Tettenhall Medical Practice
Other
Action Taken
Tettenhall Medical Practice held significant event analyses and practice meetings to discuss the case and implement changes. They updated their 'Recording Allergies' policy, changed how allergies are recorded in medical records, updated the patient summary to clearly show allergies, and mandated consultations before prescribing. (AI summary)
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Dear Mrs Lees
I write on behalf of the Tettenhall Medical Practice in response to your Regulation 28 Report dated 24 September 2020.
We note the concerns you have raised and write to reassure you of the steps that the Practice have taken to implement change and review how allergies are recorded within the electronic patient records.
Practice Discussions
1) On the 6 October 2020 the practice held a significant event analysis. All partners, managers and nurses were present and the details of Mrs Brindley’s care were presented and learning outcomes discussed at length.
2) A practice meeting was then held on 7 October with all non-clinical staff present. The conclusions of the SEA were disseminated to ensure that we all learn from the sad outcome in this case and implement changes to ensure there is no risk of repetition.
3) A further practice meeting was held on 8 December 2020 to discuss the two new policies being implemented (more set out at numbered paragraphs 4 and 5 below) and an update was provided regarding developments with a response to HM Coroner and to NHSE.
Practice Changes
4) We have reviewed how allergies are recorded in the medical records. Our discussions focused on the issues generated by this case but included a broader review of coding of all allergies. Following those discussions we have updated our policy ‘Recording Allergies in Patient Records’ and this has been provided to all staff in hard copy and is accessible on a shared computer drive. The key points are:
a) There should be a consistent approach.
b) The records should clearly state within the ‘active problems’ section if the patient has any allergy so as to ensure this information is apparent and easily accessible to anyone reviewing the records, particularly any clinician who may be unfamiliar with the previous medical history.
c) The severity of any reaction must now be recorded i.e. mild, moderate or severe. We felt that this approach would help to differentiate between mild and severe allergic reactions, encouraging clinicians to appreciate the particular circumstances.
d) The code should now also include a description of the reaction such as rash, swelling or chest tightness. Again, this is to assist clinicians to appreciate the particular circumstances.
e) We identified that the date of the allergic reaction generating the alert code does not show up when renewing a previous prescription. This issue has been highlighted and EMIS has been asked to look into the possibility of introducing this function in the alert system. Enabling this facility would allow a clinician to be better informed about the date of the previous allergic reaction before issuing a prescription.
5) We have also updated our policy on remote consultations. Previously the policy indicated that if a request is made to return a patient’s telephone call then a call should be made and, if there is no response, a voicemail left but it was then up to the patient / carer to return that call. The salient change is that the clinician or
administrative staff must now call the patient back and, if there is no reply, leave a voicemail and make a second call at least half an hour apart from the first attempt.
6) The practice is carrying out an extensive audit of all allergic reactions recorded on the electronic record system. This audit is being conducted by one of the administration team with oversight from the Practice Manager. All allergies and side effects are recorded as an ‘adverse reaction’ as this is the only alert code available. However this audit is conducting a review to make sure that wherever possible additional notes are made giving a wider description including, where known, whether the reaction is allergy/side effect, new/historical, mild/severe and symptoms of the reaction such as a rash or breathing difficulties.
7) It is now mandatory to ensure a face to face or remote consultation has taken place before prescribing any medication, ideally with the patient themselves but where this is not possible then with their carer or another healthcare professional involved in their care.
8) All clinicians have been reminded to specifically check allergies documented in the clinical record summary before prescribing for any patient.
9) Clinicians have been instructed never to prescribe any medication which has an electronic alert indicating the patient has an allergy.
10) All clinicians and administrative staff have been instructed to accurately code any prescription alerts.
Wider Education
11) has completed various educational updates including a MIMS course on avoiding prescription errors, RCGP course on prescribing, MDU course on remote consultation skills, MIMS course on allergy and anaphylaxis and BMJ course on tips for coping with change during a pandemic.
12) All clinicians have refreshed their knowledge that allergies can develop at any age and patients can suffer with anaphylaxis from drugs to which they are allergic.
13) Reminder has been made to all clinicians always to make clear and detailed notes in the patient records.
14) has reviewed various medical journal articles around the subjects of penicillin allergies and anaphylaxis from penicillin.
We hope that this will reassure HM Coroner that the Tettenhall Medical Practice have very
much taken her concerns on board and have taken steps to review our processes and implement change.
I write on behalf of the Tettenhall Medical Practice in response to your Regulation 28 Report dated 24 September 2020.
We note the concerns you have raised and write to reassure you of the steps that the Practice have taken to implement change and review how allergies are recorded within the electronic patient records.
Practice Discussions
1) On the 6 October 2020 the practice held a significant event analysis. All partners, managers and nurses were present and the details of Mrs Brindley’s care were presented and learning outcomes discussed at length.
2) A practice meeting was then held on 7 October with all non-clinical staff present. The conclusions of the SEA were disseminated to ensure that we all learn from the sad outcome in this case and implement changes to ensure there is no risk of repetition.
3) A further practice meeting was held on 8 December 2020 to discuss the two new policies being implemented (more set out at numbered paragraphs 4 and 5 below) and an update was provided regarding developments with a response to HM Coroner and to NHSE.
Practice Changes
4) We have reviewed how allergies are recorded in the medical records. Our discussions focused on the issues generated by this case but included a broader review of coding of all allergies. Following those discussions we have updated our policy ‘Recording Allergies in Patient Records’ and this has been provided to all staff in hard copy and is accessible on a shared computer drive. The key points are:
a) There should be a consistent approach.
b) The records should clearly state within the ‘active problems’ section if the patient has any allergy so as to ensure this information is apparent and easily accessible to anyone reviewing the records, particularly any clinician who may be unfamiliar with the previous medical history.
c) The severity of any reaction must now be recorded i.e. mild, moderate or severe. We felt that this approach would help to differentiate between mild and severe allergic reactions, encouraging clinicians to appreciate the particular circumstances.
d) The code should now also include a description of the reaction such as rash, swelling or chest tightness. Again, this is to assist clinicians to appreciate the particular circumstances.
e) We identified that the date of the allergic reaction generating the alert code does not show up when renewing a previous prescription. This issue has been highlighted and EMIS has been asked to look into the possibility of introducing this function in the alert system. Enabling this facility would allow a clinician to be better informed about the date of the previous allergic reaction before issuing a prescription.
5) We have also updated our policy on remote consultations. Previously the policy indicated that if a request is made to return a patient’s telephone call then a call should be made and, if there is no response, a voicemail left but it was then up to the patient / carer to return that call. The salient change is that the clinician or
administrative staff must now call the patient back and, if there is no reply, leave a voicemail and make a second call at least half an hour apart from the first attempt.
6) The practice is carrying out an extensive audit of all allergic reactions recorded on the electronic record system. This audit is being conducted by one of the administration team with oversight from the Practice Manager. All allergies and side effects are recorded as an ‘adverse reaction’ as this is the only alert code available. However this audit is conducting a review to make sure that wherever possible additional notes are made giving a wider description including, where known, whether the reaction is allergy/side effect, new/historical, mild/severe and symptoms of the reaction such as a rash or breathing difficulties.
7) It is now mandatory to ensure a face to face or remote consultation has taken place before prescribing any medication, ideally with the patient themselves but where this is not possible then with their carer or another healthcare professional involved in their care.
8) All clinicians have been reminded to specifically check allergies documented in the clinical record summary before prescribing for any patient.
9) Clinicians have been instructed never to prescribe any medication which has an electronic alert indicating the patient has an allergy.
10) All clinicians and administrative staff have been instructed to accurately code any prescription alerts.
Wider Education
11) has completed various educational updates including a MIMS course on avoiding prescription errors, RCGP course on prescribing, MDU course on remote consultation skills, MIMS course on allergy and anaphylaxis and BMJ course on tips for coping with change during a pandemic.
12) All clinicians have refreshed their knowledge that allergies can develop at any age and patients can suffer with anaphylaxis from drugs to which they are allergic.
13) Reminder has been made to all clinicians always to make clear and detailed notes in the patient records.
14) has reviewed various medical journal articles around the subjects of penicillin allergies and anaphylaxis from penicillin.
We hope that this will reassure HM Coroner that the Tettenhall Medical Practice have very
much taken her concerns on board and have taken steps to review our processes and implement change.