Download - Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience
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Danish Society for Patient Safety
Adapting Solutions for Wrong Site Surgery: The Danish Experience
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Danish Society for Patient Safety
“Something is rotten in the state of Denmark”
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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
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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
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Danish Society for Patient Safety
The organization of the Danish Reporting System
National Board of Health
Regional Patient Safety Units
Hospitals
The regional level
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Danish Society for Patient Safety
Reported adverse events
Example from Copenhagen Hospital Corporation (H:S)
Reg
ion
al le
vel
0
200
400
600
800
1000
1200
Q1-2
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2002 2003 2004 2005
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Danish Society for Patient Safety
NCPS’ 5 steps for ensuring correct surgery
JCAHO’s Universal Protocol
Known Solution
Reg
ion
al le
vel
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Danish Society for Patient Safety
Wrong site event # 1
Patient operated on the wrong side of the head
Reg
ion
al le
vel
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Danish Society for Patient Safety
Wrong site event # 2
Patient operated on the wrong finger
Reg
ion
al le
vel
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Danish Society for Patient Safety
Wrong site event # 3
Patient operated on the wrong side of the head
Reg
ion
al le
vel
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Danish Society for Patient Safety
Head Office calls for Action: Pilot test of a Danish version of NCPS’ 5 steps• Departments
without reported wrong site events
• 410 procedures• More than 90% of
the surgeons made positive comments
Participating departments
• Gynecology• Urology• Orthopedic surgery• Surgical
gastroenterology
Reg
ion
al le
vel
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Danish Society for Patient SafetyDuring this time
12 wrong site surgical events
5 was prevented before incision
7 RCA (all with incision)
1:32.500 surgical procedures
Root causes: Wrong site surgery is more likely to happen when:
Number of occurrence in the 7 RCA’s
The surgeon doesn’t participate in the preoperative identification of the patient
7
Scanty/obscure communication between OR personnel
4
Due to work pressure interruptions in the preoperative procedures
3
Significant differences between the operation schedule and the anaesthesia schedule
2
Reg
ion
al le
vel
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Danish Society for Patient Safety
• Procedure to be used by all hospitals in the Copenhagen Hospital Corporation
• News Letters• Power Point Presentations• Literature Review• FAQA• Posters
www.de5trin.dkR
eg
ion
al le
vel
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Danish Society for Patient Safety
Reg
ion
al le
vel
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Danish Society for Patient Safety
Reg
ion
al le
vel
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Danish Society for Patient Safety
Baseline – April 2005
0
5
10
15
20
25
Always/often
Now and then
Rarely/never
• 66% response rate, 40 out of 65 questionnaires fully completed (29 doctors, 11 nurses)
• Full knowledge of guideline
• Two more wrong site events identified
Questionnaire survey to 65 head of departments
Reg
ion
al le
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Danish Society for Patient Safety
The organization of the Danish Reporting System
National Board of Health
Regional Patient Safety Units
Hospitals
The national level
In 2004 additional 9 wrong site events reported to the national reporting system.
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Danish Society for Patient Safety
Epidemiology of wrong site surgery• 57 wrong site
surgical procedures reported to The Patient Insurance in 6 years
• 1:12.292 knee operations
• 1:8017 Neurosurgical procedures
27
12
98
1
0
5
10
15
20
25
30
Extremities Trunk andunpaired organs
Head and neck Paired organs Not stated
Nati
on
al le
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Danish Society for Patient Safety
Lessons learned
• Ownership to the problem requires ownership to the solution
• It makes good sense to share solutions tested and proved effect full elsewhere
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Danish Society for Patient Safety
Reporting