Upload File

danish society for patient safety patient safety the danish experience

  • Home
  • Documents
  • Danish Society for Patient Safety Patient Safety The Danish Experience
29
Danish Society for Patient Safety Patient Safety The Danish Experience

Upload: donna-jade-williams

Post on 11-Jan-2016

223 views

Category:

Documents


4 download

Report

TRANSCRIPT

Page 1: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Patient Safety

The Danish Experience

Page 2: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Exampel

Page 3: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient SafetyPatient Safety on the Danish

Healthcare Agenda

• New York (1991) 3.7%• CO/UT (1999) 3.3%• Australia (1994) 13%• UK (2000) 11%• New Zealand(2001) 13%• Denmark (2001) 9%• France (2004) 8,9% • Canada (2004) 7.5%

AE Studies

991

60

40

7 extra bed days per AE

Ref.: Schiøler T et al, UfL 2001

Page 4: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

18%

82%

Yes, I have experienced errors

No, I have not experiencederrors

22%

27%

51%

Medication

Surgery

Other errors

• 26.300 questionnaires

• Response rate 49%

Ref.: National survey on patients’ experiences, Denmark 2005

Patients’ experiences with medical errors – national survey

Page 5: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Patients’ experiences with medical errors – Copenhagen Hospital Corporation survey

9%

8%

83%

Yes, one or more minor errors

Yes, one or more serious errors

No

Have you experienced and/or been informed about errors made in connection with your hospital stay?

Ref.: Patients’ evaluations of hospital wards in the Copenhagen Hospital Corporation, 2004

Page 6: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Patients’ experiences with medical errors – Copenhagen Hospital Corporation survey

61%

32%

7%

I discovered the error myself

The doctor/the staf fdiscovered the error

Others discovered the error

How were you informed about the error?

Ref.: Patients’ evaluations of hospital wards in the Copenhagen Hospital Corporation, 2004

Page 7: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient SafetyRecommendations:

Results from the Questionnaire

• One third of professionals consider to change profession because of fear of being involved in adverse events

0

10

20

30

40

50

60

70

80

90 Never

Now and then

Often/ veryoften

Senio

r re

sident

Consu

ltant

Resi

dent

Ref.: Andersen HB 2003, Hermann N et al. 2002

Page 8: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Act on Patient Safety

• Frontline Personnel obligated to report

• Hospital Owners are obligated to act

• Board of Health is obligated to communicate

Page 9: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

§6 in Act on Patient Safety

• A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice

Page 10: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient SafetyHandling of Adverse Events

Patie

nt

Insu

ranc

eCom

plai

nt

Syst

em

Supe

rvisi

o

nAc

t on

Patie

nt S

afet

y

Page 11: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Reporting Systems

• The reports are just a sample• No true denominator

• So what can we use it for?

Page 12: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Nothing - unless

• We analyze the events • We act on the analyzes• We monitor the changes• We study the literature

Page 13: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Hospital Level

                                     

Page 14: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Event – Infusion Pump

A patient with a heart disease receives an overdose of a potent drug due to free flow failure of an infusion pump

Page 15: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Frontline Staff Hospital Regional Unit Board of Health

Data anonymized

P.S.O.

Head of dep.

PSM/CEO

Reporting

Page 16: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Score-MatrixSeverity and Probability

Catastrophic Major Moderate Minor

Frequent 3 3 2 1Occasional 3 2 1 1

Uncommon 3 2 1 1Remote 3 2 1 1

Potential and Actual Injury

Reference NCPS, VA gov

SAC 3 RCA

SAC 2 Aggregated RCA

SAC 1 Local action

Page 17: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

RCA: Free Flow and Infusion PumpProblemSeveral infusion sets present - and the pump did not alarm when a wrong set was usedNo systematic introduction to staff on how to use the different pumps that were present in the department

SolutionOnly one type of pump present in each departmentPhysical separation of different infusion setPlan for yearly introduction and checklist to ensure staff are appropriately introduced to medical equipment

Page 18: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

A Problem in all Hospitals?

AE with infusion pumps Programming and handling

22

Distant problem

15

Medication mix up

13

Free flow 4

Other 2

Total 560

50

100

150

200

250

300

350

400

450

500

Page 19: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient SafetyActions taken at Head

OfficeCentralized purchasing strategyOut phasing of all pumps that do not have set based free flow protection:• Centralization of pumps• EU-tender for new infusion sets

Page 20: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

National Level

Page 21: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Patient Safety Training

Master Class in Patient Safety

Seminars etc.

Toolkits for H:F, RCAs, HFMEA, Legal issues

Yearly conference

Page 22: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

”Safe Patient” project

• General information

• Cases• Tools• Patient

Involvement

Page 23: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

• Look a like

Case Analysis: Medication Mix Up

Page 24: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Action Plan

Page 25: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Focus 2005:

Patient Empowerment

Page 26: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

National Campaign on all Hospitals in 2005

Page 27: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

Patient Safety manpowerDanish Society for Patient Safety

National Board of Health

Regional Patient Safety Units

Hospitals

Primary Care Sector

Industry

Professions

Research

Page 28: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety

www.patientsikkerhed.dk

[email protected]

Page 29: Danish Society for Patient Safety Patient Safety The Danish Experience

Danish Society for Patient Safety


Mortality review Brian Bjørn, M.D. International Forum on Quality Improvement in Health Care Paris – April 9, 2014 Danish Society for Patient Safety

Patients for Patient Safety M argaret Murphy, Patient Advocate External Lead Advisor Patients for Patient Safety WHO Patient Safety Beaumont Hospital Transplant

PATIENT SAFETY CULTURE AND PATIENT SAFETY … · 2 Patient Safety Culture and Patient Safety Implementation in Stella Maris Hospital during National Health Insurance Era Fridawaty

DoD Patient Safety Program Patient Safety Improvement Guide

Risk Analysis of Navigational Safety in Danish Waters Maritime Authority and Royal Danish Administration of Navigation and Hydrography Risk Analysis of Navigational Safety in Danish

Patient Safety

Enhancing Patient Safety through Effective Communication Patient Safety... · Enhancing Patient Safety through Effective Communication Joint Commission Communication Standards •

PART 3—PATIENT SAFETY ORGANI- ZATIONS AND PATIENT SAFETY WORK

Act on Patient Safety in the Danish Health Care System A National … · Beth Lilja Pedersen Director of the Danish Society for Patient Safety. Something is rotten in the state of

Maryland Hospital Patient Safety Program Annual Report ... Patient... · Maryland Hospital Patient Safety Program FY13 Annual ... Maryland Hospital Patient Safety Program Annual Report

Recent Developments in Patient Safety and Scope of Patient Safety Special Interest Group Recent Developments in Patient Safety and Scope of Patient Safety

Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience

Patient safety

Enhancing Patient Safety and Outcomes: The Safe Patient Handling … Patient Safety... · Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection Presented by

PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/200812_home.pdf · Pennsylvania Patient Safety Advisory About the Pennsylvania Patient Safety Advisory

Nursing Students’ Perceptions of Patient Safety - QSEN · Nursing Students’ Perceptions of Patient Safety ... Patient Safety Culture Quality and Safety Education for Nurses

The Danish Health and Medicines Agency - also a supervisory organisation Anne Mette Dons, MD Head of Department Supervision and Patient Safety

Patient Safety - Cape Fear ValleyImprovement/Patient Safety Plan. – The 2013 National Patient Safety Goals. – What CFV is doing to address the National Patient Safety Goals and

Airway Safety Webinar PresentationL - Patient Safety Movement · • 10 Minutes: Introduction to Patient Safety Movement Foundation and Actionable Patient Safety Solutions (APSS)

Copyright 2007 Partners Radiology Patient Safety Training “Patient Safety in Radiology” Partners Radiology Patient Safety Team

PATIENT SAFETY Protecting Patient’s Right Protecting Patient’s Right General Patient Safety Measures General Patient Safety Measures Admission of the Patient

ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR … · ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR ... ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR . 2 PATIENT ... status

National Danish Survey of Patient Experiences - KOPA · National Danish Survey of Patient Experiences UNIT OF PATIENT EVALUATION, Copenhagen County ... Comparative study of in-patient

CAROLINAS REHABILITATION PATIENT SAFETY … REHABILITATION PATIENT SAFETY ORGANIZATION PARTICIPATING FACILITY AGREEMENT This Agreement is between Carolinas Rehabilitation Patient Safety

Patient aspects: A review of 58 Danish HTA reports

Patient Safety The Danish Experience

FA The future of patient data - Danish V1

THE ECONOMICS OF PATIENT SAFETY - … · • Etchells et al (2012), The Economics of Patient Safety in Acute Care. The Canadian Patient Safety Institute. The Canadian Patient Safety

Patient Safety Movement Foundation Presents · APSS #17 –Patient Safety Curriculum Patient Safety Curriculum for All Health Professionals May 8, 2019 Patient Safety Movement Foundation

Patient Safety:

PATIENT SAFETY Justin MFIZI Patient Safety officer KFH

Patient Safety Evaluation System and Patient Safety Organization Fundamentals