The Danish National Agency for Patients' Rights and Complaints Identifying the risk and assessing the frequency and severity of the risk
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1 The Danish National Agency for Patients' Rights and Complaints Identifying the risk and assessing the frequency and severity of the risk Pia Knudsen, Ph.D. Pharm, Senior Patient Safety Officer
2 18. december 2013 The Danish National Agency for Patients' Rights and Complaints How can we identify risks? slide 2 præsentationens titel der kan løbe over flere linjer Adverse drug events and medication errors: detection and classification methods T morimoto, T K gandhi, A C seger, T C hsieh, D W Bates Qual saf health care 2004;13: Doi: /qshc Patientombuddet 2013
3 18. december 2013 The Danish National Agency for Patients' Rights and Complaints slide 3 præsentationens titel der kan løbe over flere linjer How can we identify risks? Patient safety rounds Interviews, dialog and observations Identify and discuss current and potential risks. Global trigger tool A number of records is reviewed for the so-called triggers. If a trigger is present, it should be considered a warning sign and the records are examined in more detail. Patient complaints and compensations Patientombuddet 2013
4 The Danish National Agency for Patients' Rights and Complaints How can we assess and learn from the incidents? It depend on how you look at the problem Patientombuddet 2013
5 The Danish National Agency for Patients' Rights and Complaints Ulykkesmodeller Patientombuddet 2013
6 Three generations of accident models
7 The Danish National Agency for Patients' Rights and Complaints In order to learn from mistakes, we need an error classification Standardization Filter the relevant information 'Translator' Patientombuddet 2013
8 The Danish National Agency for Patients' Rights and Complaints Components in error classification Primary classification Impact the outcome or effects of medical error and systems failure, commonly referred to as harm to the patient. Type the implied or visible processes that were faulty or failed. Domain the characteristics of the setting in which an incident occurred and the type of individuals involved. Cause the factors and agents that led to an incident. Prevention and mitigation the measures taken or proposed to reduce incidence and effects of adverse occurrences. Patientombuddet 2013 Downloaded from by guest on December 12, 2013
9 The Danish National Agency for Patients' Rights and Complaints WHO, All Rights Reserved. WHO/IER/PSP/ The Conceptual Framework for the International Classification for Patient Safety is not to be reproduced Patientombuddet or published without 2013 the written consent of WHO.
10 Risk assessment Risk assessment programme overview National Patient Safety Agency. November 2006
11 18. december 2013 slide 11 præsentationens titel der kan løbe over flere linjer Creating a Patient Safety Culture. Patient Safety Culture Improvement Tool: Development and Guidelines for Use Mark Fleming and Natasha Wentzell Healthcare Quarterly, 11(Sp) March 2008: doi: /hcq
12 Adverse Event 18. december 2013 slide 12 Management Process præsentationens titel der kan løbe over flere linjer
13 18. december 2013 The Danish National Agency for Patients' Rights and Complaints Severity assessment slide 13 præsentationens titel der kan løbe over flere linjer Patientombuddet 2013
14 Example from a Danish hospital Action on different incidents Anamarie Søgaard Maj 2006 Fyns Amt Enhed for Klinisk Patientsikkerhed 14 Type of accident Classifikation Method Suicide Medicine errors SAC = 3 SAC < 3 Confusion Surgery Root cause analysis Root cause analysis Local analysis Root cause analysis Incidents Faktuel score 2 Complaints and compensation Potentiel score 3 Aggregeted root cause analysis Journal audit
15 Adverse Event 18. december 2013 slide 15 Management Process præsentationens titel der kan løbe over flere linjer
16 The Danish National Agency for Patients' Rights and Complaints Risk evaluation and action Human Error Type Slip / Lapse Rule-Based Mistake Knowledge- Based Mistake Patientombuddet 2013 Typical Forms Double capture Omission Interference Perceptual Confusion Strong-but-wrong Exception to rule Cognitive overload Confirmation bias Out of sight, out of mind Encystment Vagabonding Common Prevention Strategies Minimise interruptions Forcing functions Colour-coding, highlighting differences Checklists, memory aids Minimise / highlighteexceptions Provide feedback Manage workload Decision support Team work & CRM training
17 Adverse Event 18. december 2013 slide 17 Management Process præsentationens titel der kan løbe over flere linjer
18 18. december 2013 slide 18 præsentationens titel der kan løbe over flere linjer 1. PLAN: Plan a change or test of how something works. 2. DO: Carry out the plan. 3. STUDY: Look at the results. What did you find out? 4. ACT: Decide what actions should be taken to improve. 5. Repeat as needed until the desired goal is achieved
19 The Danish National Agency for Patients' Rights and Complaints Eksempel The Danishs Case flow NATIONAL Citizen Reporting Case handler (municipal / regional) Local case handler Case handler- NAPRC Central case handler External data users Healthcare staff Complains Compensations Patientombuddet 2013 LOCAL
20 Source of error analysis - from beginning to end Step 1: Select the topic or issue. Step 4: Identify the underlying causes. Step 2: Establish the analysis team. Step 3: Develop workflow and identify risk areas Step 5: Prepare action plans and monitoring plan. Step 6: Produce source of error analysis report 20
21 Source of error analysis - method description Published by The Danish Society for Patient Safety
22 18. december 2013 The Danish National Agency for Patients' Rights and Complaints Act on Patient Safety slide 22 præsentationens titel der kan løbe over flere linjer Frontline personnel in hospitals and in the primary care sector are obligated to report adverse events to a national reporting system Patients and relatives may report adverse events. Regions and municipalities are obligated to act on the reports. The Danish National Agency for Patients Rights and Complains is obligated to communicate the learning nationally. The purpose of the reporting system is to learn, not punish. Patientombuddet 2013
23 The Danish National Agency for Patients' Rights and Complaints Learning The health service s system for reporting inadvertent incidents (DPSD) Patient complaints Compensation
24 The Danish National Agency for Patients' Rights and Complaints Reported adverse events Patientombuddet 2013
25 The Danish National Agency for Patients' Rights and Complaints Adverse events reported in 2012 in percent WHO international classification for Defined as: Patient Safety (ICPS) Medication Incidents include, for example Adminstrative processes 1,9 18,9 prescribing 17,6 the wrong 23,2 drug or wrong dose, Blood and blood components 0 0,9 0,5 0,4 administering the wrong Buildings and infrastructure 0,1 1,2 3,4 0,9 preparation or strength, Gases and air for medical use 0 0,3 0,4 0 and medication at the Individual-team-organisation 0,3 1,7 0,9 1,3 wrong time. Infection 1,1 0,5 0 0,1 Clinical processes 1,3 19,9 8,5 22,7 Communication og documentation 2,9 17,8 12,4 18,9 Medication 68,8 23,9 40,3 29,4 Medication equipment 0,3 4,3 4,7 1,1 Patient accidents 21,6 6,7 8,3 0,7 Self-harm, Patientombuddet 2013 suicide attemps or suicide 0,1 0,9 0 0,1 Other incident type 1,5 3,1 3 1,2 Municipals Regional Private Other regional areas
26 18. december 2013 The Danish National Agency for Patients' Rights and Complaints slide Medication Incidents - Process Administration defined as: Medicine given and Patientombuddet 2013
27 18. december 2013 The Danish National Agency for Patients' Rights and Complaints slide Medication Incidents - Problem Defined as: Wrong dose due to improper strength and / or quantity. Wrong time. Not given. lack of discontinuation Patientombuddet 2013
28 Severity Harm No harm Mild Moderat Serious Deadly No harm Slight transient injury that does not require increased treatment or increased management efforts Transient injury requiring hospitalization or treatment by a medical practitioner or increased management efforts or for hospitalized patients increased treatment. Permanent injuries requiring hospitalization or treatment by a medical practitioner or increased management efforts or for hospitalized patients increased treatment, or other injuries that require urgent lifesaving treatment. Deadly
29 Procent Adverse events reported in 2012 in percent Municipals Hospitals Private Other regional Unknown 0, No harm 65 53,6 67,4 52,7 Mild 24,6 23,5 20,3 32,7 Moderat 8,6 17,1 9,2 9,9 Severe 1, ,1 Deadly 0,1 0,8 0,1 0,6
30 18. december 2013 The Danish National Agency for Patients' Rights and Complaints slide 30 præsentationens titel der kan løbe over flere linjer Incidents assessed every week The incidents classified as dead Medicine incidents classificed as; moderate serious dead Patientombuddet 2013
31 The Danish National Agency for Patients' Rights and Complaints Publications Alerts Attentions Theme reports Newsletters Annual Report Info for users Presentations Seminars Patientombuddet 2013
32 18. december 2013 The Danish National Agency for Patients' Rights and Complaints slide 32 præsentationens titel der kan løbe over flere linjer THANK YOU Pia Knudsen, Ph.D. Pharm, Senior Patient Safety Officer The Danish National Agency for Patients' Rights and Complaints Telephone Web Finsensvej Frederiksberg Denmark
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