The German experience in education on Patient Safety
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Transcript of The German experience in education on Patient Safety
IV. International Conference on Patient Safety
Finding the Best Practices for Safer Care
Madrid, 25.-26.11.2008
Matthias Schrappewww.schrappe.com
The German Experiencein Education on Patient Safety
German Coalition for Patient Safety
00qm\rm\AktPS\konz1.cdr
www.aktionsbuendnis-patientensicherheit.de
Personal Experience (Teaching)00qm\lehre\PersExp.cdr
Since 1997: lecture of QM as part of the studyof Health Economics at the University of Cologne
since 2005, as part of the MA study of Health Economics at the University of Cologne
Lecture in EBM and Clinical Epidemiology
Postgraduate training of QM 1997-2001 LÄK Nordrhein
Lectures in Governance and LeadershipProf. Dr. M. Schrappe
Quality Management
Patient Safety and Risk Management
Others
German Situation00qm\lehre\d-Situat.cdr
Curriculum on patient safetyCurriculum on QM
Skill-based training coursesPatient safety curriculum
University of Cologne: study of Health Economy
Curriculum governance and leadership
Bonn: University Institute for Patient Safety (from 1.1.09)Prof. Dr. M. Schrappe
National Physicians Organization
Regional Physicians Organizations
University Education
Presentation
Knowledge
Skills
Attitude
Perspectives and Summary
badorb\gliedrg.cdr
IV. InternationalConference onPatient Safety
The GermanExperience in Educationon Patient Safety
Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt
gliedrg.cdr
Presentation
Knowledge
Skills
Attitude
Perspectives and Summary
IV. InternationalConference onPatient Safety
The GermanExperience in Educationon Patient Safety
Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Prof. Dr. M. Schrappe
00qm\rm\swiss.cdr
Swiss Cheese - the error chain
Prof. Dr. M. Schrappe
aus: Reason BMJ 320, 2000, 768
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Prof. Dr. M. Schrappe
00qm\rm\systemat\systemat.cdr
Systematology
+
=Adverse event
Error
Preventable Adverse Event
Prof. Dr. M. Schrappe
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Incidence
Prof. Dr. M. Schrappe
0
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10 100 1000 10000 100000 1000000 10000000Stichprobe (n)
AE
(%)
00qm\rm\adevent\epidem4.cdr
Prof. Dr. M. Schrappe
Review:Incidence AE*
*AE = adverse event
147/184 trials
Agenda Patientensicherheit 2006
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Stichprobe (n)
Patie
nten
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AD
E(%
)
Prof. Dr. M. Schrappe
00qm\rm\adevent\epidem4.cdr
Review:Incidence ADE*
68/184 trials
Agenda Patientensicherheit 2006
*ADE = adverse drug event
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Incidence
Kind of events
Prof. Dr. M. Schrappe
Falls:
Autopsy-Studies:
Decubitus (w/o. Stad. 1):
Nosocomial Infections:
Adv. Drug Events:
Adv. Med. Device Events:
Prevalence: 2,4%
Metaanalysis: 10,1%
Prevalence: 4,2%
Prevalence D: 3,6%
Metaanalysis: 2,1%
Incidence: 8,4 %
Dassen 2004
AHRQ 2002
Dassen 2004
Rüden 1996
Lazarou 1998
Samore 2004
00qm\rm\adevent\epidem2.cdr
Frequency of in Hospitalsadverse events
Prof. Dr. M. Schrappe
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Incidence
Kind of events
Prevention
Prof. Dr. M. Schrappe
Prevention Wrong Site Surgery
Bild: aus Presseservice Gesundheit AOK 28.4.05
00qm\rm\seitenvw\seitenID.cdr
Prof. Dr. M. Schrappe
Prevention: ErgonomyOrganizetechnicalprocessessafely
from: T.M. Nolan: System changes to improve patient safety. BMJ 320,2000,771
00qm\rm\praev\geldauto.cdr
Prof. Dr. M. Schrappe
IT and Error-Prevention
- Improvement of communication- Access to knowledge- Coming to information- Support of calculations- Support of timeliness- Monitoring- Give decision aids
Bates, DW, Gawende AA: Improving Safetywith Information Technology.NEJM 348, 2003, 2526
00qm\rm\praev\bates03.cdr
Prof. Dr. M. Schrappe
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Incidence
Kind of events
Prevention
Informed consent and litigation
Prof. Dr. M. Schrappe
Knowledge
00qm\rm\lehre\knowledge.cdr
Modern understanding of incidents (error chain)
Nomenclature
Incidence
Kind of events
Prevention
Informed consent and litigation
Prof. Dr. M. Schrappe
gliedrg.cdr
Presentation
Knowledge
Skills
Attitude
Perspectives and Summary
IV. InternationalConference onPatient Safety
The GermanExperience in Educationon Patient Safety
Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt
Events: to understand the process
Act CausingPreventable
Adverse Event
00qm\rm\pa\prozess_Sicht.cdr
Unsafe Acts
Unsafe Care Process
Prof. Dr. M. Schrappe
Act CausingPreventable
Adverse Event
Unsafe Care ProcessIndividualTask
TechnicalEnvironmentOrganization
Events: to understand the process
00qm\rm\pa\prozess_Sicht.cdr
Unsafe Acts
Prof. Dr. M. Schrappe
Skills
00qm\rm\lehre\skills.cdr
Processanalysis after critical incidents
How to measure: random bias, small numbers
Prof. Dr. M. Schrappe
00qm\rm\zählen.cdr
Measurement and Counting
events / 100 patients ?
events / 100 admissions ?
events / 1000 patient-days ?
events / 100 patients at risk ?
events / 1000 patient-days at risk ?
Prof. Dr. M. Schrappe
Skills
00qm\rm\lehre\skills.cdr
Processanalysis after critical incidents
How to measure: random bias, small numbers
Human factors
Prof. Dr. M. Schrappe
Skills
00qm\rm\lehre\skills.cdr
Processanalysis after critical incidents
How to measure: random bias, small numbers
Human factors
Why not doing what we are knowing?
Prof. Dr. M. Schrappe
VF\Eff_Gap.cdr
Effectiveness Gap: DeterminantsPatient-related factors
Health Care Professionals
Organisations
System factors
AgeGenderEthnic group ComorbidityPreferences
Skills and knowledgeWillingness to learnAttitudes
FlexibilityAbility to integrate innovationsIntegration of heterogeneityFinancingSectoral organisation (Germany!)
Prof. Dr. M. Schrappe
Skills
00qm\rm\lehre\skills.cdr
Processanalysis after critical incidents
How to measure: random bias, small numbers
Human factors
Why not doing what we are knowing?
Concepts of organizational learning
Prof. Dr. M. Schrappe
Skills
00qm\rm\lehre\skills.cdr
Processanalysis after critical incidents
How to measure: random bias, small numbers
Human factors
Why not doing what we are knowing?
Concepts of organizational learning
Prof. Dr. M. Schrappe
gliedrg.cdr
Presentation
Knowledge
Skills
Attitude
Perspectives and Summary
IV. InternationalConference onPatient Safety
The GermanExperience in Educationon Patient Safety
Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt
Aktion Saubere Hände
00infqm\ash\allg.cdr
Learning by feedback
Volume of hand desinfectants
Publicity: TV, mass media
National agenda
Prof. Dr. M. Schrappe
German Clean Your Hands Campaigne
gliedrg.cdr
Presentation
Knowledge
Skills
Attitude
Perspectives and Summary
IV. InternationalConference onPatient Safety
The GermanExperience in Educationon Patient Safety
Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt
Institute for Patient SafetyMedical Faculty of the Friedrich-Wilhelms-University of Bonn
00qm\rm\ifps\ifps.cdr
Federal Ministry of Health, donations, 28 sponsors
1.1.2009, official opening 8.5.2009
Integration in education of health professions
Patient safety indicators, epidemiology and measurement,implementation research, safety culture
Prof. Dr. M. Schrappe
Financing
Start
Teaching
Research topics
Summaryzusfassg.cdr
Don’t underestimate knowledge (e.g., systematology,epidemiology)
Skills: establishing new training facilities - process analysis after catastrophic events, human factorsAttitude: integrate safety in university and basiceducation, understand organizational learning
Perspective: making regional experiencestrengthening skill-orientationhelp physicians to trust in the benefit of change in organizational culturedevelop targeted programms for professionsintegrate patient safety in university education and outcome research
Prof. Dr. M. Schrappe