1 FRAM course in Sweden 2014 Qulturum Jönköping County Council In cooperation with Stockholm County Council and Erik Hollnagel
2 Investigating accidents and risk in Swedish health care Compulsory by law Far from all accidents and risk are analysed Handbook with methodology based om RCA and HFMEA.
3 FRAM in Swedish health care Courses have been given Som minor use No spread
4 FRAM in Swedish health care, a new course effort January to March 2014 Six teams participating A three days course spread over a period of six weeks Own work with analysing own cases in the intermediate time The Danish handbook was used in this course Erik Hollnagel teaching
5 Day 1 10:30 11:45 Theory. From Safety I to Safety II. 11:45 12:30 Lunch :30 FRAM, theory and model 13:30 14:45 FRAM, functions and aspects, incl. practice 14:45 15:00 Fika 15:00 15:45 FRAM, planning an analysis 15:45 16:30 Planning of own work
6 Day 3 10: Presentation of own work, reflections and discussion, x 6 teams 15:15 16:00 FRAM, how can it be used? 16:00 16:30 Vägen FRAM (FRAM, the road ahead), concluding remarks
7 Day 2 10: Presentation of own work, reflections and discussion, x 6 teams 15:15 16:00 FRAM, models and variability 16:00 16:30 Planning own work
8 Six teams Health care staff Majority long experience in health care Majority experienced in patient safety and in work with accident analyses
9 Six teams six different topics for analysis 1. An event with a patient suffering renal failure due to medication error (metformin) in relation to contrast CT-scan. 2. Risk analysis concerning prescription of morfin for epidural analgesia on general wards. 3. An event concerning missed prescription of anticoagulants in transition from hospital to home. 4. An event where an infusion was administered subcutaneously by mistake in a situation with shortage of staff and beds with appropriate competencies. 5. An event with medication error with a to high dose of morfin 6. A risk analysys concerning preparation of water for renal dialysis
10 Experiences 20 students attended the course. Students had long experience of work and safety work in health care. Attendance and interest was high Spontaneously FRAM was aknowledged as a method suitable for health care but maybe to difficult or complex for widespread use FRAM analyses was not completed during the course period, approximately to the phase where variability is analysed
11 Experiences Course evaluation Students opinion on FRAM was evaluated with questions answered on a scale with 1 as lowest, and 10 as highest score.
12 Experiences Course evaluation Students overall valued the course high (median 7, quartiles 6-9) Of great value for their work (8, 6-9) They believed that FRAM is of high value in health care (8, 7-9) They plan to use in their further work (7, 6-9).
13 FRAM in Swedish health care, further plans Preliminary plans New course autumn 2014 Three days, over a period A little less theory An example of a FRAM analysis incorporated in the course More time for teams work with support during course days
14 FRAM training courses in Denmark 3 training courses: June 2013 (test run), October 2013 and May 2014 A preliminary Handbook (DK), is tested in May/June 2013 The first version of the Handbook in Danish is published in September 2013 The first version of the Handbook in English is published in June updated with the FRAM Visualizer The second version of the Handbook in Danish is planned to be published end 2014: FRAM Visualizer, FRAM for System Design, FRAM and LEAN
15 FRAM training courses in Denmark A two days course spread over a period of 2-3 weeks The participants worked with their own case in the intermediate time In total 59 participant from 4 of the 5 regions in Denmark, both somatic/psychiatric hospital units and emergency medical services Total score 8.8 (October 2013) and 8.7 (May 2014) - out of 10.0 Typical profile for participants: Risk managers, Quality Coordinators and Clinicians responsible for analyzing adverse events
16 Comments October 2013 Improvements: Theoretical presentation also on Day 2 Fewer presentations of cases on Day 2 not all More time between first and second day of the course Day 1 is too theoretical - add more exercises A follow-up course Dedicated courses for example managers
17 Comments May 2014 Good combination of teachers, both theoretical and practical approaches Very good combination with practical exercises + own work Improvements: Review only examples of cases, not all (day 2) FRAM as a risk analysis (proactive) Workshop, working with own case under supervision. More practical exercises in combination with the theory
19 Thank you for your attention! Center for Kvalitet, Middelfart:
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