PATIENT SAFETY AND CLINICAL RISK MANAGEMENT IN OUR ...hi.simplit.lt/uploads/news/id518/1. SiNASP_CReal_Spain_2014.pdf · PATIENT SAFETY AND CLINICAL RISK MANAGEMENT IN OUR HEALTHCARE

PATIENT SAFETY AND CLINICAL RISK

MANAGEMENT IN OUR HEALTHCARE AREA

César Llorente Parrado

Quality Department. GAI. Ciudad Real (Castile - Spain).

February 21st.

1. Integrated Healthcare Model: Patient Safety

Multidisciplinary Team

2. Our Patient Safety Reporting System: SiNASP

CONTENTS

4. SiNASP management: regional/ national level

3. SiNASP management: hospital level

5. SiNASP: strengths and barriers




CONTENTS




PATIENT SAFETY MULTIDISCIPLINARY TEAM

1. Promote a Patient Safety CULTURE in professionals

2. Use Patient Safety Reporting Systems to LEARN

from errors

3. ANALYZE our care processes, identifying critical

control points

4. Implement evidence based PATIENT SAFETY

PRACTICES.

Objectives


Groups

CLINICAL RISKS

IDENTIFICATION

SAFE MEDICATION

PRACTICES

INFECTION

CONTROL

EVIDENCE BASED PS

PRACTICES


PATIENT SAFETY COMMITTEE

Technical support body to implement improvement actions

and assess Chief Executive Office in Patient Safety Politics in

Healthcare Area.

-Medical Director (President).

-Nursing Director.

-Quality Departement (Secretary).

-PSMT Groups representatives.

Monthly schedule




CONTENTS




Our Patient Safety Reporting System: SiNASP

- Web-based patient safety reporting system TO identify adverse

events (harm), incidents (errors with no harm) or "near misses".

- Many times causes and contributing factors of risk situations tend

to recur.

- SiNASP let us to identify safety hazards, prioritize where to focus

our efforts, develop interventions to prevent or mitigate these

hazards, and evaluate whether the interventions reduced harm.

Goals

- VOLUNTARY.

- NON-PUNITIVE.

- CONFIDENTIAL: at 15 days is automatically deleted the following

information:

Exact time and date the incident occurred.

Email address and notifier name.

Professional categories of people involved.


Main characteristics

- WHO ARE THE REPORTERS? Any

professional (healthcare or

not) who identifies an incident involving

patient safety

occurred in their workplace.

- WHAT IS REPORTED?

Near missed: potential incidents (proactive

attitude).

No harm incidents.

Adverse events (harmful events).


1. Identification


1. Identification


1. Identification

SECTIONS

- Incident description and classification (NOT include

data identifying patients or professionals (name, nº

hist, ID...).

- Patient: age, gender, harm (yes/no)

- Causes/ contribuiting factors .

- Suggestions for improvement in opinion of the

notifier.


2. Management.

PRIORITIZATION:

1-2%

5-10%

15-20%

25-30%

50% no SAC (near missed)


3. Dissemination.

- Feedback e-mail to notifiers confirming

reception (in case of identification).

- Information to notifiers about incident

management process (in case of

identification).


3. Dissemination.

RESULT DISSEMINATION STRATEGIES:

Periodic reports of aggregate data with implemented/planned

risk reduction strategies.

Patient Safety Alerts, focused on specific aspects.

Case studies ("story of a patient").

Meetings or seminars on specific hospital departaments or

Primary care facilities.


3. Dissemination.

System

coverage Dissemination

seminars

+Dissemination

seminars

Dissemination

seminars

> Reporting departments:

Emergency, Critical Care Unit,

Hospital Farmacy, Anestesiology.

GAI CIUDAD REAL (HOSPITAL AND PRIMARY CARE

FACILITIES). SiNASP GROUP PSMT

Responsible for managing detected notifications and

implementing action plans


Management Levels

SPANISH MINISTRY OF HEALTH & CASTILIAN

DEPARTMENT OF HEALTH

Responsible for periodic analysis of aggregate data to

identify trends and risks in order to develop general

recommendations and patient safety alerts.

CONTENTS







SiNASP Management: hospital level

https://www.sinasp.es/

MAIN PAGE NOTIFICATION

QUESTIONNAIR

E

INFORMATION HELP

TRAINING

COURSE

https://www.sinasp.es/


Reporters/users


Access to questionnaire

Hospital

Code Recover a previously saved

notification

Start a new

notification

Where it happened

When it happened

People related to the incident

Information about the reporter

Professional name and e-mail: not

mandatory fields INC

IDE

NT

(I)

Description: free text

INC

IDE

NT

(II

)

NOT INCLUDE DATA

IDENTIFIYING PROFESSIONALS

OR PATIENTS (names, medical

record ID…).

Categories related to

the incident

Ex: medication, falls,

surgical procedures,

laboratory, infection control,

patient id

Incident estimated frequency: (5 categories

from less to more frequency estimated by reporter).

Incident Risk Level PA

TIE

NT

Patient characteristics: age

and gender

Type of incident: -Near missed.

-Incident with no harm

-Adverse event (+ type and severity of damage)

The system calculates the risk level (SAC) automatically according to the data we have

introduced in terms of severity and frequency

CA

US

ES

Contribuiting factors: free text

1. Professional factors Training / knowledge / competence of professionals

Behavior / conduct for professionals

Communication Problems

Stressors / emotional / fatigue

2. Patient factors Limitations for communication with the patient (foreign, cognitive impairment,…

Condition / severity of the patient / complex clinical problems

3. Working environment / facilities / equipment

4. Organizational factors Standards / procedures / protocols work (lack or inadequacy)

Organizational culture

Issues in teamwork

Insufficient human resources / workload

5. External factors

Categories and subcategories

contributing factors related to

the incident

RIS

K R

ED

UC

TIO

N

ME

AS

UR

ES

Measures for improvement: free text

Stop and Save the notice to finish later

Complete notification


Managers


https://www.sinasp.es/gestor

REPORTS NOTIFICATIONS INDICATORS HOSPITAL

SINASP

MANAGEMENT

PLANS FOR

IMPROVEMENT

FILTERS: SEARCH ENGINE

SUMMARY LIST



MA

NA

GE

ME

NT

Introduction: Notification status: open/ close (in process??)

Manager name

Incident definition: It is the information appearing in manager

summary of incidents page

Possibility of incident prevention in the future: evidence of incident preventability.

From less to more preventability degree (6 categories).

Manager recommendations: FREE TEXT.

Actions: Report the event to administration

Research by Root Cause Analysis (RCA)

Research by simplified version of RCA

Monitoring aggregate data

Mechanisms to reduce risk

MA

NA

GE

ME

NT

FILTERS: SEARCH

ENGINE

SUMMARY LIST

ADD NEW

PLAN

PLANS FOR

IMPROVEMENT

MA

NA

GE

ME

NT

SUMMARY LIST

PLANS FOR

IMPROVEMENT

ADDING A NEW PLAN

ACTION PLAN

IDENTIFICATION

GOALS

PLAN DESCRIPTION

ACTIONS TO BE TAKEN

INDICATORS

REPORTS

FILTERS:

SEARCH ENGINE

BASIC

REPORT

COMPARATIVE

ANALYSIS

FREE TEXT. Sections: Context

Contribuiting factors

Relevant examples

Suggestions for improvement View report (PDF)

Save report Recover report

REPORTS

MONTHS TOTAL

INDICATORS

NOTIFICATIONS VOLUME

Number of notifications received

Ratio notifications * 100 / hospital beds

NOTIFICATION ISSUES

% high risk incidents SAC 1 and 2 / total

% reporters identified

NOTIFICATIONS MANAGEMENT

Average time allocation –manager appointment- (days)

Notification mean time management. (days)

% of unmanaged notifications> 1 month

% notifications closed with actions

NOTIFICATIONS ANALYSIS

% notifications SAC 1 and SAC 2 with RCA –Root Cause Analysis- indication

% notifications RCA with RCA indication

% RCA finished / total number of notifications

Number of SiNASP local group meetings for analysis

FEEDBACK

% of sent feedback e-mails/ total of identified reporters

Number of saved reports in the system

Number of disseminated reports to professionals

Number of “case presentation” sessions

INDICATORS

HOSPITAL ID

SiNASP

MANAGERS

TRAINING COURSE STUDENTS

E-MAIL

RESPONSE

CENTER SiNASP

MANAGEMENT




CONTENTS




SiNASP Management: central level

SPANISH MINISTRY OF HEALTH &

CASTILIAN DEPARTMENT OF HEALTH

Responsible for periodic analysis of aggregate data to

identify trends and risks in order to develop general

recommendations and patient safety alerts.

HOSPITALS

Responsible for managing detected notifications and

implementing action plans

– Support centers in the use and management of SiNASP.

– Periodic reports on coverage of SiNASP.

– Analysis of aggregate data (Regional level).

– Define regional/ national policies for patient safety considering the information in the system.


Reports have same structure and contents as

local level reports…

Information NOT available to regional/national level:

From reporter: Hospital identification

Date and time the incident occurred

Reporter data identification

Patient Age

From local managers: Notification management status

Local manager identification

Local manager recommendations

Local manager comments





CONTENTS




• Institutional leadership support in promoting a culture of patient safety and providing resources.

• Feedback to professionals on incident trends and solutions.

• Common, agreed terminology and standards (who should report and what gets reported).

• Secure and web-based system that simplifies reporting by non-expert professionals. Accessible from any institutional or personal computer.

• Confidential management at regional/ national level: the identities of the patient, reporter, and institution are never revealed.

• Independent. Reporting system independent of any authority with the power to punish the reporter.

SiNASP: strengths and barriers

Strengths


• Lack of legal privilege for reporters and managers (system confidentiality has no legal support).

• Lack of patient safety culture: lack of awareness of the need to reduce medical errors and improve patient safety.

• Still fear of reprisal. Fear of retaliation against themselves or punishment of others as a result of reporting.

• Sense of futility: in some cases lack of feedback from local managers to front-line professionals/ lack of visible changes in response to reports.

• Time conflict between clinical workload and work involved in event reporting.

• Event reports would be view as indicators of incompetence.


Weaknesses


Weaknesses: legal issues

Spain has no specific legislation protecting

reporters and system managers.

Most healthcare incidents and adverse events have no legal

implications because its causes can not be identified intentionality

or negligence. So the existence of a legislation to protect

professionals and managers in these cases, which are the

majority, can be very convenient for the consolidation of systems.

Denmark and US have specific regulations which aims to facilitate

and promote the implementation of reporting systems and

analysis of adverse events with strong protection of confidentiality

for patients, professionals and reporting institutions.


Weaknesses: legal issues

Litigation and claims

Negligence

Adverse events

Prevantable No Prevantable

Incidents

Near missed

Healtchcare risk

If you want to build a ship, don't drum up people to

collect wood and don't assign them tasks and work, but

rather teach them to long for the endless immensity of

the sea.

Weaknesses: Safety Culture

Antoine de Saint-Exupéry


PATIENT SAFETY AND CLINICAL RISK

MANAGEMENT IN OUR HEALTHCARE AREA

César Llorente Parrado

Quality Department. GAI. Ciudad Real.

February 21st.

Documents

PATIENT SAFETY AND CLINICAL RISK MANAGEMENT IN OUR ...hi.simplit.lt/uploads/news/id518/1. SiNASP_CReal_Spain_2014.pdf · PATIENT SAFETY AND CLINICAL RISK MANAGEMENT IN OUR HEALTHCARE