Safety and Improvement in Primary Care

The Essential Guide

Paul Bowie, Carl De Wet

• Publisher: CRC Press
• Year: 2020
• eBook ISBN: 9781910227022
• Topic: Business
• Subtopic: Family Medicine & General Practice
• Index: Business

In recent decades most of the international effort given over to studying and improving the safety of patient care has been focused in acute hospital settings. To some extent this was always something of a puzzle to those of us with a direct interest in this important issue...Now, however, the tide is slowly turning. Policymakers, healthcare leader

Part I
Understanding Systems

CHAPTER 1

‘The heart of the matter’: a parent’s perspective

Margaret Murphy

More than anything, this is what distinguishes the great from the mediocre. They didn’t fail less. They rescued more.¹

This chapter is about what I like to call ‘the heart of the matter’ - the patient’s experience of healthcare and how that experience can drive improvement in clinical practice. I would like to tell you about the patient journey of my own 21-year-old son Kevin through the Irish healthcare system in the closing years of the millennium as a means of first identifying and then discussing some of the challenges in providing safe care. Challenges that, if not appropriately met at primary care level, can have devastating consequences for patient, family and clinician. I would like to share some of my own reflections about Kevin’s experiences before concluding with a ‘wish list’ of recommendations to help improve the quality and safety of care in the future.

KEVIN’S JOURNEY

I offer you the ultimate official data in relation to Kevin - his death certificate which lists: ‘multi-organ failure, hypercalcaemia, parathyroid tumour’. Nothing or no one had prepared us for this - we had no warning, we never considered his life to be in danger and no one had intimated that this was the case. We had questions and we needed answers. How can a 21-year-old boy be admitted to hospital on a Thursday and die on the Sunday? What went wrong?

During 1997 Kevin presented on a number of occasions with persistent back pain to his general practitioner (GP). He was referred to an orthopaedic consultant in the autumn when he didn’t improve. Blood tests were requested at the clinic and revealed abnormally high levels of plasma calcium, at 3.51 mmol/L (normal range 2.05-2.60 mmol/L). There were also other abnormal measures - for example, a plasma creatinine level indicative of a more than 50% loss of overall renal function. All of the abnormal results were underlined in the laboratory report. However, when writing to the GP the consultant underplayed the high calcium levels and ignored the plasma creatinine level. That letter is not on the GP’s file and the consultant’s intention to see Kevin again early in the new year was therefore also never conveyed. Kevin was also unaware that he would have a follow-up appointment.

It is significant that throughout Kevin’s care only one set of clinical eyes saw those particular test results - at no point in his care was the hard copy forwarded and neither did it travel with Kevin as part of a patient-held record - no one else, patient or clinician, had an opportunity to revisit them or question them again.

After repeated consultations in general practice, Kevin was on each occasion returned to us as seemingly healthy and without explanation for his sometimes unacceptable and erratic behaviour. Only later did we learn that this behaviour was due to the chemical imbalance caused by his undiagnosed medical condition and the fact that while his bones were being starved and softening, the viscosity of his blood was being altered and putting a huge strain on his heart.

Kevin’s medical record contains an entry made by the GP’s secretary:

Telephone call from patient’s mother. She is extremely worried about her son. She wishes you to know that she thinks he may be depressed also. Failed his first year exams, Repeating and not doing well either, finding it hard to study. He is now remaining in bed a lot. She has arranged an appointment with Dr X (a psychiatrist) tomorrow and would like to have results of bloods, bone scan, etc for the consultation. She wonders if he really has a back problem. What can I tell the mother? She wishes to speak to you. Results in file.

The GP’s response: ‘Fax results to Dr X’ There was no direct contact with the mother or the patient.

Kevin spent the summer of 1999 in the United States. On his return he again consulted his GP, complaining of lethargy, occasional vomiting and continuing bone pain. Blood and urine samples were taken and the test results were telephoned to the surgery the next day. The practice nurse wrote the results on a Post-it note and drew attention to the high calcium level, now 5.73 mmol/L.

The GP seemingly ignored the high calcium levels, and in his referral to the hospital included only those elements of the blood test results that supported his own diagnosis of leptospirosis - although he did send the Post-it note with the letter. It was at this point that Kevin’s contact with primary care came to an end. Our next interaction with his primary care physician was to inform him of Kevin’s death.

When compiling the file in the hospital on admission on the Thursday, the Post-it note containing those vital calcium results was stuck to the back of the letter and was not seen until 6 weeks after Kevin’s death. The standard blood tests in that particular hospital did not include calcium. So, throughout Kevin’s time there, they remained unaware of his dangerously high calcium levels. Instead, a diagnosis of nephritis was made.

Despite his continuing decline, no alarm was raised. He became dehydrated and described worsening muscle pain and neurological problems. His medical record quotes him as saying: ‘I have crazy thoughts coming into my head’ The same notes also show advancing renal failure. At this time, no medical personnel seemed to appreciate how ill Kevin had become as his condition continued to deteriorate rapidly. Finally, he was transferred to Cork University Hospital (CUH).

I can recall speaking with a consultant in the hospital corridor on the afternoon before Kevin was transferred to CUH. I asked: ‘Are you concerned at all about the delay in his transfer, because I have this desperate sense of urgency (hand on my chest)?’ Kevin’s brother interjected and inquired: ‘What will they do differently in CUH?’ The consultant replied: ‘They’ll do nothing different. Perhaps they’ll take a biopsy on Monday or Tuesday! Kevin was dead on Sunday.

It was at CUH where we first heard concerns about his high calcium levels, then 6.1 mmol/L! Unfortunately, Kevin was managed at registrar level. Senior personnel and more aggressive treatments were not available at the weekend. We cannot say if that would have resulted in a better outcome, but it would be nice for me, his mother, to know that he was given every chance.

During Sunday, Kevin was ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• About the editors
• List of contributors
• Dedication
• Acknowledgements
• Introduction
• Part I Understanding Systems
• Part II People and Improvement
• Part III Learning for Improvement
• Part IV Managing Patient Safety
• Part V Improvement Methods
• Epilogue
• Index