29. German Hospital Conference, Düsseldorf, BLAME-FREE CULTURE, ERROR REPORTING AND ERROR MANAGEMENT - THE DANISH EXPERIENCE

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1 29. German Hospital Conference, Düsseldorf, BLAME-FREE CULTURE, ERROR REPORTING AND ERROR MANAGEMENT - THE DANISH EXPERIENCE ASGER HANSEN DANISH ASSOCIATION OF HOSPITAL MANAGEMENT COPENHAGEN, DENMARK

2 CONTENT: 1. PATIENT SAFETY ON THE INTER- NATIONAL AND E.U.`s AGENDA`s 2. PATIENT SAFETY IN DENMARK - PAST, CURRENT AND FUTURE ACTIVITIES: The Adverse Event Study A Learning-oriented Reporting System Act on Patient Safety from Danish Society for Patient Safety Examples of Patient Safety Initiatives Annual Report of Patient Safety Activities Patients Experiences and the Patients Book Evaluation and recommandations of Patient Safety Future Directions 3. CONCLUSIONS

7 Patient Safety What is it? Patient Safety haven t we always had that? Do you mean staff safety? It s just another word for quality improvement

9 ADVERSE EVENT An adverse event shall mean an event resulting from treatment by or stay in a hospital and not from the illness of the patient, if such event is at the same time either harmful, or could have been harmful had it not been avoided beforehand, or if the event did not occur for other reasons. Adverse events shall comprise events and errors known and unknown

12 Why was everybody not just blaming each other? No Press Time out

15 Why did the politicians adopt these recommendations? Because nobody would argue publicly against a law New government new politics 5 very simple and down to earth examples of how to learn from adverse events

17 6 in Act on Patient Safety A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice

19 REPORTING TO COUNTIES AND NATIONAL BOARD OF HEALTH The obligation for a healthcare worker to report adverse events, which occur in connection to a patienttreatment or stay in a hospital include events, that the healthcare worker direct observe in connection to the event takes place. Reporting to the county must be done latest 7 days after the healthcare worker recognize the adverse event. Reforwarding to the National Board of Health must be done immediately after finishing the administrative procedures in connection to the single event, however latest 90 days after the county have received the report from the healthcare worker. The rewarding must be anonymixed which makes it immediately possible to identify involved healthcare workers and patients.

21 Root Cause Analysis -Time required for each analysis Time required on each analysis (N=90) Hours okt-2001 okt-2002 okt-2003 okt-2004 okt-2005 date

22 Confidential versus anonymous reporting Who Reports? Anonymous reporting decreases 9% 8,4% 8% 7% 7,0% 6% 5% 5,3% 5,6% 5,6% 5,0% 4% 3% 3,3% Doctors Nurses Others 2% 1% 0% Q2 Q3 Q4 Q1 Q2 Q3 Q

23 Complaint System Why did the reporting system not effect the patients rights? Act on Patient Safety Insurance System Supervisory System The Patient Insurance Association, The Patients Board of Complaints of The Danish Public Health Authorities

26 Reported adverse events Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q

27 REPORTS AND PUBLICATION OF ADVERSE EVENTS In 2004 and 2005 a total of 3626 and 9096 adverse events were reported to the National Board of Health, respectively. About 40 % of the adverse events reported were events concerning medication, 12 % operative or invasive procedures and 48 % other adverse events. Every three month the National Board of Health publishes a news letter. Based on the information from different sources e.g. the adverse events reported, the risk managers in the councils and the Danish Medicines Agency, the National Board of Health publishes acute notices concerning patient safety.

28 How did Patient Safety become part of the health care stakeholders agenda? Danish Society for Patient Safety: Established December, 2001 Board represents hospital owners, professions, industry, research, patient and consumer organizations Goal is to ensure that Patient Safety aspects are considered in all decisions made in health care First aim: Make suggestions for a national reporting system

29 Do reporting systems improve safety? Maybe - if it has leadership support Maybe - if the reports are analyzed Maybe - if learning is shared Maybe - if action is taken Maybe - if solutions are monitored

30 Examples of changes resulting from the national reporting system

34 Key data from an external evaluation Q.: Does reporting lead to changes? Doctors Nurses Patient Safety Managers Yes 71% 67% 99% No 29% 33% 1% Ref.: Evaluation of Act on Patient Safety

35 EVALUATION AND RECOMMENDATIONS DO THE LOCAL AND REGIONAL REPORTING SYSTEM OPERATE AS INTENDED? Elaboration and expansion of information about definition of adverse events Strengthen continued focus on learning Focus on follow-up Weighing of ressources

36 EVALUATION AND RECOMMENDATIONS DO THE CENTRAL REPORTING SYSTEM OPERATE AS INTENDED? Activities to improvement of data entry Visual profiling of Patient Safety Close co-operating between National Board of Health and the regions Continued development of the Danish Patient Safety Base

37 EVALUATION AND RECOMMENDATIONS HOW TO EXTEND THE PATIENT SAFETY ARRANGEMENT? The development of the Patient Safety arrangement should initially extend to General Practioners, medical specialists, pharmacists, nursing home and homecare The Patient Safety arrangement should be build around the existing arrangement to ensure a better transition (the system and the content) Continuation training in the implementation of the Patient Safety arrangements should be on focus

38 Why did the patients support a no blame system? Harmful adverse events were not a surprise to the patients Understanding of the systemic perspective Did not change the patients legal rights or the patients possibilities 82% 18% Yes, I have experienced errors No, I have not experienced errors

42 Primary Sector Patient Reporting Act on Patient Safety is expected to include the primary sector and patient reporting by January 1st 2008

Travel letter from student exchange Student exchange in Bangkok, Thailand

Travel letter from student exchange Student exchange in Bangkok, Thailand Name: Marlene Andersen E-mail: Tapir@ofir.dk Phone number: Who did you travel with, if any: We were 12 nurse students in my exchange