How to Change Adverse How to Change Adverse Event Reporting into Risk Event Reporting into Risk

Management PractiseManagement PractiseRitva Inkinen, project manager, patient safetyRitva Inkinen, project manager, patient safety

ritva.inkinen@pshp.fiTanja Lönnberg, spesializedTanja Lönnberg, spesialized

nurse in nephrologynurse in nephrologytanja.lonnberg@pshp.fi

1st Nordic Patient Safety Conference1st Nordic Patient Safety ConferenceStockholm, May 20th- May 21st 2010Stockholm, May 20th- May 21st 2010

Finnish Patient Safety Strategy Finnish Patient Safety Strategy 2009- 2013 2009- 2013

Mission: We are promoting patient Mission: We are promoting patient safety togethersafety together

Vision: Patient safety will be embedded Vision: Patient safety will be embedded in the structures and methods of in the structures and methods of operation:operation:

care and treatment is effective and safecare and treatment is effective and safe Perspectives: culture, management, Perspectives: culture, management,

legislation and responsibilitylegislation and responsibility Objectives: learning, management, Objectives: learning, management,

patient involving, reportingpatient involving, reporting

Patient Safety Development in Patient Safety Development in Tampere University HospitalTampere University Hospital

Strategy for the executive program years Strategy for the executive program years 2008-2012 is to increase patient safety 2008-2012 is to increase patient safety through development projectsthrough development projects

Focus of projects is based on:Focus of projects is based on:

- the strategy- the strategy

- use of data from adverse event - use of data from adverse event reportingreporting

- self evaluation (EFQM)- self evaluation (EFQM)

- changes in structures and practise- changes in structures and practise

Planning and Creating the New Planning and Creating the New Nephrology Expertise Center in TAUHNephrology Expertise Center in TAUH

Foundation for safety culture:Foundation for safety culture:

- patient safety- patient safety

- safe working conditions- safe working conditions

- employee welfare- employee welfare

- risk management- risk management

Regional hospitalsHealth centersHome hospitals

Home nursingCare institutions

home/emergency

General practitioner

Refer-ral

inpatient careDischarge Home

PoliclinicOf

Internal med.

policlinic- appointment- Peritoneal dialysis- pre- dialysis- procedures

”renal disease”

examinationsFollow-up care

New appointment

PoliclinicOf

Vascular surg.Possible kidney

transplant

Hemodialysis

Peritoneal dialysis

Renal replacementtherapy

What has been doneWhat has been done

Analysis of AE-reporting data (2007-2009, Analysis of AE-reporting data (2007-2009, n=316 in nephrological unit) n=316 in nephrological unit)

Medication prevalence, quidelines for minimum Medication prevalence, quidelines for minimum regisration, checklist for patient dischargingregisration, checklist for patient discharging

Existing and possible risks evaluated by staff Existing and possible risks evaluated by staff 20102010

Large survey about working conditions and Large survey about working conditions and employee welfare 2009employee welfare 2009

Questionnaire for patients 2010Questionnaire for patients 2010 FMEAFMEA

Identification of potential risks in the nephrolgy units

Patient inquiry on theneeds for improvement

Mapping the current process of a kidney patient • critical points based on the risks identified• elimination of waste

Mapping the future process of a kidney patient

Formulation of an operational plan for the new nephrolgy centre

Mapping the current process of an emergency patient in Internal Medicine Defintion of the minimumrequirements for recordingpatient data

Checklist for the discharge of a patient

Survey for the personnel on the employee welfare

Improving the care of Improving the care of a kidney patienta kidney patient

2007 2008 2009

Mapping the current process of a kidney patient

- Outpatient clinic- Ward- Peritoneal dialysis, hemodialysis

2010

Recommendations for safe medication practise

Risk identification of medication practise

Adverse event reporting, kick-off 1.10.2007

Plans for medication safety

Adverse event reporting• establishment of the practise• analysis of the incidents

Referral

Primary care

Labservices

Imagingservices

Phramacy Technicalservices

Admin.services

Critical phases in order to keep the service

statement

Service stateme

nt1 23

4

56

789

10

11

12

13

14

Where do we find the risks?Where do we find the risks?

Specialised care

OrganisationOrganisation

PatientPatientCommunicat

ion

Communication

EquipmentEquipment

Team workTeam work

Working conditionsWorking conditions

Education and skillsEducation and skills

TasksTasks

Information does notgo with the patient

Data is recorded in too many places

Communication betweenProfessional groups

Slowness and blocks in patientDatabase software

The good care ofa kidney patientis compromised

Resposibilities forregular and fault maintenance

Shortage of spare devices

Education and instructions for use

Inventories are notclose to the point of use

Noise

Access of outsiders intoCare facilities

Insufficient room forPatien moving (with or without aids)

Insufficient storage space

Limited protection of privacy

Sufficiency of Isolation facilities

Insufficient room for silence work

Hygiene- unclear separationBetween clean and unclean

Suffiency of skill- holiday season/Sudden leaves of absence

Insufficient introduction

Working solo because ofInsufficient personnel

Large number of temporary workers

Acute dialyses

Number of patients/Patient room (Washroom/Toilet)

Following hygiene regulations (MRSA)

Lack of common set of rules

Lack in perceiving theEntity of care

Lack of common policies for communication

Lack of common documenting practice

Know- how consentrated on few

Set policies are not always followed

Problems are notAcknowledget or addressed

Roles described – task Sharing does not work inpracticeLack of recources inhibits

Implementation of introduction

Lack of skilled staff forteaching patients

AN EXAMPLE OF FAILURE MODE AND EFFECTS ANALYSIS (FMEA)AN EXAMPLE OF FAILURE MODE AND EFFECTS ANALYSIS (FMEA) System name: Kidney patient care/adverse event reportingSystem name: Kidney patient care/adverse event reporting

Responsible: Nephrology Unit/ Tampere University HospitalResponsible: Nephrology Unit/ Tampere University Hospital

FMEA responsible: Ritva InkinenFMEA responsible: Ritva Inkinen

Failure Mode

Effect Causes Detection method

Severity

Occu

rrence

Defection

RPN Initial

The medication information is inaccurate when the patient is received in the ward

The ward personnel have to do extra work to find out the correct medication

There is no uniform way to record medication information

Check the medication data upon recording

4 8 6 192

The examinations needed for the diagnosis are not performed before transferring the patient

The correct care is delayed and the clinical condition is compromised

There is no uniform way to check whether all necessary exams have been done

Check that the examinations have been performed and the results have been recorded

6 7 5 210

Values of S between 1 and 10; values of O between 1 and 10; values of D between 10 and 1

Recommended actions

Owner Action taken Severity

Occurrence

Defection

RPN initial

Standardized procedures to record medication data Prevalence twice a year

yes 4 5 4 80

Checklist on actions that must be done before transferring the patient

yes 4 3 2 24

GoalsGoals Safety culture is the basis for patient careSafety culture is the basis for patient care Improving kidney patient process (PDCA)Improving kidney patient process (PDCA) Patients participate in improving patient Patients participate in improving patient

safetysafety Staff learn to identify problems and harms Staff learn to identify problems and harms

in processes and systemsin processes and systems Patient safety is included in managemet Patient safety is included in managemet

and decision- making and decision- making

ConclusionsConclusions

Project is ongoing until 2012Project is ongoing until 2012 At the moment harms and risks in At the moment harms and risks in

patient care are identified from patient care are identified from individual point of view individual point of view

Open patient safety culture must Open patient safety culture must develop step by stepdevelop step by step

Management and funding must Management and funding must always be in evidencealways be in evidence