FM & PH – Anaemia

In module Family Medicine and Public Health

Mr Gary Range, a 65 year old man, presents with musculoskeletal back pain.

Anaemia ILOs

Guidance and Resources – Anaemia

Case Introduction – Anaemia

Further Case Information – Anaemia

Background Science – Anaemia

Case Conclusion – Anaemia

Formative Assessment – Anaemia

Guidance and Resources – Anaemia

In case FM & PH – Anaemia

Learning Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

Recommended essential Reading

· see anemia case in year 4

Patient safety resources on 1MedLearn

· 6 Adverse Event Analysis _ Patient Safety_ Achieving a New Stan

· Adverse Events, Near Misses, and Errors _ AHRQ Patient Safety

· Patient Safety Errors in HC part 1

· Vincent Essentials of Patient Safety-2012

· Clinical quality 5 – Tools for safety

· Clinical quality 2 – Healthcare culture and safety

· Reason J. 1990. Human Error – in which you will find Reason’s ‘Swiss Cheese Model’ of Error

· GMC Raising and Acting on Concerns about Patient Safety

· Year 4 PCC session 14 ‘Challenging Communication with Patients’Year 4 TCD Anaemia

· National Essential Safety Requirement in KSA

· Good medical practice

· Saudi Medical Regulations in Practice

Additional Reading/Resources

Human Factors: further information from NHS England

GMC: Duty of Candour, When Things Go Wrong

Communication Systems in Health Care

NICE Guidelines for Recognition and Referral of Suspected Cancer

Human Factors video ‘Just a routine operation’ by Martin Bromiley: you may have watched this video during simulation, clinical debrief or PCC sessions in Year 3 but is still worth watching again: https://youtu.be/JzlvgtPIof4

Clinical Human Factors Group (CHFG)
This is a collaboration of healthcare professionals, managers, service users and experts in human factors, in order to bring about positive change in the NHS

Designing Out Medical Error (DOME)
The Designing Out Medical Error (DOME) project aimed to better understand and map healthcare processes on surgical wards, establishing an evidence base to design equipment and products which better supports these processes and therefore reduce instances of medical error.

The Health Foundation
This is a charity which aims to improve health and healthcare in the UK

CASE COMPONENT

Case Introduction – Anaemia

In case FM & PH – Anaemia

Mr Gary Range is now a 65 year old man (you have met him in week 1, but time has passed by more quickly for him than for you!). He has had hypertension for the past 11 years. He has some occasional musculoskeletal back pain, which has been successfully managed with paracetamol, swimming and being back aware since he was about 40. More recently knee pain has been more of a problem for him, and he has had to take the occasional codeine tablet to help with the pain. He has put his knee problems down to his work as a carpenter in the past. He attends his GP Dr Jones for a medication review at the request of the practice.

Mr Range reports that he is feeling tired and wonders if his blood pressure tablets are to blame, or if he isn’t eating enough as he has been trying to lose weight. He says he has felt this way for about the last 4 months.

Dr Jones reviews his medication list:

Repeat Medication:

· Amlodipine 10mg once daily for the past 12 years

· Paracetamol 500mg – 1-2 qds prn for the past 1 year

Acute medication:

· Codeine 30mg, qds PRN 100 tablets – issued 2 months ago

Allergies/intolerances:

· Ramipril (cough)

· Losartan (rash)

Further Case Information – Anaemia

In case FM & PH – Anaemia

Before Dr Jones approaches the medication review or asks more about the tiredness, he takes a moment to review the scanned documents on Mr Range’s medical record, whilst using an automated blood pressure machine to take Mr Range’s blood pressure. He notices a letter from the consultant at the orthopaedic clinic at St Elsewhere’s Hospital.

This was received 2 months earlier and filed away as ‘no action required’.

Letter from orthopaedic clinic to the GP surgery

ST ELSEWHERE’S GENERAL HOSPITAL
DEPARTMENT OF ORTHOPAEDIC SURGERY
HILL VALLEY
TEL: 555 123 4567CLINIC: Mr Bloggs/Gen/Ortho 20/12/16
Typed: 06/01/17Dear Dr Jones,Re: Mr Gary Range, dob 28/08/50
17 Manck Street, Manchester
Hospital number XX334 543Many thanks for referring this 65 year old gentleman, who as you say is greatly troubled by left knee pain and stiffness, which is significantly restricting his exercise, and greatly affecting his quality of life. I note from your initial referral that the physiotherapy arranged by our musculoskeletal team has not benefited Mr Range, hence the request for a surgical option to be considered. He has no history of knee trauma.I note that Mr Range takes amlodipine for his hypertension and paracetamol. He is allergic to some medicines but can’t tell me which ones.Socially Mr Range is a retired carpenter. He lives with his wife and 2 daughters, smokes about 20 cigarettes per day, and takes about 20 units of alcohol weekly. He drives. He is unable to do any sport or indeed any regular exercise because of his knee pain, despite his best efforts.On examination, Mr Range has a raised BMI of 35, is slowly and painfully mobile, with a marked limp on the left leg. All movements of his left knee are very restricted and painful, in keeping with the x-ray findings. There is no obvious ligament damage.His knee x-ray confirms well marked osteoarthritis of the knee, with marked loss of joint space. The blood results arranged by our musculoskeletal team earlier showed a normal ESR and CRP, ruling out the unlikely possibility of an inflammatory diagnosis; a FBC showed anaemia with a picture suggesting iron deficiency – many thanks for taking the necessary actions about this, I am most grateful. His blood glucose, thyroid and renal function were normal, as was his blood pressure in pre-op clinic.I discussed our possible treatment options with Mr Range and explained that major knee surgery was a big undertaking with no guarantee of success. I impressed on him the critical importance of weight reduction, explained to him the static and dynamic forces affecting the knee, when standing and moving, and explained how even modest weight reduction might well start to improve his symptoms. Mr Range would like to go away and reflect on these options, and so for the moment I have discharged him back to your care, although of course please do refer him back to us if things worsen and you wish us to consider a surgical option.

Thank you again for this referral.
Yours sincerely,

Mr Joseph Bloggs
Consultant Orthopaedic Surgeon, specialising in knee and hip surgery
St Elsewhere’s Hospital

Dr Jones is alarmed to notice that letter states the patient has iron deficiency anaemia, but unfortunately no action appears to have been taken about this.

Dr Jones discusses this letter with Mr Range, and establishes that although Mr Range has been feeling very tired, his only symptom is that of painful knees. Dr Jones asks directly about ‘red flags’. 

Dr Jones asks these questions and confirms that Mr Range has no symptoms other than occasional ‘heart burn’ for which he takes over-the-counter medications and hadn’t mentioned as put down to being normal ‘ if you love take-away foods’. He does not take ibuprofen, as he was advised years ago when he took it for his back, that it can cause stomach upset and it is not a good idea to take it long term.

Dr Jones arranges a repeat blood test to include FBC and ferritin levels, plus baseline renal, liver and thyroid function, and decides to do a 2 week referral to his local gastroenterology service to rule out blood loss from the GI tract, as per NICE guidelines.

In week 2 of the GP/PH block, you have learnt about referrals on this pathway. This is another example. Think back to Week 2 and the communication around referring a patient. Think about what important information the patient will need when being advised about such a referral, and go back to revise this if you need to.

What should the GP do about his discovery that investigation into the anaemia could have taken place 2 months ago when the letter came to the GP surgery?

It is often helpful to outline to the patient about the subsequent thorough investigation that will take place into this incident so that lessons can be learnt, to prevent a similar thing happening in future. This is called a ‘Significant Event Analysis’ and is commonly undertaken in GP practices. These analyses help to identify where things went wrong, with a no blame culture, and identify where things could be improved in future. Such systems of review might also help highlight a pattern of behaviour or pattern of systems failure, which can then be learnt from and changes made. The individuals involved would also reflect on such incidents in their portfolios for appraisal purposes. This is in-line with the GMC Guidance ‘Raising and Acting on Concerns’

All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity are being compromised. Raising and acting on concerns about patient safety (2012) sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety)

IN PRACTICE:
Could your GP show you an example of an SEA or event which has been discussed? What happened? What lessons were learnt?

Dr Jones outlines the issue in the letter and apologises, as per the GMC guidelines. He also discusses his recommendation for referral on the 2ww pathway, and the reason for this. Mr Range is a little shocked as he ‘only came for a medication review’ but appreciates Dr Jones apologising and is pleased that things are going to be investigated.

IN PRACTICE:
How does your practice sort out their ‘post’? What systems are in place to reduce the risk of errors due to written communication? What happens to letters from hospital? Are faxes dealt with differently? How are the letters reviewed? How many letters does your GP typically read per day?

CASE COMPONENT

Background Science – Anaemia

In case FM & PH – Anaemia

You might want to revise Year 4, Anaemia case

and Swiss-cheese model of error Year 4 PCC session 14 ‘Challenging Communication with Patients’

The ‘Swiss Cheese’ model proposed by James Reason demonstrates how gaps in culture, defenses, barriers, and safeguards align and permit errors to propagate unchecked, leading to harm.

Reference: Weiser, T. G. et al. (2013) Safety in the operating theatre—a transition to systems-based care Nat. Rev. Urol. doi:10.1038/nrurol.2013.13

Have a think about what factors might have contributed to the error in this case.

CASE COMPONENT

Case Conclusion – Anaemia

In case FM & PH – Anaemia

Mr Range comes back to see Dr Jones 3 weeks later. His blood tests were normal other than a slight anaemia with iron deficiency. He had already had an upper GI endoscopy and a lower GI endoscopy. He was found to have a hiatus hernia and gastritis, which was coded on Mr Range’s GP notes. He was prescribed a proton-pump inhibitor, omeprazole. A review was booked in the hospital outpatient clinic for 3 months’ time. At that point, his renal profile and FBC was re-checked, and happily all results were normal. Mr Range overhauled his diet and lifestyle to optimise his weight, and his knee pain improved significantly.

The case was discussed at an SEA meeting at the practice. This was attended by all GPs at the practice and the practice manager. The factors relating to the error, within the practice and as a whole were discussed.

The possible contributing factors (or ‘holes’ within a Swiss Cheese) which lined up to contribute to the delay in this case which were discussed at the meeting included:

1.The letter was dictated 2 weeks after the clinic

2.    The letter was received by the GP practice 3 weeks after it had been dictated (over a month since the patient attended clinic where the result was detected)

3.    The information regarding an action for the GP was not clearly highlighted in the letter

4.    The GP who reviewed the consultant’s letter was reading many letters at high speed due to workload

5.    The patient didn’t know himself about the finding of anaemia

6.    Possible delays due to Christmas working arrangements of supportive/administrative and/or clinical staff (look at the dates on the letter)

Reflection Point:

How do you think you would feel if you had been involved in an error? How do you deal with stress in your studies generally? This links back to some work in Year 1 for your portfolio, where you wrote a ‘Reflective Piece on maintaining your own health’. Look back at this piece and see if things have changed now you are in 4th year. You might want to write another reflection or speak to GPs and other healthcare professionals and staff at the practice. If you are struggling, there are many sources of help available. Speak to your Academic Advisor, a tutor or you can also get help and advice directly via your hospital or central SWAPs team.

The GPs reviewed the medical record, including when the ibuprofen had been discussed 15 years earlier. It was noted that the GP had documented a conversation with Mr Range that it was to be used for short term relief of his mechanical back pain, and the benefits and risks and to return if any side effects. It was agreed that this was an example of good practice to be continued.

IN PRACTICE:
Review how your practice generates prescriptions. What is the difference between ‘acutes’ and ‘repeats’? How are each requested? What are the review processes and safety features? Are ‘over the counter’ medications recorded?

The practice also discussed ‘Human Factors’ The principles and practices of Human Factors focus on optimising human performance through better understanding the behaviour of individuals, their interactions with each other and with their environment. By acknowledging human limitations, Human Factors offers ways to minimise and mitigate human frailties, so reducing medical error and its consequences. The system-wide adoption of these concepts offers a unique opportunity to support cultural change and empower the NHS to put patient safety and clinical excellence at its heart. Human Factors principles can be applied in the identification, assessment and management of patient safety risks, and in the analysis of incidents to identify learning and corrective actions.

Human Factors in Healthcare – A Concordat from the National Quality Board

The outcomes of the SEA included:

1.    Everyone being reminded again of the importance of carefully reading every word on every letter, and taking steps to ensure that each GP is able to work safely. This included time for breaks. A proposal was made to instigate a 20 minute “coffee break” after morning surgery.

2.    The practice would review the process of medication reviews, to include documentation of over the counter medications if used regularly. In this case, this might have revealed Mr Range’s use of over-the-counter antacid medication, which could have triggered further investigation at an earlier stage.

3.    The GPs would continue to document carefully regarding advice about risks and benefits of medications, including advice about what to do if specific side effects were encountered.

4.    The practice would inform the consultant of the error, and outline suggestions for change to help the GPs and reduce the risk of similar happening in future, including:

1.    Timely dictation and sending of letters, even during holiday periods

2.    Helpful to highlight specific actions for the GP, either at the start of the letter, in a separate paragraph or in bold

3.    Informing the patient of results either during clinic or by copying the patient into the clinic letter

CASE COMPONENT

Formative Assessment – Anaemia