Scotland Only - Clinical Safety Issue – eGFR Results Review

This communication relates to patients at Vision GP practices across Scotland who may require review of treatment plans in place for management of chronic kidney disease. Your attention and action on this is requested in mitigation of the identified risk to patient safety.

Background

Vision has been made aware of an issue in relation to the way that eGFR result data extracted from Vision is being displayed on Scottish Care Information – Diabetes Collaboration (SCI-DC). Where a ‘greater than’ > symbol is present in a recorded eGFR result, it is not included with the eGFR numerical result extracted for SCI-DC. There is a clinical safety aspect to this because where a eGFR result is recorded as >59, it is displaying on SCI-Diabetes as 59. A eGFR value less than 60 is considered an abnormal result, with a value greater than 59 a normal result. As normal results (recorded as >59) are displaying on SCI-DC as 59, they are being included as abnormal results. As an abnormal eGFR result is an indicator of chronic kidney disease, this issue has a potential impact on the management of patients with diabetes. This group of patients is high-risk for renal impairment, and eGFR is a value that clinicians will look at during most consultations relating to diabetes care.

There is a risk that a patient may have had inappropriate treatment recommended / initiated for management of chronic kidney disease as a result of a viewer of SCI-DC incorrectly interpreting as abnormal an eGFR result of >59 when displayed as 59 on SCI-DC.

Note that this issue is only relevant to eGFR results recorded as >59 when viewed on SCI-DC. Where a eGFR result recorded as >59 is viewed within Vision, it will be correctly displayed as >59 with the ‘greater than’ > symbol included.

Since the issue was identified we have been working closely with SCI-DC and an enhancement has been made that will include the ‘greater than’ > symbol with the eGFR numerical result extracted for SCI-DC, meaning that eGFR results recorded as >59 will correctly display on SCI-Diabetes as >59, going forward.

We have established that there are a number of patients at Vision GP practices across Scotland who have had a recorded eGFR value of >59 incorrectly extracted for SCI-DC as 59. Your practice may wish to review such patients for the appropriateness of their treatment plans in mitigation of the risk identified. In order to help with this, an ad-hoc Vision search has been produced (see attached ‘SCIDC_eGFR_v8_dlm650.VisSrch’) for your practice to run to enable identification of relevant patients to check that appropriate care has indeed been delivered.

SCIDC_eGFR_v8_dlm650.VisSrch

Running the Vision search to identify patients and action required by GPs

1. Run the attached 'SCIDC_eGFR_v8_dlm650.VisSrch' ad-hoc Vision search to identify patients registered at your practice who have had a recorded eGFR value of >59 incorrectly extracted for SCI-DC as 59 and potentially may have had inappropriate treatment recommended / initiated for management of chronic kidney disease as a result of their eGFR result being incorrectly interpreted as abnormal when viewed on SCI-DC.

2. Review the appropriateness of treatment plans in place for management of chronic kidney disease for the patients identified following running of the ad-hoc Vision search.

3. Report to Vision by contacting their Head of Clinical Safety at richard.ellis-gibson@visionhealth.co.uk if any identified patient has suffered harm as a result of inappropriate treatment having been given for management of chronic kidney disease.