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Safety in Practice: collaborative improvement in primary care

Safety in Practice: collaborative improvement in primary care

What is 'Safety in Practice'?

'Safety in Practice' in primary care is a collaborative programme led by Counties Manukau District Health Board (DHB) with primary healthcare organisations (PHOs) in the Auckland region [find out more about the Safety in Practice programme]. We have adapted a methodology from NHS Scotland to improve patient safety within primary care.

What are we trying to achieve?

While some improvement work occurs in primary care services, it is often adhoc and not consistent across the Auckland region.

Primary health services across the Auckland region decided to collaborate to enhance the quality improvement capability of general practices (GPs) by focusing on patient safety. We adopted a methodology adapted from NHS Scotland with an aim to:


GP capacity and capability in quality and patient safety improvement methods and processes


and/or reduce harm and improve the quality of care for patients with chronic conditions through safer and better management of medications


and develop GP practice systems and processes, to ensure critical high risk processes are carried out safely and reliably


a culture of safety within their working environments


High-risk focus areas

They decided to focus on three high-risk areas associated with patient harm:

1. Warfarin management

Warfarin is used to prevent the development of blood clots related to a number of medical conditions. It is a medication that requires regular monitoring as each patient will have a different reaction to the medication, eg one patient may only need a small amount of Warfarin for it to work well for them while another may need a larger amount.

We want to make sure that:

  • medical staff are using the correct guidelines when determining Warfarin doses
  • each patient understands what Warfarin does, how it interacts with food, other medication and what to do if levels are too high or too low
  • each patient is taking the prescribed Warfarin dose
  • blood-testing occurs at the time requested

2. Management of laboratory results

A large number of blood tests are ordered by general practices for their patients. We want to make sure that:

  • the right test is ordered at the right time
  • there is a plan in place when the test results comes back
  • all tests and plans of care are documented in the patient’s file so that general practitioners and/or practice nurses involved in their care are able to understand what needs to happen

3. Reconciliation of medication on discharge from hospital

When someone goes to hospital, their medications are often changed. We want to make sure that:

  • any changes to medications prescribed (ie new, changed or stopped) while in hospital are identified by hospital clinical pharmacists and medical staff
  • the general practice (GP) is aware of any changes and that they update their patient’s file in a timely way
  • the patient understands the changes to their medications

What did we find?

Twenty-three general practices across the region joined the programme to look at one of the three high-risk areas. We conducted a baseline audit for each of the three areas to show compliance rates to agreed standards:

High-Risk Focus Area

No. of General Practices

Compliance Rate

Warfarin management



Management of laboratory results



Reconciliation of medication on discharge from hospital



PHOs involved in the Safety in Practice programme
PHOs involved in the Safety in Practice programme

What have we done?

Each general practice began by reviewing how they currently manage their chosen high-risk focus area and identified how these could be improved. Successful and unsuccessful ideas were shared by general practices at collaborative learning sessions.

The key improvements for each High-Risk Focus area were:

1. Warfarin management

What have we done to improve Warfarin management?

  • Consistent use of evidence based protocols
  • Nurses-led management of INR follow-up
  • Simplification of daily warfarin doses
  • Developed electronic tool for monitoring INR results and warfarin doses
  • Identified patients with poor understanding of medication and provided targeted education
  • Developed education tools in multiple languages (Samoan, Tongan, more to follow)

Example of Warfarin education tool in Samoan
Example of Warfarin education tool in Samoan

2. Management of laboratory results

Management of laboratory results:

  • Simplifying of processes
  • Standardised quick keys to enter plan in comments field
  • Education for new staff, locums and part timers
  • Explored options for patient access to results through patient portal
  • Reduced number of unnecessary tests by modifying blood test form

laboratory management processes
New laboratory management processes

3. Reconciliation of medication on discharge

  • Standardised process to document changes in medication
  • Guide sheet/algorithm for specific long term conditions to assist nurse to carry out post discharge check
  • Dedicated time allocated to check discharge summaries

Standardised documentation of medication changes
Standardised documentation of medication changes

Did we make a difference?

  • All three clinical areas have seen marked improvement in compliance
  • GP practices learning from one another has supported this improvement

Increase to 74% from 10% for warfarin management compliance
Increase to 74% from 10% for warfarin management compliance

Increase to 90% from 60% for laboratory results management compliance
Increase to 90% from 60% for laboratory results management compliance

Increase to 62% from 15% for medication reconciliation post discharge compliance

Feedback from general practices

"Before safety in practice there were no flashing lights to say things weren’t working – just a silent trend of harm in the background"

"It makes the doctor’s job easier. Now the doctor is better informed when they see the patient – know their meds have changed and that they’ve been in hospital"

"It was a lot of extra work but if we want to improve patient care we need to do these things"

"It was great to see what other clinics were doing and know it wasn’t just us having problems"

Lessons Learnt

  • Great potential and energy for improvement in general practice
  • Time is precious in primary care given mix of health care service and small business models
  • Practices need really clear idea of what the requirements of programme will be before committing to programme
  • Collaborative sessions highly effective way of sharing ideas
  • Data collection needs to be quick and easy
  • Understanding correlation between audits and resulting continuous improvements helps teams stay focused and engaged

Where to from here?

Year two of the project commenced in July 2015 with 32 practices from across the region. Eight practices from the Waitemata district are involved in the collaborative, with each practice working on one of the following areas:

  • Medication reconciliation
  • Laboratory results handling
  • Prescribing and monitoring of Warfarin
  • Prescribing of pain relief including codeine, tramadol etc

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