ALIAS Conference 14-15 June 2012, Florence                                                             (Italy)            ...
Differences in safety and reliability    Bagnara, Parlangeli, Tartaglia. Applied ergonomics, 2010
Risk perception                        vsUnsafe climate5.6% naval aviators vs 17.5% healthcareoperators (20.9% in emergenc...
Emotional involvement                The technology barrier is thin  Direct relationship between the doctor and the patien...
The barriers to ultrasafe      Amalberti, R. et. al. Ann Intern Med 2005;142:756-764
When compared with traditional HROs, hospitals are      undoubtedly high-risk organizations, but havespecificities and exp...
Outline•   Incidence of adverse events•   Difficulty in improving patient safety•   Patient safety interventions and syste...
Outline•   Incidence of adverse events•   Difficulty in improving patient safety•   Patient safety interventions and syste...
The starting point
Incidence of adverse events (1964-2010)
First conclusions (2008)  Eight studies including a total of 74 485 patient  records were selected. The median overall inc...
Adverse events in developing countries  Of the 15 548 records reviewed, 8.2% showed at least one  adverse event, with a ra...
Adverse events in Italy (2011)Italy               Tartaglia    quality    7573         5,17   56,7 Tuscany teaching    Tar...
Outline•   Incidence of adverse events•   Difficulty in improving patient safety•   Patient safety interventions and syste...
Improving slowly Advancing the science of patient safety. Shekelle PG, Pronovost PJ, Wachter RM et Al. Ann Intern Med. 201...
The impact of the context    What context features might be important determinants of the effectiveness    of patient safe...
A framework for classifying patientsafety practices      A framework for classifying patient safety practices: results fro...
Improving slowly Advancing the science of patient safety. Shekelle PG, Pronovost PJ, Wachter RM et Al. Ann Intern Med. 201...
The impact of the patient safety culture    Randomized sample of 942 healthcare workers in    18 Italian HospitalsMore of ...
We can’t wait so long                        B. Pedersen, HEPS Oviedo, 2011
Outline•   Incidence of adverse events•   Difficulty in improving patient safety•   Patient safety interventions and syste...
• Clinical information available in hospital  outpatient clinics• Prescribing for hospital inpatient• Equipment availabili...
Reliability of the healthcaresystemHow reliable are clinical systems in the UK NHS? A study of seven NHS organisations    ...
Reliability of the healthcaresystems  Based on the approach of the US Institute for Healthcare Improvement  (IHI):  - reli...
Outline•   Incidence of adverse events•   Difficulty in improving patient safety•   Patient safety interventions and syste...
Understanding systems and the effect ofcomplexity on patient care                                 Vincent, 2005
Patient safety practices as a system       Right antibiotic                          Nutritional      Prevention of   Fall...
Good practices in critical care • Deploy Rapid Response • Deliver Reliable, Evidence-Based Care for Acute   Myocardial • P...
Good practices in OR, surgical unit • look-alike, sound-alike medication names; • patient identification; • communication ...
Surgical checklist:   resultsNEJM 360;5 nejm.org january 29, 2009The rate of death was 1.5% before the checklist was intro...
Certified good practices
Efficacy of the accreditationprocess on patient safety                    Efficacia dellaccreditamento studio             ...
The accreditation system of theTuscany RegionStandardization of processes with definition of main phases and quality and s...
Good Practices 2011         2011         indicator   indicator       indicator                      voluntary accreditatio...
Balancing Patient safety culture
Patient safety culture in Tuscany
The Disclosure                                                                                  Best practices            ...
Implications for the future• Evaluation of the adherence of the units  involved to clinical/ organizational practices  and...
Thanks for your attention!    Sara Albolino, PHD, CRM    Riccardo Tartaglia, MD, Eur-Erg    www.regione.toscana.it/rischio...
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Apply Patient Safety Solutions to Clinical Practice: why is it so hard by S. Albolino and R. Tartaglia

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Apply Patient Safety Solutions to Clinical Practice: why is it so hard by S. Albolino and R. Tartaglia

  1. 1. ALIAS Conference 14-15 June 2012, Florence (Italy) A SESAR Innovation Challenge: Responsibilities, Liabilities and Automation in Aviation Apply patient safety solutions to clinical practice. Why is it so hard?Sara Albolino, PHD, CRMRiccardo Tartaglia, MD, Eur-Ergwww.regione.toscana.it/rischioclinicorischio.clinico@regione.toscana.it
  2. 2. Differences in safety and reliability Bagnara, Parlangeli, Tartaglia. Applied ergonomics, 2010
  3. 3. Risk perception vsUnsafe climate5.6% naval aviators vs 17.5% healthcareoperators (20.9% in emergency department andoperating room) Gaba et al., 2003
  4. 4. Emotional involvement The technology barrier is thin Direct relationship between the doctor and the patient “double human being systems”
  5. 5. The barriers to ultrasafe Amalberti, R. et. al. Ann Intern Med 2005;142:756-764
  6. 6. When compared with traditional HROs, hospitals are undoubtedly high-risk organizations, but havespecificities and experience systemic socio-organizational barriers that make them difficult to transform into HROs Bagnara, Parlangeli, Tartaglia. Applied ergonomics, 2010
  7. 7. Outline• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and implications for the future
  8. 8. Outline• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and implications for the future
  9. 9. The starting point
  10. 10. Incidence of adverse events (1964-2010)
  11. 11. First conclusions (2008) Eight studies including a total of 74 485 patient records were selected. The median overall incidence of inhospital adverse events was 9.2%, with a median percentage of preventability of 43.5%. More than half (56.3%) of patients experienced no or minor disability, whereas 7.4% of events were lethal. Operation- (39.6%) and medication-related (15.1%) events constituted the majority.
  12. 12. Adverse events in developing countries Of the 15 548 records reviewed, 8.2% showed at least one adverse event, with a range of 2.5% to 18.4% per country.
  13. 13. Adverse events in Italy (2011)Italy Tartaglia quality 7573 5,17 56,7 Tuscany teaching Tartaglia quality 4227 6,7 42,9 hospitals Community Tartaglia quality 7066 1,9 56,8 hospitals 600.000 patients experience an adverse events every year
  14. 14. Outline• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and implications for the future
  15. 15. Improving slowly Advancing the science of patient safety. Shekelle PG, Pronovost PJ, Wachter RM et Al. Ann Intern Med. 2011 May 17;154(10):693-6. • Despite a decades worth of effort, patient safety has improved slowly • Complexity of the interventions and diversity of the contexts matter
  16. 16. The impact of the context What context features might be important determinants of the effectiveness of patient safetynpractice interventions? Peter J Pronovost, John Øvretveit, BMJ Qual Saf 2011
  17. 17. A framework for classifying patientsafety practices A framework for classifying patient safety practices: results from an expert consensus process Peter J Pronovost, John Øvretveit, BMJ Qual Saf 2011
  18. 18. Improving slowly Advancing the science of patient safety. Shekelle PG, Pronovost PJ, Wachter RM et Al. Ann Intern Med. 2011 May 17;154(10):693-6. Evaluation of the impact of this characteristics is important: • To help organization judge wheter an intervention shown to be effective elsewhere is likely to work in their settings • To propose cointerventions that can support implementation of a given practice • To evaluate if the costs of an intervention may outweigh its benefits
  19. 19. The impact of the patient safety culture Randomized sample of 942 healthcare workers in 18 Italian HospitalsMore of 70% professionals declared to haveexperienced an adverse events but half of them did notreport them because:•It is not a priority•Fear of mistrust among colleagues•There is not a reporting culture in my organization
  20. 20. We can’t wait so long B. Pedersen, HEPS Oviedo, 2011
  21. 21. Outline• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and implications for the future
  22. 22. • Clinical information available in hospital outpatient clinics• Prescribing for hospital inpatient• Equipment availability in the operating theatre• Equipment available for inserting peripheral intravenous lines
  23. 23. Reliability of the healthcaresystemHow reliable are clinical systems in the UK NHS? A study of seven NHS organisations Burnett S, Franklin BD, Moorthy K, Vincent et al. BMJ Qual Saf (2012). doi:10.1136/bmjqs-2011-000442
  24. 24. Reliability of the healthcaresystems Based on the approach of the US Institute for Healthcare Improvement (IHI): - reliability of <80 e 90%, indicates a lack of any articulated common process, - whereas reliability of around 95% suggests the presence of a clearly articulated process For healthcare organisations to begin to improve the reliability: - need for articulating or documenting the process as it is expected to function - define the required outputs. - this is a prerequisite for understanding where processes fail
  25. 25. Outline• Incidence of adverse events• Difficulty in improving patient safety• Patient safety interventions and system reliability• What to do: the importance of the system approach and implications for the future
  26. 26. Understanding systems and the effect ofcomplexity on patient care Vincent, 2005
  27. 27. Patient safety practices as a system Right antibiotic Nutritional Prevention of Falls Check list at the right CVC infection Prevention moment risk Correct patient Oncologic Communication Clinical audit Pain identification therapy of adverse management management event Reporting Prevention of Clean Incident never events decubituus reporting hands ulcers Management of Modified eraly Unified Mortality and the oral warning systen morbidity Therapeutic anticoagulant review therapy form Prevention of Preventio of Survellaince of the Deep venous Post-partum dystocyia antibiotic thrombosis emorragy resistance
  28. 28. Good practices in critical care • Deploy Rapid Response • Deliver Reliable, Evidence-Based Care for Acute Myocardial • Prevent Adverse Drug Events (ADEs) • Prevent Central Line • Prevent Surgical Site Infections • Prevent Ventilator-Associated Pneumonia Berwick 122.000 Pronovost 33.000
  29. 29. Good practices in OR, surgical unit • look-alike, sound-alike medication names; • patient identification; • communication during patient hand-overs; • performance of correct procedure at correct body site; • control of concentrated electrolyte solutions; • assuring medication accuracy at transitions in care; • avoiding catheter and tubing misconnections; • single use of injection devices; • improved hand hygiene to prevent associated infection; Nine patient safety solutions’, 2007
  30. 30. Surgical checklist: resultsNEJM 360;5 nejm.org january 29, 2009The rate of death was 1.5% before the checklist was introduced and declined to0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients atbaseline and in 7.0% after introduction of the checklist (P<0.001).
  31. 31. Certified good practices
  32. 32. Efficacy of the accreditationprocess on patient safety Efficacia dellaccreditamento studio randomizzato che dimostra che ci sono evidenze sulla parte organizzativaHealth service accreditation as a predictor of clinical and organisational performance: a blinded, random,stratified study Jeffrey et al.Qual Saf Health Care 2010;19: 14e21. doi:10.1136/qshc.2009.033928
  33. 33. The accreditation system of theTuscany RegionStandardization of processes with definition of main phases and quality and safetystandards:• Surgical pathway• Oncological/ screening pathway• Medical pathway• ER/ critical care pathway• Trauma pathway• Pediatric and obstetric pathway• Rehabilitation pathway• Mental Health and physical and psychological dependence pathway Accreditation through autocertification and random controls
  34. 34. Good Practices 2011 2011 indicator indicator indicator voluntary accreditation total AOUC 0,60 3,56 4,16 AOUP 1,56 8,57 10,13 Number of applied AOUS 0,00 9,18 9,18 patient safety AUOM 2,23 6,97 9,87 Fond. Monasterio practices for ecach 0,00 12,90 12,90 AUSL1 2,19 3,33 5,51 clinical unit of the ASL2 1,05 10,13 11,18 hospital ASL3 2,52 5,81 7,84 ASL4 1,96 3,25 5,21 ASL5 5,37 4,93 10,30 ASL6 0,00 3,48 3,48 ASL7 3,26 0,65 3,91 ASL8 2,76 7,12 9,88 AUSL9 12,03 2,81 14,84 ASL10 0,96 1,65 2,61 ASL11 0,86 8,22 9,31 ASL12 4,65 2,21 6,85
  35. 35. Balancing Patient safety culture
  36. 36. Patient safety culture in Tuscany
  37. 37. The Disclosure Best practices Adverse events http://web.rete.toscana.it/vetrinaasl/servlet Claims rate /gatewayThere is a positive correlation between public disclosure andaccreditation scores H Ito, H Sugawara Qual Saf Health Care 2005; 14:87–92. doi: 10.1136/qshc.2004.010629
  38. 38. Implications for the future• Evaluation of the adherence of the units involved to clinical/ organizational practices and national recommendations already diffused• Standardization of processes with definition of common safety standards throughout the units involved• Measure process indicators and outcome indicators
  39. 39. Thanks for your attention! Sara Albolino, PHD, CRM Riccardo Tartaglia, MD, Eur-Erg www.regione.toscana.it/rischioclinico rischio.clinico@regione.toscana.it

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