patient safety and clinical risk management in our .... sinasp_creal_spain_2014.pdf · patient...
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PATIENT SAFETY AND CLINICAL RISK
MANAGEMENT IN OUR HEALTHCARE AREA
César Llorente Parrado
Quality Department. GAI. Ciudad Real (Castile - Spain).
February 21st.
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1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
2. Our Patient Safety Reporting System: SiNASP
CONTENTS
4. SiNASP management: regional/ national level
3. SiNASP management: hospital level
5. SiNASP: strengths and barriers
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1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
2. Our Patient Safety Reporting System: SiNASP
CONTENTS
3. SiNASP management: hospital level
4. SiNASP management: regional/ national level
5. SiNASP: strengths and barriers
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PATIENT SAFETY MULTIDISCIPLINARY TEAM
1. Promote a Patient Safety CULTURE in professionals
2. Use Patient Safety Reporting Systems to LEARN
from errors
3. ANALYZE our care processes, identifying critical
control points
4. Implement evidence based PATIENT SAFETY
PRACTICES.
Objectives
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PATIENT SAFETY MULTIDISCIPLINARY TEAM
Groups
CLINICAL RISKS
IDENTIFICATION
SAFE MEDICATION
PRACTICES
INFECTION
CONTROL
EVIDENCE BASED PS
PRACTICES
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PATIENT SAFETY MULTIDISCIPLINARY TEAM
PATIENT SAFETY COMMITTEE
Technical support body to implement improvement actions
and assess Chief Executive Office in Patient Safety Politics in
Healthcare Area.
-Medical Director (President).
-Nursing Director.
-Quality Departement (Secretary).
-PSMT Groups representatives.
Monthly schedule
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1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
2. Our Patient Safety Reporting System: SiNASP
CONTENTS
3. SiNASP management: hospital level
4. SiNASP management: regional/ national level
5. SiNASP: strengths and barriers
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Our Patient Safety Reporting System: SiNASP
- Web-based patient safety reporting system TO identify adverse
events (harm), incidents (errors with no harm) or "near misses".
- Many times causes and contributing factors of risk situations tend
to recur.
- SiNASP let us to identify safety hazards, prioritize where to focus
our efforts, develop interventions to prevent or mitigate these
hazards, and evaluate whether the interventions reduced harm.
Goals
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- VOLUNTARY.
- NON-PUNITIVE.
- CONFIDENTIAL: at 15 days is automatically deleted the following
information:
Exact time and date the incident occurred.
Email address and notifier name.
Professional categories of people involved.
Our Patient Safety Reporting System: SiNASP
Main characteristics
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- WHO ARE THE REPORTERS? Any
professional (healthcare or
not) who identifies an incident involving
patient safety
occurred in their workplace.
- WHAT IS REPORTED?
Near missed: potential incidents (proactive
attitude).
No harm incidents.
Adverse events (harmful events).
Our Patient Safety Reporting System: SiNASP
1. Identification
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Our Patient Safety Reporting System: SiNASP
1. Identification
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Our Patient Safety Reporting System: SiNASP
1. Identification
SECTIONS
- Incident description and classification (NOT include
data identifying patients or professionals (name, nº
hist, ID...).
- Patient: age, gender, harm (yes/no)
- Causes/ contribuiting factors .
- Suggestions for improvement in opinion of the
notifier.
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Our Patient Safety Reporting System: SiNASP
2. Management.
PRIORITIZATION:
1-2%
5-10%
15-20%
25-30%
50% no SAC (near missed)
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Our Patient Safety Reporting System: SiNASP
3. Dissemination.
- Feedback e-mail to notifiers confirming
reception (in case of identification).
- Information to notifiers about incident
management process (in case of
identification).
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Our Patient Safety Reporting System: SiNASP
3. Dissemination.
RESULT DISSEMINATION STRATEGIES:
Periodic reports of aggregate data with implemented/planned
risk reduction strategies.
Patient Safety Alerts, focused on specific aspects.
Case studies ("story of a patient").
Meetings or seminars on specific hospital departaments or
Primary care facilities.
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Our Patient Safety Reporting System: SiNASP
3. Dissemination.
System
coverage Dissemination
seminars
+Dissemination
seminars
Dissemination
seminars
> Reporting departments:
Emergency, Critical Care Unit,
Hospital Farmacy, Anestesiology.
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GAI CIUDAD REAL (HOSPITAL AND PRIMARY CARE
FACILITIES). SiNASP GROUP PSMT
Responsible for managing detected notifications and
implementing action plans
Our Patient Safety Reporting System: SiNASP
Management Levels
SPANISH MINISTRY OF HEALTH & CASTILIAN
DEPARTMENT OF HEALTH
Responsible for periodic analysis of aggregate data to
identify trends and risks in order to develop general
recommendations and patient safety alerts.
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CONTENTS
1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
3. SiNASP management: hospital level
2. Our Patient Safety Reporting System: SiNASP
4. SiNASP management: regional/ national level
5. SiNASP: strengths and barriers
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SiNASP Management: hospital level
https://www.sinasp.es/
MAIN PAGE NOTIFICATION
QUESTIONNAIR
E
INFORMATION HELP
TRAINING
COURSE
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SiNASP Management: hospital level
Reporters/users
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SiNASP Management: hospital level
Access to questionnaire
Hospital
Code Recover a previously saved
notification
Start a new
notification
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Where it happened
When it happened
People related to the incident
Information about the reporter
Professional name and e-mail: not
mandatory fields INC
IDE
NT
(I)
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Description: free text
INC
IDE
NT
(II
)
NOT INCLUDE DATA
IDENTIFIYING PROFESSIONALS
OR PATIENTS (names, medical
record ID…).
Categories related to
the incident
Ex: medication, falls,
surgical procedures,
laboratory, infection control,
patient id
Incident estimated frequency: (5 categories
from less to more frequency estimated by reporter).
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Incident Risk Level PA
TIE
NT
Patient characteristics: age
and gender
Type of incident: -Near missed.
-Incident with no harm
-Adverse event (+ type and severity of damage)
The system calculates the risk level (SAC) automatically according to the data we have
introduced in terms of severity and frequency
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CA
US
ES
Contribuiting factors: free text
1. Professional factors Training / knowledge / competence of professionals
Behavior / conduct for professionals
Communication Problems
Stressors / emotional / fatigue
2. Patient factors Limitations for communication with the patient (foreign, cognitive impairment,…
Condition / severity of the patient / complex clinical problems
3. Working environment / facilities / equipment
4. Organizational factors Standards / procedures / protocols work (lack or inadequacy)
Organizational culture
Issues in teamwork
Insufficient human resources / workload
5. External factors
Categories and subcategories
contributing factors related to
the incident
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RIS
K R
ED
UC
TIO
N
ME
AS
UR
ES
Measures for improvement: free text
Stop and Save the notice to finish later
Complete notification
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SiNASP Management: hospital level
Managers
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SiNASP Management: hospital level
https://www.sinasp.es/gestor
REPORTS NOTIFICATIONS INDICATORS HOSPITAL
SINASP
MANAGEMENT
PLANS FOR
IMPROVEMENT
FILTERS: SEARCH ENGINE
SUMMARY LIST
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MA
NA
GE
ME
NT
Introduction: Notification status: open/ close (in process??)
Manager name
Incident definition: It is the information appearing in manager
summary of incidents page
Possibility of incident prevention in the future: evidence of incident preventability.
From less to more preventability degree (6 categories).
Manager recommendations: FREE TEXT.
Actions: Report the event to administration
Research by Root Cause Analysis (RCA)
Research by simplified version of RCA
Monitoring aggregate data
Mechanisms to reduce risk
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MA
NA
GE
ME
NT
FILTERS: SEARCH
ENGINE
SUMMARY LIST
ADD NEW
PLAN
PLANS FOR
IMPROVEMENT
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MA
NA
GE
ME
NT
SUMMARY LIST
PLANS FOR
IMPROVEMENT
ADDING A NEW PLAN
ACTION PLAN
IDENTIFICATION
GOALS
PLAN DESCRIPTION
ACTIONS TO BE TAKEN
INDICATORS
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REPORTS
FILTERS:
SEARCH ENGINE
BASIC
REPORT
COMPARATIVE
ANALYSIS
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FREE TEXT. Sections: Context
Contribuiting factors
Relevant examples
Suggestions for improvement View report (PDF)
Save report Recover report
REPORTS
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MONTHS TOTAL
INDICATORS
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NOTIFICATIONS VOLUME
Number of notifications received
Ratio notifications * 100 / hospital beds
NOTIFICATION ISSUES
% high risk incidents SAC 1 and 2 / total
% reporters identified
NOTIFICATIONS MANAGEMENT
Average time allocation –manager appointment- (days)
Notification mean time management. (days)
% of unmanaged notifications> 1 month
% notifications closed with actions
NOTIFICATIONS ANALYSIS
% notifications SAC 1 and SAC 2 with RCA –Root Cause Analysis- indication
% notifications RCA with RCA indication
% RCA finished / total number of notifications
Number of SiNASP local group meetings for analysis
FEEDBACK
% of sent feedback e-mails/ total of identified reporters
Number of saved reports in the system
Number of disseminated reports to professionals
Number of “case presentation” sessions
INDICATORS
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HOSPITAL ID
SiNASP
MANAGERS
TRAINING COURSE STUDENTS
RESPONSE
CENTER SiNASP
MANAGEMENT
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1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
2. Our Patient Safety Reporting System: SiNASP
CONTENTS
3. SiNASP management: hospital level
4. SiNASP management: regional/ national level
5. SiNASP: strengths and barriers
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SiNASP Management: central level
SPANISH MINISTRY OF HEALTH &
CASTILIAN DEPARTMENT OF HEALTH
Responsible for periodic analysis of aggregate data to
identify trends and risks in order to develop general
recommendations and patient safety alerts.
HOSPITALS
Responsible for managing detected notifications and
implementing action plans
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– Support centers in the use and management of SiNASP.
– Periodic reports on coverage of SiNASP.
– Analysis of aggregate data (Regional level).
– Define regional/ national policies for patient safety considering the information in the system.
SiNASP Management: central level
Reports have same structure and contents as
local level reports…
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Information NOT available to regional/national level:
From reporter: Hospital identification
Date and time the incident occurred
Reporter data identification
Patient Age
From local managers: Notification management status
Local manager identification
Local manager recommendations
Local manager comments
SiNASP Management: central level
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1. Integrated Healthcare Model: Patient Safety
Multidisciplinary Team
2. Our Patient Safety Reporting System: SiNASP
CONTENTS
3. SiNASP management: hospital level
4. SiNASP management: regional/ national level
5. SiNASP: strengths and barriers
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• Institutional leadership support in promoting a culture of patient safety and providing resources.
• Feedback to professionals on incident trends and solutions.
• Common, agreed terminology and standards (who should report and what gets reported).
• Secure and web-based system that simplifies reporting by non-expert professionals. Accessible from any institutional or personal computer.
• Confidential management at regional/ national level: the identities of the patient, reporter, and institution are never revealed.
• Independent. Reporting system independent of any authority with the power to punish the reporter.
SiNASP: strengths and barriers
Strengths
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SiNASP: strengths and barriers
• Lack of legal privilege for reporters and managers (system confidentiality has no legal support).
• Lack of patient safety culture: lack of awareness of the need to reduce medical errors and improve patient safety.
• Still fear of reprisal. Fear of retaliation against themselves or punishment of others as a result of reporting.
• Sense of futility: in some cases lack of feedback from local managers to front-line professionals/ lack of visible changes in response to reports.
• Time conflict between clinical workload and work involved in event reporting.
• Event reports would be view as indicators of incompetence.
SiNASP: strengths and barriers
Weaknesses
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SiNASP: strengths and barriers
Weaknesses: legal issues
Spain has no specific legislation protecting
reporters and system managers.
Most healthcare incidents and adverse events have no legal
implications because its causes can not be identified intentionality
or negligence. So the existence of a legislation to protect
professionals and managers in these cases, which are the
majority, can be very convenient for the consolidation of systems.
Denmark and US have specific regulations which aims to facilitate
and promote the implementation of reporting systems and
analysis of adverse events with strong protection of confidentiality
for patients, professionals and reporting institutions.
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SiNASP: strengths and barriers
Weaknesses: legal issues
Litigation and claims
Negligence
Adverse events
Prevantable No Prevantable
Incidents
Near missed
Healtchcare risk
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If you want to build a ship, don't drum up people to
collect wood and don't assign them tasks and work, but
rather teach them to long for the endless immensity of
the sea.
Weaknesses: Safety Culture
Antoine de Saint-Exupéry
SiNASP: strengths and barriers
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PATIENT SAFETY AND CLINICAL RISK
MANAGEMENT IN OUR HEALTHCARE AREA
César Llorente Parrado
Quality Department. GAI. Ciudad Real.
February 21st.