11 spanish experience in clinical risk management aegris (spanish society of clinical risk...
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SPANISH EXPERIENCE IN CLINICAL RISK MANAGEMENT
SPANISH EXPERIENCE IN CLINICAL RISK MANAGEMENT
AEGRIS (Spanish Society of Clinical Risk Management)Department of General and Digestive Surgery
Clinical Risk Management UnitComplejo Hospitalario de Ciudad Real. Spain
AEGRIS (Spanish Society of Clinical Risk Management)Department of General and Digestive Surgery
Clinical Risk Management UnitComplejo Hospitalario de Ciudad Real. Spain
EUROPEAN WORKSHOP ON HEALTHCARE RISK MANAGEMENT
Roma, June 13th 2005
EUROPEAN WORKSHOP ON HEALTHCARE RISK MANAGEMENT
Roma, June 13th 2005
THE SPANISH EXPERIENCE IN RISK MANAGEMENT…..
FROM A NATIONAL AND REGIONAL POINT OF VIEW…
TO THE PRACTICAL REALITY IN A TERTIARY HOSPITAL
THE SPANISH EXPERIENCE IN RISK MANAGEMENT…..
FROM A NATIONAL AND REGIONAL POINT OF VIEW…
TO THE PRACTICAL REALITY IN A TERTIARY HOSPITAL
17 REGIONS + 2 CITIES
18 HEALTH AUTHORITIES
CiudadReal
Spanish Legal System• Criminal Court• Administrative Court. In a public Health System all
the compensation claims are against the institution, not the individual (Laws: 30/1992, 4/1999, 19/2003)
Spanish Legal System• Criminal Court• Administrative Court. In a public Health System all
the compensation claims are against the institution, not the individual (Laws: 30/1992, 4/1999, 19/2003)
Since there are 18 different Health Authorities it is nearly impossible to obtain global data on
the number and economical impact of claims. All public data available are those from the
INSALUD between 1995 and 2000
Since there are 18 different Health Authorities it is nearly impossible to obtain global data on
the number and economical impact of claims. All public data available are those from the
INSALUD between 1995 and 2000
• INSALUD: 13 million population• 1995-1998: 6,000,000 €• 1998 – 2000: 9,000,000 €• 2000 – 2002: 18,000,000 €• 2003 – 2004: 26,500,000 €• 63 million € in 2003 for all the NHS.• Number of claims from 1995 to 2000: 2.700 with an increase of 15% every year
• INSALUD: 13 million population• 1995-1998: 6,000,000 €• 1998 – 2000: 9,000,000 €• 2000 – 2002: 18,000,000 €• 2003 – 2004: 26,500,000 €• 63 million € in 2003 for all the NHS.• Number of claims from 1995 to 2000: 2.700 with an increase of 15% every year
• ACCIDENT/ 100 BEDS: 2,1
• COST/BED: 310 €
• COST/ACCIDENT: 15.000 €
• ACCIDENT/ 100 BEDS: 2,1
• COST/BED: 310 €
• COST/ACCIDENT: 15.000 €
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
1. Prioritize
2. Improve reporting systems
3. Improve professional competence
4. Improve common strategies in all the different organizations
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
1. Prioritize
2. Improve reporting systems
3. Improve professional competence
4. Improve common strategies in all the different organizations
NATIONAL INITIATIVES
• GOVERNMENT…• NHS Quality Agency. Four step policy:
1.- PRIORITIZE
Patient Safety Meeting (Feb 8th, 2005)
Experts Workshop
Technical Group involving all regions
Proposals to the National Health Authorities
• GOVERNMENT…• NHS Quality Agency. Four step policy:
1.- PRIORITIZE
Patient Safety Meeting (Feb 8th, 2005)
Experts Workshop
Technical Group involving all regions
Proposals to the National Health Authorities
NATIONAL INITIATIVES
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
2.- REPORTING SYSTEMS
Still doubts to be resolved……
• Confidentiality
• Independence from Insurance companies and Justice
• Not punitive…
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
2.- REPORTING SYSTEMS
Still doubts to be resolved……
• Confidentiality
• Independence from Insurance companies and Justice
• Not punitive…
NATIONAL INITIATIVES
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
4.- IMPROVE COMMON STRATEGIES
• With Professional associations
• With patient’s associations
• With judges
• Create a safety policy….
• GOVERNMENT…
• NHS Quality Agency. Four step policy:
4.- IMPROVE COMMON STRATEGIES
• With Professional associations
• With patient’s associations
• With judges
• Create a safety policy….
NATIONAL INITIATIVES
• GOVERNMENT…• NHS Quality Agency. Four step policy:
SAFETY POLICY
6,000,000 € BUDGET. 4 objectives
1. Study the incidence of adverse events
2. Training for medical and non medical staff
3. Identification systems for in- patients
4. Improvement of Nosocomial infection rate
• GOVERNMENT…• NHS Quality Agency. Four step policy:
SAFETY POLICY
6,000,000 € BUDGET. 4 objectives
1. Study the incidence of adverse events
2. Training for medical and non medical staff
3. Identification systems for in- patients
4. Improvement of Nosocomial infection rate
NATIONAL INITIATIVES
• GOVERNMENT…• NHS Quality Agency. Four step policy:
SAFETY POLICY
6,000,000 € BUDGET• Allocated to the Regional Health Authorities to complete
the four objectives
• GOVERNMENT…• NHS Quality Agency. Four step policy:
SAFETY POLICY
6,000,000 € BUDGET• Allocated to the Regional Health Authorities to complete
the four objectives
NATIONAL INITIATIVES
1. AEGRIS• Training in Clinical Risk Management. • Publications. • Courses. • Annual Congress dedicated to CRM
2. Patient Safety Centre (Avedis Donavedian Foundation)
1. AEGRIS• Training in Clinical Risk Management. • Publications. • Courses. • Annual Congress dedicated to CRM
2. Patient Safety Centre (Avedis Donavedian Foundation)
NON GOVERNMENTAL INITIATIVES
1. IDEA project. San Juan University. Prof Aranaz.
2. Medication errors, ISMP Spain. Universities of Salamanca, Barcelona, Madrid, Pais Vasco
3. Adverse events incidence. Cataluña hospitals. MAPFRE foundation
4. And so on…….
1. IDEA project. San Juan University. Prof Aranaz.
2. Medication errors, ISMP Spain. Universities of Salamanca, Barcelona, Madrid, Pais Vasco
3. Adverse events incidence. Cataluña hospitals. MAPFRE foundation
4. And so on…….
SCIENTIFIC RESEARCH
REGIONAL HEALTH AUTHORITY REGIONAL INITIATIVES
MURCIAMURCIA
MURCIA HEALTH AUTHORITY REGIONAL INITIATIVES
1.- Creation of a Central Patient Safety Regional Unit• Run by experienced professionals in Clinical Risk Management• All the background and information from previous claims• Support for Risk Management Programmes• Drive Adverse Events studies• Create an Incident Reporting System• Analyse Incidents reported centrally and propose corrective measures in collaboration with the Local CRM Units• Training of medical and non medical staff in CRM• Appoint Clinical Risk Managers
2.- Creation of Local Clinical Risk Management Units
In one years timeIn one years time
CASTILLA LA MANCHA HEALTH AUTHORITY (SESCAM)
LOCAL INITIATIVES
CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL. SEPTEMBER 2004
• CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL GENERAL HOSPITAL 2004
1. SUPPORT FROM THE CHIEF EXECUTIVE OF THE SESCAM
2. SUPPORT FROM THE HOSPITAL MANAGER3. SUPPORT FROM THE HEAD OF DPTS4. STAFF (MEDICAL, NURSES, AUXILIARY NURSES,
ADMINISTRATIVE, PORTERS….)WHO WANTED TO VOLUNTARILY COLLABORATE IN THE PROJECT ……remunerated with days
• CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL GENERAL HOSPITAL 2004
1. SUPPORT FROM THE CHIEF EXECUTIVE OF THE SESCAM
2. SUPPORT FROM THE HOSPITAL MANAGER3. SUPPORT FROM THE HEAD OF DPTS4. STAFF (MEDICAL, NURSES, AUXILIARY NURSES,
ADMINISTRATIVE, PORTERS….)WHO WANTED TO VOLUNTARILY COLLABORATE IN THE PROJECT ……remunerated with days
HOW TO IDENTIFY RISKS IN A PRACTICAL WAY?
HOW TO IDENTIFY RISKS IN A PRACTICAL WAY?
Mainly by clinicians3 area supervisors (surgical, medical and central
sevices) and 2 nurses from A&E3 surgeonsMedical staff, nurses, auxiliary nurses who want to
participate from:GENERAL SURGERYAÐEATRESNUCLEAR MEDICINEGYNAE AND OBSTNEPHROLOGYENT…
Mainly by clinicians3 area supervisors (surgical, medical and central
sevices) and 2 nurses from A&E3 surgeonsMedical staff, nurses, auxiliary nurses who want to
participate from:GENERAL SURGERYAÐEATRESNUCLEAR MEDICINEGYNAE AND OBSTNEPHROLOGYENT…
CLINICAL RISK MANAGEMENT UNITCLINICAL RISK MANAGEMENT UNIT
All work full time in their clinical work and help in the Unit as volunteers the time they can
Unit situated on the 7th floor, 24 m2 ….…far from the Executive Management of the Hospital
All work full time in their clinical work and help in the Unit as volunteers the time they can
Unit situated on the 7th floor, 24 m2 ….…far from the Executive Management of the Hospital
CLINICAL RISK MANAGEMENT UNITCLINICAL RISK MANAGEMENT UNIT
OBJECTIVESOBJECTIVES
Risk Assessment of the UnitsImplementing an incident reporting systemAnalysis of incidents
Identification, common proposals for changes in close collaboration with the Head of Dpt, follow up of actions taken
Cooperation in how to develope and produce reports reports after receiving a claim
Risk Assessment of the UnitsImplementing an incident reporting systemAnalysis of incidents
Identification, common proposals for changes in close collaboration with the Head of Dpt, follow up of actions taken
Cooperation in how to develope and produce reports reports after receiving a claim
OBJECTIVESOBJECTIVES
Advise in high risk situationsRM Continuous Education for staffHelp in the design of RM Programmes for the
Dpts that want to collaborateEstablish a“zero tolerance” policy related to
agression against staff
Advise in high risk situationsRM Continuous Education for staffHelp in the design of RM Programmes for the
Dpts that want to collaborateEstablish a“zero tolerance” policy related to
agression against staff
ACTIONS PERFORMEDACTIONS PERFORMED
73 actions…..Presentation of the CRM Unit at the General
Session of the HospitalPresentation of the Law 41 at the General
Session of the HospitalAll Informed Consent forms from the Dpt of
General and Digestive surgery were adapted to comply with the new Law 41
Creation of an Informed Consent process for sedation in terminal patients
73 actions…..Presentation of the CRM Unit at the General
Session of the HospitalPresentation of the Law 41 at the General
Session of the HospitalAll Informed Consent forms from the Dpt of
General and Digestive surgery were adapted to comply with the new Law 41
Creation of an Informed Consent process for sedation in terminal patients
Confidentiality in the Pathology results circuitAssessment of high risk situations when asked by
nurses or physicians involvedConfidentiality for admitted patientsNew circuit for pathology specimens obtained in
theatre
Confidentiality in the Pathology results circuitAssessment of high risk situations when asked by
nurses or physicians involvedConfidentiality for admitted patientsNew circuit for pathology specimens obtained in
theatre
ACTIONS PERFORMEDACTIONS PERFORMED
Claim reports (11 cases)Intervention in risk situations when the family or
relatives are not happy with medical care given (internal medicine, urology, A&E)
Reports about capability of medical and non medical staff….that can affect patient safety….can this resident, doctor, nurse take care of the patient??
First step after physical and non physical violence against staff
Claim reports (11 cases)Intervention in risk situations when the family or
relatives are not happy with medical care given (internal medicine, urology, A&E)
Reports about capability of medical and non medical staff….that can affect patient safety….can this resident, doctor, nurse take care of the patient??
First step after physical and non physical violence against staff
ACTIONS PERFORMEDACTIONS PERFORMED
Modification of the diagnostic imaging contrast medium injection protocol at the Nuclear Medicine Department (double cheking)
Assessment of Medication errors on the wardsCreation of a “Patient Safety Comission” with
the participation of all the directors of the hospital and Health and Safety
Clinical Risk Management 50 hours course ready to start
Modification of the diagnostic imaging contrast medium injection protocol at the Nuclear Medicine Department (double cheking)
Assessment of Medication errors on the wardsCreation of a “Patient Safety Comission” with
the participation of all the directors of the hospital and Health and Safety
Clinical Risk Management 50 hours course ready to start
ACTIONS PERFORMEDACTIONS PERFORMED
Adverse Incident Review of Medical records. Clinical application of the research project. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent
Effect of Distractions in theatre related to Patient Safety. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent
Adverse Incident Review of Medical records. Clinical application of the research project. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent
Effect of Distractions in theatre related to Patient Safety. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent
NEW RESEARCH PROJECTSNEW RESEARCH PROJECTS
NURSES ACTIONS PERFORMEDNURSES ACTIONS PERFORMED
Creation of an information leaflet for auxiliary nurses who are new starters to theatre explaining Pathology specimen circuit…and what to do with them
Design of Induction Programmes for nurses working in A&E, Surgical Area and ICU
Identification band for patients admitted to A&ENew counting system for swabs in theatrePilot project for a new medication system (Surgical
Department)Collaboration with Haematology in the design of the
transfusion process/policy circuitOrganizational changes in A&E aiming to improve
Patient Safety
Creation of an information leaflet for auxiliary nurses who are new starters to theatre explaining Pathology specimen circuit…and what to do with them
Design of Induction Programmes for nurses working in A&E, Surgical Area and ICU
Identification band for patients admitted to A&ENew counting system for swabs in theatrePilot project for a new medication system (Surgical
Department)Collaboration with Haematology in the design of the
transfusion process/policy circuitOrganizational changes in A&E aiming to improve
Patient Safety
MAJOR PROBLEMS FOR THE UNITMAJOR PROBLEMS FOR THE UNIT
LACK OF TIME..........LACK OF TIME..........
SCEPTISCISM.........SCEPTISCISM.........
IT IS NOT A PRIORITY NOW…..IT IS NOT A PRIORITY NOW…..
I DO NOT COLLABORATE WITH THE MEDICAL DIRECTORS……
I DO NOT COLLABORATE WITH THE MEDICAL DIRECTORS……
IF IT IS RUN BY SURGEONS I DON’T WANT TO KNOW ANYTHING ABOUT IT........
IF IT IS RUN BY SURGEONS I DON’T WANT TO KNOW ANYTHING ABOUT IT........
THE FUTURE IS NOT EASY, BUT NOBODY SAID IT WAS GOING TO BE
AND A FINAL CONCLUSION…
THE FUTURE IS NOT EASY, BUT NOBODY SAID IT WAS GOING TO BE
AND A FINAL CONCLUSION…
THE SUCCESS OF CLINICAL RISK MANAGEMENT DEPENDS
DIRECTLY ON THE INVOLVEMENT OF ALL MEDICAL AND NON MEDICAL STAFF WORKING IN A HOSPITAL….
THE SUCCESS OF CLINICAL RISK MANAGEMENT DEPENDS
DIRECTLY ON THE INVOLVEMENT OF ALL MEDICAL AND NON MEDICAL STAFF WORKING IN A HOSPITAL….
….IT DOES NOT DEPEND ONLY UPON THE POLITICAL DESIRE…..
“DO IT…….IT WILL WORK”
….IT DOES NOT DEPEND ONLY UPON THE POLITICAL DESIRE…..
“DO IT…….IT WILL WORK”
PATIENT SAFETY POLICIES WE ALL DREAM OF.........
PATIENT SAFETY POLICIES WE ALL DREAM OF.........
DON QUIJOTE RULES….
DON QUIJOTE RULES….
If you follow these rules , Sancho, . Your days will be long,. Your fame eternal,. You will receive many gifts,. Your happiness will be impossible to
describe,. Your children will marry as you desire. You will live in peace with your people. And you will improve patient safety….
If you follow these rules , Sancho, . Your days will be long,. Your fame eternal,. You will receive many gifts,. Your happiness will be impossible to
describe,. Your children will marry as you desire. You will live in peace with your people. And you will improve patient safety….
“2005. IV CENTENARY”
EL INGENIOSO HIDALGO DON QUIJOTE DE LA
MANCHAPART II
CHAPTER XLI
“2005. IV CENTENARY”
EL INGENIOSO HIDALGO DON QUIJOTE DE LA
MANCHAPART II
CHAPTER XLI