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
Danish Society for Patient Safety
“Something is rotten in the state of Denmark”
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
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
Danish Society for Patient Safety
The organization of the Danish Reporting System
National Board of Health
Regional Patient Safety Units
Hospitals
The regional level
Danish Society for Patient Safety
Reported adverse events
Example from Copenhagen Hospital Corporation (H:S)
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200
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Q1-2
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2002 2003 2004 2005
Danish Society for Patient Safety
NCPS’ 5 steps for ensuring correct surgery
JCAHO’s Universal Protocol
Known Solution
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Danish Society for Patient Safety
Wrong site event # 1
Patient operated on the wrong side of the head
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Danish Society for Patient Safety
Wrong site event # 2
Patient operated on the wrong finger
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Danish Society for Patient Safety
Wrong site event # 3
Patient operated on the wrong side of the head
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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
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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
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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
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Danish Society for Patient Safety
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Danish Society for Patient Safety
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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
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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.
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
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25
30
Extremities Trunk andunpaired organs
Head and neck Paired organs Not stated
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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
Danish Society for Patient Safety
Reporting
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