Martine de Bruijne, Cordula Wagner Safety 4 Patients
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1 Patient safety and patient outcomes Martine de Bruijne, Cordula Wagner Safety 4 Patients TRIP symposium, 19 maart 2013
2 Safety 4 patients 2
3 Patient safety milestones Harvard Medical Practice Study To Err is Human IOM Report JCAHO National Patient Safety Goals Institute for Healthcare Improvement 100K lives Campaign Better faster III: Rein WIllems: Hier werk je veilig of je werkt hier niet Report I: Adverse events in Dutch hospitals Prevent harm, work safe Report II Adverse events in Dutch hospitals? April 13: Report safety campaign 10 topics November 13 Report III: Adverse events in Dutch hospitals Reduction of adverse events?
4 Patient safety research NL Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 4
5 5
6 Record review - + Patient harm? Health limitation? Related to health care? Preventable?
7 Potentially preventable adverse events % 2.9% 30,000 38,600 0,0 1,0 2,0 3,0 4,0 % of hospital admission
8 Potentially preventable hospital deaths % 5.5% ,0 1,0 2,0 3,0 4,0 5,0 6,0 7,0 % percentage of hospital admissions
9 % of hospital admissions Type of preventable AEs 1,8 1,6 1,4 1,2 1 0,8 0,6 0,4 0,
10 Causes Age Complexity Length of stay Hospital mortality Patient More openess More attention Culture Verschil zorggerelateerde schade Electronic records Registration quality Change in reviewer Chance Methods Care Better faster programme Guidelines Inspection / audits
11 Patient safety research NL Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 11
12 Root causes of 881 surgical incidents Human intervention error technic organisation human pa 12
13 Human factors 13
14 Human factors 14
15 WORKSYSTEM 15
16 Communication errors 16
17 Patient safety research NL Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 17
18 Safety campaign Safety management system Topics: 1. Postoperative infections 2. Sepsis 3. Rapid response team 4. Medication errors 5. Elderly patients 6. Acute coronary syndromes 7. Pain 8. High risk medication 9. Wrong site/patient 10. Contrast nephropathy 18
19 How? Crew resource management Training Instruments 19
20 Communication in hospital Admin 12 Admin 1 Sr nurse 22 Admin 11 Allied health 3 Sr dr 3 Jr RN 9 Admin 8 Admin 9 Sr nurse 13 Jr dr 2 Sr RN 13 Sr RN 14 Sr RN 6 Sr nurse 18 Admin 4 Sr nurse 1 Sr RN 1 Sr nurse 9 Jr dr 10 Jr dr 21 Sr nurse 11 Admin 3 Jr dr 7 Sr nurse 21 Admin 5 Sr dr 7 Jr dr 15 Sr nurse 6 Admin 2 Jr dr 20 Sr dr 5 Jr RN 4 Jr dr 8 Sr nurse 17 Ward asst 1 Sr nurse 2 Admin 10 Admin 7 Jr dr 5 Sr dr 4 Sr dr 1 EN 4 Sr nurse 4 Sr RN 5 Admin 6 Jr dr 17 Sr nurse 8 Jr dr 12 Sr RN 4 Sr nurse 10 Ward asst 2 Jr dr 9 Jr dr 23 Sr nurse 5 Jr dr 1 Sr dr 2 Sr RN 7 Sr nurse 14 Sr nurse 12 Allied health 4 Jr dr 4 Sr nurse 3 Jr RN 10 Sr RN 8 Sr dr 6 Jr RN 8 Sr nurse 7 Jr dr 13 Jr RN 11 Jr RN 3 Sr RN 2 Jr dr 16 Sr nurse 15 Sr RN 10 Jr dr 29 Jr dr 6 Jr dr 11 Jr RN 1 Sr nurse 16 Jr dr 22 Allied health 2 Jr RN 6 Jr dr 18 Jr dr 24 EN 5 Jr RN 2 Jr dr 25 Sr RN 9 Allied health 1 Jr RN 5 Sr RN 11 Jr dr 14 Jr dr 19 Jr dr 3 Sr nurse 19 Jr dr 27 Jr dr 30 Jr dr 26 Jr dr 28 Sr RN 3 EN 2 Jr RN 7 EN 1 EN 3 EN 6 Sr nurse 20 Jr RN 12 Sr RN 12 Problem solving networks in an ED Nurses Doctors Allied health Admin and support [Creswick, Westbrook and Braithwaite, 2009] 20
21 Functioning like cocons Nurse Surgeon Anesthesist Scrub nurse TRM
22 CRM Team Leadership Teamwork Communication Situational Awareness Shared aims Standardisation Nurse Surgeon Scrub nurse Anesthesist TRM
23 Patient safety research NL Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 23
24 Effects of CRM team training Both simulation training and classroom based training improve.... Knowledge.. Attitude.. Behaviour However limited effects on patient outcomes within 6 to 12 months
25 Time-out Eye hospital Rotterdam Korne DF de. Divergent sight: studies on the application of industrial quality and safety improvement methods in eye hospitals. Proefschrift, Academisch Medisch Centrum, Universiteit van Amsterdam, 2011
26 26
27 Contrastnephropathy Preliminary results (nov 12) % patients with registerd egfr before contrast administring 27
28 Medication verification Preliminary results (nov 12) % Patients treated with complete bundle admissions discharge 28
29 Expected reports April 2013: Results implementation 10 topics safety campaign November 2013: Report III: Adverse events in Dutch hospitals 29
30 Patient safety research NL Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 30
31 31
32 Improve safety culture Vooruitstrevend Veiligheid is een integraal onderdeel van alles wat we hier doen Trust and openess Proactief We zijn alert op mogelijke risico s Bureaucratisch We hebben systemen om alle risico s te managen Reactief Na elk incident nemen we actie Ontkennend Waarom tijd verdoen aan veiligheid, wij leveren goede zorg Behaviour 32
33 Multiprofessional competencies 33
34 Basic quality registration Show results with more ease 34
35 PROTON II: Sanquin & Julius Center & EMGO+ 35
36 Thank you! Translating evidence to safer care Measuring harm Evaluating impact Understanding causes Identifying solutions 36
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