paul bartels & jan mainz patient safety - dk 2004 helsinki enqual workshop 2 april 2nd 2004

Patient Safety - DK 2004

HelsinkiENQual Workshop 2

April 2nd 2004

Patient Safety – DK 2004

1934 Law of Doctors practice of medicine

(Revised 2000)

1987 Law of Patient Complaints Council

(Revised 2003)

Patient Safety – DK 2004

Definitions of :- 3 degrees of culpability- Surveillance, judgement and punitive

measures

Against doctors and nurses involved in adverse events

with patient injury or complaints

Patient Safety – DK 2004

Protection of society !

Elimination of bad apples !

Power to the National Health Board !

Judgments of health-professionals by a council of peers, lay people chaired by a judge !

Patient Safety – DK 2004

1997 Law of patient insurance (rev. 2003)

No-fault compensation after iatrogenic injury:

- due to medical practice below standard

- due to unusually severe complications

- due to technology malfunction

- If injury could have been avoided by using an alternative method

Patient Safety – DK 2004

2000 – after the IOM-report :´’5-10 % of all US patients are injured by adverse events’

We don’t have these problems in Denmark ? – or do we?

National Pilot Study of Adverse Events

Patient Safety – DK 2004

Retrospective – based on evaluation of 1100 medical

records.

4 counties : Metropolitan/ rural, University/district/local

hospitals

Results:

114 records with adverse events and injury

40 % preventable

7 deaths

Conlusion : We have a problem

Patient Safety – DK 2004

2001-2003:Local initiatives:Copenhagen Hospital Corporation unit of patient safety:Translates JCHAO and VHA methods to DK

New Tools

Local county strategies and experiments:Patient perspectives, Audit, Human factors

Preparation of political decisions

Patient Safety – DK 2004

2001 Danish Society for Patient Safety

(Patient Safety Foundation):

Hospital owners, Danish Medical Ass., Ass of Nurses, Drug- and Medical Device Industry associations, Apothecaries association

Patient Safety – DK 2004

DSPS cont.

Scientific meetings

Development of educational material

Courses in patient safety

Newsletter and homepage (Warning and advice)

Establishing of local and internatational

networks

Patient Safety – DK 2004

2002-2003 National Survey:

Attitudes of Healthcare-professionals to reporting,

analysis and learning from adverse events.

Confidential – not anonymous

Fear of Health Authorities, management,professional

peers:

Patient Safety also requires change of culture

Patient Safety – DK 2004

2003 Act of Patient Safety:WE MARGRETHE THE SECOND by the grace of God Queen of

Denmark, hereby make known

The objective of the Act is to improve patient safety within the Danish health care system. The Act shall apply to the reporting of advers events occuring with the treatment of patients…. (www.patientsikkerhed.dk)

Patient Safety – DK 2004

Obligations according to the Act:

- All healthcare workers: Report A.E.- Hospital owners: Systems for receiving

analyzing and learning from A.E. reports

- National Health Board: Web-based Confidential IT-system. National Database of A.E. + analyses.

Patient Safety – DK 2004

Act (cnt.)

Authorities:

Informations from the reporting system are absolutely confidential and cannot be used as evidence in court, evidence for action from health authorities against professionals or diciplinary actions from the hospital owner.

Patient Safety – DK 2004

Act. (Cnt)

Only in-hospital events (primary care in 2006)

Medication events

Events related to invasive procedures

Serious events

Patient Safety – DK 2004

Implementation of a safety organisation

Clinical level :

Medical risk coordinator in every department:

Senior doctor/nurse

Risk managers (Healthcare profs) at every

hospital and/or county.

Patient Safety – DK 2004

Medical risk coordinator :Knowledge – motivation of peers – assesment of A. E.

Risk Manager:Analysis (Root Cause, Audit, Data from other sources)Administrations of the reporting system

Patient Safety – DK 2004

Management:

Departmental : Main responsibility for conducting analysis and drawing conclusions (change of practice)

Finding ressources – TIME !

Establish non-blame culture

Patient Safety – DK 2004

Management – Hospital /County

Ensure the presence of proper methods,

dedicated staff and relevant training.

Nonblaming Culture

(It can be learned – even by medical directors

and senior surgeons)

Patient Safety – DK 2004

Training:

Heads of departments (all) 1. day

(Overview – the law – the patient perspective – human ressource management of staff involved in A.E.)

Patient Safety – DK 2004

Medical risk coordinator Training:

Two days:

As head of departments plus training in

assesment and root-cause analysis

Human factor analysis

Patient Safety – DK 2004

Risk Manager Training:14 days National level:

In- depth training in assesment and root-cause analysis Supervision of actual case-work

Human factor analysis

prospective risk-assesment in planning of clinical pathways

Patient Safety – DK 2004

Act – implementation: status after 3 monthsÅrhus County /DK

- 75 / 500 reports- 140/ ? Clinicians trained- 4/ 43 Risk managers in training- Official (politically approved) policy

promoting no-blame culture- Publications and policies spread all over the

county

Patient Safety – DK 2004

Future Needs

Sound evidence based surveillance tools – real indicators.

DO PATIENTS GET VALUE FOR THE MONEY AND EFFORTS SPENT HERE ?