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How Scotland is leading the world in its approach to improving patient safety

Scotland’s approach to improving patient safety has attracted world-wide attention and is delivering impressive results, Clare Morrison, Scotland correspondent, reports

By Clare Morrison

Scotland’s approach to improving patient safety has attracted world-wideattention and is delivering impressive results, Clare Morrison, Scotland correspondent, reports

Since 2008, the Scottish Patient Safety Programme (SPSP) has been working steadily to improve the safety and reliability of care across the whole of NHS Scotland. Initially concentrating on acute care, the latest data show that the programme has delivered a 12.4 per cent cut in hospital mortality rates since it was launched (PJ 2013;290:262).

It is perhaps not surprising that these results are getting world-wide recognition. One example of this comes from Don Berwick, of the US Institute for Healthcare Improvement. “The SPSP marks Scotland as a leader, second to no nation on earth, in its commitment to reducing harm to patients, dramatically and continually,” he says. His opinion is particularly relevant at the moment since he was appointed to run a new national advisory group on the safety of patients in England last week.

How it works

So what is the SPSP approach all about? Its aim is simple: to improve quality and embed a safety culture in everyday practice. It does this in a structured way and on a large (national) scale. To deliver its aims, SPSP has programmes in five areas: acute care (adults), maternity care, paediatric care, mental health and primary care.

Within each of these areas are a number of quality improvement goals or standards. Health professionals from all disciplines are involved in working towards delivering these standards. How this is achieved differs from hospital to hospital or GP practice to GP practice, since there is an onus on those working at grass-roots level to assess their own individual systems and identify the improvements they need to make to meet the quality standards.

For example, one of the standards in the primary care programme is that the dose of warfarin should be prescribed according to local guidance. If a GP practice found it was not doing this, the practice team would need to investigate the reasons why not. It might be that local guidance did not exist or that GPs were not aware of local guidance: whatever the reason, it is unlikely to be an identical answer at every practice. Therefore, any changes needed would have to be decided at a practice level. This model of quality improvement follows the “PDSA” (plan, do, study, act), cycle which involves making small changes to improve quality.

The SPSP approach seems to work, or so the reduction in mortality rates seen through the acute care programme indicates. Medicines management is one of the focus areas in the acute care programme and pharmacists have been heavily involved.

Ian Rudd, SPSP fellow and principal pharmacist (clinical) at Raigmore Hospital, NHS Highland, explains that pharmacists have had a number of roles including: improving medicines reconciliation on patient admission and discharge from hospital, making warfarin use safer, participating in ward rounds in intensive care units, improving medicines management in the peri-operative period, participation in venous thromboembolism working groups, improving management of patients with sepsis and improving the use of antibiotics.

Primary care

Primary care is the next area in the SPSP spotlight. Research provides clear reasons for needing a primary care programme: 12 per cent of hospital admissions are due to suboptimal primary care and 6.5 per cent of admissions to adverse effects of medicines. Of the medicines-related admissions, 67 per cent are thought to be preventable. This explains why safer medicines is one of the three work streams in the programme.

The medicines work is built around “care bundles”. A care bundle is simply a structured way to assess whether good quality care has been delivered against four or five measures. Implementing this bundle on a regular basis enables a practice to measure continually the quality of its care and identify areas for improvement. An example is provided in the Panel. Three care bundles are included in the programme: for warfarin, disease modifying antirheumatic drugs and medicines reconciliation.


Warfarin bundle

The SPSP Primary Care warfarin care bundle involves a GP practice identifying 10 patients per month and assessing their care against the following quality standards. For each patient, each of the following statements should be answered with a “yes” or “no”:

•    Warfarin dose is prescribed according to local guidance
•    INR test is planned according to local guidance
•    Patient complying with dosage instructions
•    INR is taken according to previous recommendation
•    Patient receives regular education
•    Have all the above measures been met?

The aim is that by assessing what a practice delivers against these measures and making any changes necessary, the safety and reliability of care will continually improve.


Medicines reconciliation appears in both the primary and acute care SPSP work streams. The primary care programme booklet explains: “Patients frequently move across different parts of the health service. It’s vital that an accurate record of what medication a patient is taking is maintained and communicated appropriately. But medicines reconciliation is not easy to do when the service can be fragmented and there is no single patient record.” However, it suggests that by sticking to a simple procedure and working together, it will be possible to get an accurate medicines record for the vast majority of patients. In primary care, this includes ensuring medication changes stated on discharge documents are acted upon and discussed with the patient within specific times.

What’s next?

Over the next year, the SPSP in Primary Care will start to be implemented. It is expected that certain aspects of the programme will be included in the GP contract while implementation of other parts will be agreed locally by NHS boards. Work on extending the SPSP approach to other areas — including community pharmacy, nursing, dentistry and optometry — is also ongoing. It is expected that testing of the community pharmacy programme will begin later this year.

The SPSP approach appears to be firmly embedded in Scotland’s health policy. Alex Neil, Scotland’s health secretary, said this week: “We want every Scottish patient to be confident that the NHS care and treatment they receive is safe, every time.”

With safe use of medicines so prominent in the acute and primary care programmes, it is vitally important that pharmacists play a key role in delivering the SPSP aims.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2013.11118816

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