19, 20].

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The Safety Checklist for GP Educational SupervisorsThe Safety Checklist for GP Educational Supervisors [1] was developed to assist in the delivery of safety-critical educational issues in the first 12 week period of GP Specialty Training (Table 2, p. 7). 14 safety critical domains and 47 related areas are presented as essential components of training, and each area is now aligned with the newly refreshed 12 RCGP competencies of the ‘Patient Safety and Quality of Care’ module [14].

The checklist can be used in a variety of ways [21]:

To refer to during induction, or be used to inform the development of new induction processes.

To ensure that safety-critical educational tasks are completed efficiently.

To improve reliability of safety-critical educational provision.

To be used as supporting evidence (for deanery and accreditation visits) of core safety education and training.

To potentially minimise any medico-legal implications for the GP Educational Supervisor and trainee.

Adaptation of the Safety Checklist as a Self-Assessment ToolThe checklist was originally developed and validated for educational supervisors, to assist in the delivery of safety-critical issues in the opening 12 weeks of training. It has been re-aligned to the new RCGP curriculum [14], and adapted for use by GP trainees as a self-assessment tool to guide patient safety-related learning needs, and to monitor future progress.

This checklist is presented in Table 3: 12 Week Self Assessment Checklist for Specialist Trainees, p.16

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This checklist is presented in Table 2: Safety Checklist for GP Educational Supervisors, p.8

References1. Bowie, P., McKay, J., and Kelly, M. (2012). Maximising harm

reduction in early specialty training for general practice: validation of a safety checklist. BMC Fam. Pract. 13, 62. Available at: http://www.biomedcentral.com/1471-2296/13/62.

2. Committee on Quality of Health Care in America & Institute of Medicine (2000). To Err is Human: Building a Safer Health System (Washington D.C.: National Academy Press).

3. World Health Organization (2011). Patient Safety Curriculum Guide - Multi-Professional Edition. (Switzerland) Available at: http://www.who.int/patientsafety/education/curriculum/tools-download/en/ [Accessed May 22, 2015].

4. Mitchell, I., Schuster, A., Smith, K., Pronovost, P., and Wu, A. (2015). Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after “To Err is Human.” BMJ Qual. Saf., bmjqs–2015–004405. Available at: http://qualitysafety.bmj.com/lookup/doi/10.1136/bmjqs-2015-004405.

5. Bates, D. W., Larizgoitia, I., Prasopa-Plaizier, N., and Jha, A. K. (2009). Global priorities for patient safety research. BMJ 338, b1775. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19443552.

6. McKay, J., Bradley, N., Lough, M., and Bowie, P. (2009). A review of significant events analysed in general practice: implications for the quality and safety of patient care. BMC Fam. Pract. 10, 61.

7. The Health Foundation (2011). Levels of harm in primary care. Available at: http://www.health.org.uk/publication/levels-harm-primary-care.

8. Kilminster, S., Cottrell, D., Grant, J., and Jolly, B. (2007). AMEE Guide No. 27: Effective educational and clinical supervision. Med. Teach. 29, 2–19. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17538823 [Accessed October 9, 2012].

9. Wearne, S., Dornan, T., Teunissen, P. W., and Skinner, T. (2012). General practitioners as supervisors in postgraduate clinical education: An integrative review. Med. Educ. 46, 1161–1173.

10. Bruijn, M., Busari, J. O., and Wolf, B. H. M. (2006). Quality of clinical supervision as perceived by specialist registrars in a university and district teaching hospital. Med. Educ. 40, 1002–1008.

11. Dornan, T., Ashcroft, D., Healthfield, H., Lewis, P., Miles, J., Taylor, D., Tully, M., and Wass, V. (2009). An in depth investiation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 1–215. Available at: http://www.gmc-uk.org/FINAL_Re-port_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf.

12. Slight, S. P., Howard, R., Ghaleb, M., Barber, N., Franklin, B. D., and Avery, A. J. (2013). The causes of prescribing errors in English general practices: A qualitative study. Br. J. Gen. Pract. 63, 713–720.

13. Ahmed, M., Arora, S., McKay, J., Long, S., Vincent, C., Kelly, M., Sevdalis, N., and Bowie, P. (2014). Patient safety skills in primary care: a national survey of GP educators. BMC Fam. Pract. 15, 206. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4275946&tool=pmcentrez&ren-dertype=abstract.

14. RCGP (2016). The RCGP Curriculum: Professional & Clinical Modules. 2.01-3.21. Available from: http://www.rcgp.org.uk/training-exams/gp-curriculum-overview/document-version.aspx

15. RCGP, and COGPED (2014). Guidance for Deaneries/LETBs on the Standards for GP Specialty Training Available at: http://www.rcgp.org.uk/training-exams/~/media/Files/GP-training-and-exams/Information-for-deaneries-train-ers-supervisors/Guidance-for-deaneries-on-standards-for-GP-training-Jan-2014.ashx [Accessed August 17, 2015].

16. Borchard, A., Schwappach, D. L. B., Barbir, A., and Bezzola, P. (2012). A systematic review of the effectiveness, com-pliance, and critical factors for implementation of safety checklists in surgery. Ann. Surg. 256, 925–33. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22968074 [Accessed August 31, 2015].

17. Merry, A. F., and Mitchell, S. J. (2016). Advancing patient safety through the use of cognitive aids. Qual. Heal. Care, bmjqs–2015–004984–. Available at: http://qualitysafety.bmj.com/content/early/2016/01/04/bmjqs-2015-004984?pa-petoc [Accessed January 5, 2016].

18. WHO (2008). Surgical Safety Checklist (First Edition). Avail-able at: http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf?ua=1.

19. Walker, I. A., Reshamwalla, S., and Wilson, I. H. (2012). Surgical safety checklists: do they improve outcomes? Br. J. Anaesth. 109, 47–54. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22649183 [Accessed July 28, 2015].

20. Braham, D. L., Richardson, A. L., and Malik, I. S. (2014). Application of the WHO surgical safety checklist outside the operating theatre: medicine can learn from surgery. Clin. Med. (Northfield. Il). 14, 468–474. Available at: http://www.clinmed.rcpjournal.org/content/14/5/468.full.pdf+html.

21. Bowie, P., McKay, J., and Kelly, M. (2014). A safety checklist for specialty training. In Safety and Improvement in Prima-ry Care: The Essential Guide, P. Bowie and C. de Wet, eds. (London: Radcliffe Publishing Ltd), pp. 177–186

This briefing is based on the following paper:

Bowie, P., McKay, J., & Kelly, M. (2012). Maximising harm reduction in early specialty training for general practice: validation of a safety checklist. BMC Family Practice, 13(1), 62. doi:10.1186/1471-2296-13-62.

NHS Education for Scotland is a national health board responsible for education, training and workforce development for those who work in NHS Scotland.

We undertake a range of patient safety educational research to support the delivery of safe, effective and person-centred care.

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Specialty Training for General Practice Table 2: Safety Checklist for GP Educational Supervisors[1]

Essential issues to be covered during the initial 12 week specialty training period in the General Practice setting. Suggested mappings against the 12 RCGP key areas are noted [14], (Table 1).

Name of Specialty Trainee:

Theme A: Prescribing Safely

Item Safety Critical AreaRCGP

Competency No. (Table 1)

✓ Comments / Actions

1 Knowledge of high risk medications (e.g. NSAIDs & Warfarin, Methotrexate) 6, 7

2Controlled Drugs (e.g. knowledge of storage, does adjustment, prescription format)

6, 1

3 Awareness of Health Board/Formulary Prescribing Guidance 12

4 Knowledge of practice repeat prescribing system 10

5Risks associated with signing repeat & special requests without consulting records

6, 7

6 Monitoring drug side-effects (e.g. Myalgia with Statins) 6, 7

8

Specialty Training for General Practice Table 2: Safety Checklist for GP Educational Supervisors[1]

Theme B: Dealing with Medical Emergency




7

Ensuring adequate emergency treatment knowledge/confirmation of CPR knowledge & skills (in past 12 months)

6

8 Surgery emergency bag/tray & equipment 6

9 Contents of doctors’ emergency bag/case (where appropriate) 6

10Awareness of emergency contacts (e.g. ambulance, police, social work...)

6

9

Theme C: Specific Clinical Management




11

Recognising & acting on red flags or serious illness (e.g. patients needs immediate admission or urgent outpatient referral)

4

Theme E: Patient Referrals




14

Identifying the need for referral (i.e. recognition of condition requiring further investigation and/or treatment)

4

15 Referral system (e.g. how and when to refer ‘urgently’ and ‘routinely’) 10, 12

16Clinical appropriateness of referral (e.g. ensure correct clinical priority and correct specialty)

12

17Quality of acute referral letter (e.g. past medical history, medication status, social circumstances)

10

10

Theme D: Dealing Effectively with Results of Investigation Requests




12 Need to follow-up & act on results and hospital letters 1

13 Knowledge of practice systems for results handling 10

Theme F: Effective and Safe Communication




18

Knowledge of internal communication processes within the practice (e.g. email, message systems, practice meetings...)

10

19How to liaise with and understand the roles of team members: who, purpose, how, where, when?

8

20Safe communication with patients and relatives (e.g. consultations, phone calls and letters).

5

Theme G: Consulting Safely




21 How to safety-net (face-to-face) 3

22 How to safety-net (when providing telephone advice) 3

23 Awareness of guidelines for use of Chaperones 2, 1

11

Theme H: Ensuring Confidentiality




24 Avoiding breaches of confidentiality 2

25 Appropriate disclosure of medical and personal information 2

Theme I: Awareness of the Implications of Poor Record Keeping




26 Failing to keep records 1

27 Failing to keep accurate records 1

28 Failing to confirm patient identity 1

29 Failing to document all patient contacts 1

30 Knowledge of related legal issues 1

12

Theme J: Raising Awareness of Personal Resonsibility




31 Awareness of professional accountability 1

32 Recognising the limits of own clinical competence 1

33 How and when to seek help 1

34 Personal organisation and effectiveness 1

Theme K: Dealing with Child Protection Issues




35 Recognition of harm and potential for harm in children 11

36 How to liaise with other agencies 8

37 Breaching confidentiality 1, 2

13

Theme L: Enhancing Personal Safety




38 How to access emergency alarms/panic button for personal safety 1

39 Dealing with aggressive & violent patients 1

40 Ensuring personal safety and security on home visits 1

Theme M: Emphasising the Importance of the Learning Environment




41 Ensure rapid access to supervisory advice, feedback and support 9

42 Raise awareness of practice team contribution and support 9

43 Ensure reflective learning recorded in E-Portfolio 9

44 Knowledge of clinical audit and significant event analysis 9

14

Theme N: Safe Use of Practice Computerised Systems




45 Ensure proficiency in using practice computer system 10

46How to prioritise computer system safety alerts (e.g. yellow and red traf-fic lights)

10

47The need to avoid common pitfalls (e.g. leaving notes open and writing up the wrong patient)

10

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Specialty Training for General Practice Table 3: 12 Week Self Assessment Checklist for Specialty Trainees

This form is to be completed around 12 weeks into the training period in the General Practice setting, to assess levels of confidence in safety-critical areas.

Suggested mappings against the 12 RCGP key areas are noted [14], (Table 1).

Theme A: Prescribing Safely

Item Safety Critical AreaConfidence

Level (Please circle)

RCGP Competency No. (Table 1)

Comments / Actions

1Knowledge of high risk medica-tions (e.g. NSAIDs & Warfarin, Methotrexate)

1 2 3 4 5 6, 7

2

Controlled Drugs (e.g. knowledge of storage, does adjustment, prescription format)

1 2 3 4 5 6, 1

3 Awareness of Health Board/Formulary Prescribing Guidance 1 2 3 4 5 12

4 Knowledge of practice repeat prescribing system 1 2 3 4 5 10

5Risks associated with signing repeat & special requests without consulting records

1 2 3 4 5 6, 7

6 Monitoring drug side-effects (e.g. Myalgia with Statins) 1 2 3 4 5 6, 7

Level of confidence rating scale (1 to 5) where 1=Low, 3=Moderate, 5=High

16

Theme C: Specific Clinical Management




Comments / Actions

11

Recognising & acting on red flags or serious illness (e.g. patients needs immediate admission or urgent outpatient referral)

1 2 3 4 5 4

Specialty Training for General Practice Table 3: 12 Week Self Assessment Checklist for Specialty Trainees

Theme B: Dealing with Medical Emergency




Comments / Actions

7

Ensuring adequate emergency treatment knowledge/confirmation of CPR knowledge & skills (in past 12 months)

1 2 3 4 5 6

8 Surgery emergency bag/tray & equipment 1 2 3 4 5 6

9 Contents of doctors’ emergency bag/case (where appropriate) 1 2 3 4 5 6

10Awareness of emergency contacts (e.g. ambulance, police, social work...)

1 2 3 4 5 6

17

Theme D: Dealing Effectively with Results of Investigation Requests




Comments / Actions

12 Need to follow-up & act on results and hospital letters 1 2 3 4 5 1

13 Knowledge of practice systems for results handling 1 2 3 4 5 10

Theme E: Patient Referrals




Comments / Actions

14

Identifying the need for referral (i.e. recognition of condition requiring further investigation and/or treatment)

1 2 3 4 5 1

15Referral system (e.g. how and when to refer ‘urgently’ and ‘routinely’)

1 2 3 4 5 10, 12

16

Clinical appropriateness of referral (e.g. ensure correct clinical priority and correct specialty)

1 2 3 4 5 12

17

Quality of acute referral letter (e.g. past medical history, medication status, social circumstances)

1 2 3 4 5 10

18

Theme F: Effective & Safe Communication




Comments / Actions

18

Knowledge of internal communication processes within the practice (e.g. email, message systems, practice meetings...)

1 2 3 4 5 10

19

How to liaise with and understand the roles of team members: who, purpose, how, where, when?

1 2 3 4 5 8

20Safe communication with pa-tients and relatives (e.g. consul-tations, phone calls and letters).

1 2 3 4 5 5

Theme G: Consulting Safely




Comments / Actions

21 How to safety-net (face-to-face) 1 2 3 4 5 3

22 How to safety-net (when providing telephone advice) 1 2 3 4 5 3

23 Awareness of guidelines for use of Chaperones 1 2 3 4 5 2,1

19

Theme H: Ensuring Confidentiality




Comments / Actions

24 Avoiding breaches of confidentiality 1 2 3 4 5 2

25Appropriate disclosure of medical and personal information

1 2 3 4 5 2

Theme I: Awareness of the Implications of Poor Record Keeping




Comments / Actions

26 Failing to keep records 1 2 3 4 5 1

27 Failing to keep accurate records 1 2 3 4 5 1

28 Failing to confirm patient identity 1 2 3 4 5 1

29 Failing to document all patient contacts 1 2 3 4 5 1

30 Knowledge of related legal issues 1 2 3 4 5 1

20

Theme J: Raising Awareness of Personal Responsibility




Comments / Actions

31 Awareness of professional accountability 1 2 3 4 5 1

32 Recognising the limits of own clinical competence 1 2 3 4 5 1

33 How and when to seek help 1 2 3 4 5 1

34 Personal organisation and effectiveness 1 2 3 4 5 1

Theme K: Dealing with Child Protection Issues




Comments / Actions

35 Recognition of harm and potential for harm in children 1 2 3 4 5 11

36 How to liaise with other agencies 1 2 3 4 5 8

37 Breaching confidentiality 1 2 3 4 5 1, 2

21

22

Theme L: Enhancing Personal Safety




Comments / Actions

38How to access emergency alarms/panic button for personal safety

1 2 3 4 5 1

39 Dealing with aggressive & violent patients 1 2 3 4 5 1

40 Ensuring personal safety and security on home visits 1 2 3 4 5 1

Theme M: Emphasising the Importance of the Learning Environment




Comments / Actions

41Ensure rapid access to supervisory advice, feedback and support

1 2 3 4 5 9

42 Raise awareness of practice team contribution and support 1 2 3 4 5 9

43 Ensure reflective learning recorded in E-Portfolio 1 2 3 4 5 9

44 Knowledge of clinical audit and significant event analysis 1 2 3 4 5 9

Theme N: Safe Use of Practice Computerised Systems




Comments / Actions

45 Ensure proficiency in using practice computer system 1 2 3 4 5 10

46How to prioritise computer system safety alerts (e.g. yellow and red traffic lights)

1 2 3 4 5 10

47

The need to avoid common pitfalls (e.g. leaving notes open and writing up the wrong patient)

1 2 3 4 5 10

23

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Driving Improvements in Healthcare: Implementation Evidence

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© NHS Education for Scotland 2017. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

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