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
[email protected] Lönnberg, spesializedTanja Lönnberg, spesialized
nurse in nephrologynurse in [email protected]
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
Top Related