The German experience in education on Patient Safety

The German Experience in Education on Patient Safety IV. International Conference on Patient Safety Finding the Best Practices for Safer Care Madrid, 25.-26.11.2008 Matthias Schrappe www.schrappe.com

00qm\\rm\\aktps\\brosch.cdr Prof. Dr. M. Schrappe

00qm\\rm\\AktPS\\konz1.cdr German Coalition for Patient Safety www.aktionsbuendnis-patientensicherheit.de

00qm\\lehre\\PersExp.cdr Personal Experience (Teaching) Patient Safety and Risk Management since 2005, as part of the MA study of Health Economics at the University of Cologne Quality Management Since 1997: lecture of QM as part of the study of Health Economics at the University of Cologne Postgraduate training of QM 1997-2001 LÄK Nordrhein Others Lecture in EBM and Clinical Epidemiology Lectures in Governance and Leadership Prof. Dr. M. Schrappe

00qm\\lehre\\d-Situat.cdr German Situation National Physicians Organization Curriculum on patient safety Curriculum on QM Curriculum governance and leadership Regional Physicians Organizations Skill-based training courses Patient safety curriculum University Education University of Cologne: study of Health Economy Bonn: University Institute for Patient Safety (from 1.1.09) Prof. Dr. M. Schrappe

badorb\\gliedrg.cdr Presentation Knowledge Skills Attitude Perspectives and Summary The German IV. International Prof. Dr. med. Matthias Schrappe Experience in Education Conference on Generalbevollmächtigter des AR on Patient Safety Patient Safety Klinikum der Goethe-Univ. Frankfurt

gliedrg.cdr Presentation Knowledge Skills Attitude Perspectives and Summary The German IV. International Prof. Dr. med. Matthias Schrappe Experience in Education Conference on Generalbevollmächtigter des AR on Patient Safety Patient Safety Klinikum der Goethe-Univ. Frankfurt

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Prof. Dr. M. Schrappe

00qm\\rm\\swiss.cdr Swiss Cheese - the error chain aus: Reason BMJ 320, 2000, 768 Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Nomenclature Prof. Dr. M. Schrappe

00qm\\rm\\systemat\\systemat.cdr Systematology Error + Adverse event = Preventable Adverse Event Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Nomenclature Incidence Prof. Dr. M. Schrappe

00qm\\rm\\adevent\\epidem4.cdr 100 Agenda Patientensicherheit 2006 90 80 Review: 70 Incidence AE* 60 147/184 trials AE (%) 50 40 30 20 10 0 10 100 1000 10000 100000 1000000 10000000 Stichprobe (n) *AE = adverse event Prof. Dr. M. Schrappe

00qm\\rm\\adevent\\epidem4.cdr Agenda Patientensicherheit 2006 100 90 Review: 80 Incidence ADE* 70 Patienten mit ADE (%) 68/184 trials 60 50 40 30 20 10 0 10 100 1000 10000 100000 1000000 10000000 Stichprobe (n) *ADE = adverse drug Prof. Dr. M. Schrappe event

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Nomenclature Incidence Kind of events Prof. Dr. M. Schrappe

00qm\\rm\\adevent\\epidem2.cdr Frequency of adverse events in Hospitals Nosocomial Infections: Prevalence D: 3,6% Rüden 1996 Adv. Drug Events: Metaanalysis: 2,1% Lazarou 1998 Adv. Med. Device Events: Incidence: 8,4 % Samore 2004 Decubitus (w/o. Stad. 1): Prevalence: 4,2% Dassen 2004 Falls: Prevalence: 2,4% Dassen 2004 Autopsy-Studies: Metaanalysis: 10,1% AHRQ 2002 Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Nomenclature Incidence Kind of events Prevention Prof. Dr. M. Schrappe

00qm\\rm\\seitenvw\\seitenID.cdr Prevention Wrong Site Surgery Bild: aus Presseservice Gesundheit AOK 28.4.05 Prof. Dr. M. Schrappe

00qm\\rm\\praev\\geldauto.cdr Prevention: Ergonomy Organize technical processes safely from: T.M. Nolan: System changes to improve patient safety. BMJ 320,2000,771 Prof. Dr. M. Schrappe

00qm\\rm\\praev\\bates03.cdr IT and Error-Prevention - Improvement of communication - Access to knowledge - Coming to information - Support of calculations - Support of timeliness - Monitoring - Give decision aids Bates, DW, Gawende AA: Improving Safety with Information Technology. NEJM 348, 2003, 2526 Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\knowledge.cdr Knowledge Modern understanding of incidents (error chain) Nomenclature Incidence Kind of events Prevention Informed consent and litigation Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\skills.cdr Skills Processanalysis after critical incidents Prof. Dr. M. Schrappe

00qm\\rm\\pa\\prozess_Sicht.cdr Events: to understand the process Unsafe Care Process Act Causing Unsafe Acts Preventable Adverse Event Prof. Dr. M. Schrappe

00qm\\rm\\pa\\prozess_Sicht.cdr Events: to understand the process Individual Unsafe Care Process Task Technical Environment Act Causing Organization Unsafe Acts Preventable Adverse Event Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\skills.cdr Skills Processanalysis after critical incidents How to measure: random bias, small numbers Prof. Dr. M. Schrappe

00inf_qm\\infcontr\\cholera.cdr Cholera-Epidemie London 1854 Prof. Dr. M. Schrappe

00qm\\rm\\zählen.cdr Measurement and Counting events / 100 patients ? events / 100 admissions ? events / 1000 patient-days ? events / 100 patients at risk ? events / 1000 patient-days at risk ? Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\skills.cdr Skills Processanalysis after critical incidents How to measure: random bias, small numbers Human factors Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\skills.cdr Skills Processanalysis after critical incidents How to measure: random bias, small numbers Human factors Why not doing what we are knowing? Prof. Dr. M. Schrappe

VF\\Eff_Gap.cdr Effectiveness Gap: Determinants Patient-related factors Age Gender Ethnic group Comorbidity Preferences Health Care Professionals Skills and knowledge Willingness to learn Attitudes Organisations Flexibility Ability to integrate innovations Integration of heterogeneity System factors Financing Sectoral organisation (Germany!) Prof. Dr. M. Schrappe

00qm\\rm\\lehre\\skills.cdr Skills Processanalysis after critical incidents How to measure: random bias, small numbers Human factors Why not doing what we are knowing? Concepts of organizational learning Prof. Dr. M. Schrappe

00infqm\\ash\\allg.cdr Aktion Saubere Hände German Clean Your Hands Campaigne Learning by feedback Volume of hand desinfectants Publicity: TV, mass media National agenda Prof. Dr. M. Schrappe

00qm\\rm\\ifps\\ifps.cdr Institute for Patient Safety Medical Faculty of the Start Friedrich-Wilhelms- University of Bonn 1.1.2009, official opening 8.5.2009 Teaching Integration in education of health professions Research topics Patient safety indicators, epidemiology and measurement, implementation research, safety culture Financing Federal Ministry of Health, donations, 28 sponsors Prof. Dr. M. Schrappe

zusfassg.cdr Summary Don’t underestimate knowledge (e.g., systematology, epidemiology) Skills: establishing new training facilities - process analysis after catastrophic events, human factors Attitude: integrate safety in university and basic education, understand organizational learning Perspective: making regional experience strengthening skill-orientation help physicians to trust in the benefit of change in organizational culture develop targeted programms for professions integrate patient safety in university education and outcome research Prof. Dr. M. Schrappe

Schluß Vielen Dank für Ihre Aufmerksamkeit ! Prof. Dr. M. Schrappe

The German experience in education on Patient Safety

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