Patient Safety the Dutch way

Sylvia Fontaine Senior Quality Advisor, Hospital Coördinator SMS and ISO

The Netherlands

The past(1991)

The Present (2011)

Bigger, completer, better

2005 2010

Surface area 22.000 m2 58.000 m2

Beds 386 405

Operating rooms 5 10Operating rooms 5 10

IC 7 beds, level 1 12 beds, level 2

Docters 97 131

Employees 1.311 1.800

Budget € 75 mln € 133 mln

Clinical recordings 13.000 16.000

400.000

300.000

185.000

250.000

350.000+

Almere grows, so do we. . .

200.000

100.000

0

1980 1986 1994 1999 2008 2015 2030

10.000

50.000

100.000

140.000

185.000

Dutch Patient Safety Program (SMS) ‘Prevent Injury, Work Safely’Injury, Work Safely’

Safety Management System in the Flevo HospitalObjective Incident Reporting

• The report `you work here safely or not at all` by Rein Willems (2004)

• EMGO/Nivel-research avoidable adverse events

Motivation

and mortality in Dutch hospitals commissioned by the Order of Medical Specialists (2007)

• A Pilot project launched in 9 hospitals succesfully

The SMS systeem: • Continuously signals risks• Implements improvements• Secures hospital policy

Context SMS

• Secures hospital policy• Evaluates and improves

Using this system:1. To controle the risk for patients2. To reduce (unintentional) damage to the patient

•

The Safety Management system:

• Supports all Dutch hospitals by offering knowlege and offering a cooperation structure

Objectives

• 50% reduction of preventable unintentional injury • All hospitals are SMS accredited or certified by

December 31 2012 and have achieved the ten themes goals

• Objectives 10 themes achieved

•

• The Dutch Hospital Association (NVZ),• Netherlands Federation of University Medical

Centres (NFU),

Promoters

• Order of Medical Specialists (OMS), • The Netherlands Centre for Excellence in

Nursing (LEVV) • Nurses and Care Providers in the Netherlands

(V&VN).

SMS Security program runs from January 2008 to December 2012 and is funded partly by a grant from the Ministry of Health and partly by the program promoters

Projectduration & finance

program promoters

• 93 Hospitals• 9 Hospital Networks• Participation in the SMS Safety Program is open

to all Dutch hospitals

Participants

to all Dutch hospitals • Specially developed training courses and

conferences and participation in the nine hospital networks.

Two lines:- Line 1: The further introduction of a Safety

Management System (SMS)

The approach

- Line 2: Specific interventions in which results can be achieved quickly

The basic elements for a certified SMS consist off at least:

1. Formulating a security policy and strategy 2. Creating a 'safe' culture

Basic elements SMS

3. Reporting incidents safely 4. Systematic Risk analysis5. A process for continuous improvement of the

(patient) safety

1. Prevention of hospital infections after an operation2. Prevention of injury in patients with sepsis including a central venous line

(infection, blood poisoning)3. Early recognition of patients with threatened vital functions4. Prevention of medication errors, with attention mainly on transfer times

10 Interventions

4. Prevention of medication errors, with attention mainly on transfer times5. Prevention of accidental avoidable harm to elderly patients6. Prevention of death through a sudden unexpected heart attack (acute

myocardial infarction)7. Prevention of unnecessary patient suffering as a result of pain8. Prevention of incidents associated with the preparation and administration

of high-risk medication9. Prevention of mix-ups in and among patients10. Prevention of renal insufficiency (inadequate kidney function) through the

use of contrast agents and medication

Reporting and analysing incidents andriskmanagement is an important part of the SMS.

Objective:

Know your risk

To understand the functioning of the careprocess. The focus is not on the mistake a personmakes but on the conditions under which peoplework and how care is organized

• In 9 pilot hospitals the basic elements for the SMS system had been laid down, tested and, where necessary, further developed.

DTA 8009

• The basic requirments have now been laid down in a Dutch Technical Agreement (DTA 8009)

• Management should be responsible for a good reporting system

• Information from the incidents should be used to

The DTA and incident reporting

• Information from the incidents should be used to identify the main risks.

• Information from incident reports should be used for performing retrospective risk assessment to prevent similar incidents in the future.

• Starting Incident reporting Better Faster 2006• Manual reporting vs Digital reporting• Designing a Report form

Objective for our Hospital

• Designing a Report form• Formulating conditions for Local Reporting

Committee• Transforming Central Reporting Committee• Statutes

• Implementation in all hospitals, incident reporting in all departments

• Safe reporting means that employees are

Objective

confident that there is no blame if they report an incident

• Employees are encouraged to report

• Anything that is not carried out as specified in regulations

What to report?

• Any adverse event

A Digital reporting systeem• Most flexible and comprehensive system• Also Benchmark solution available!!• Solution which is fully customizable to the smallest details• Point-and-click configuration (no programming)

Results

• Point-and-click configuration (no programming)• 100% web based, no client side installations• Platform & database independent• Highly connectable • Modular and scalable• Very user-friendly

• 20 Local reporting committies on patiëntwards incl laboratory, pharmacy, radiology and out patiënt departments

• Rollout to other departments (kitchen, reception and security)

Results

and security) • 2573 Incidents 2009 (2119 in 2010)- 1933 near-incidents (1635 in 2010)- 640 incidents (484 in 2010)

• Transform Central Reporting Committee• Statutes

examination

falls

feeding

blood products

personnel

patient identification

4

3

2

2

1

1

6

4

3

3

2

2

1

20092010

0 5 10 15 20 25 30 35

medication

non classified

equipment

treatment

specialistic department

information

32

19

11

11

8

6

32

17

10

10

9

6

• Quick response• Improvement program• Team involvement • Awareness

Results

• Awareness

• no head of department as a member of the incident commission (conflict of interest)

• Seperate system for analysing dysfunction of employee

• Chairman of Board of Directors• Representative Medical Staff• Representative Nursing Staff• Quality & Organisation Consulting

Responsablity SMS FlevoHospital

• Quality & Organisation Consulting