Dutch Patient Safety Program (SMS) ‘Prevent Injury, Work Safely’Safety Management System in the Flevo Hospital Objective Incident Reporting
Motivation• The report `you work here safely or not at all` by Rein Willems (2004)• EMGO/Nivel-research avoidable adverse events and mortality in Dutch hospitals commissioned by the Order of Medical Specialists (2007)• A Pilot project launched in 9 hospitals succesfully
Context SMSThe SMS systeem:• Continuously signals risks• Implements improvements• Secures hospital policy• Evaluates and improvesUsing this system:1. To controle the risk for patients2. To reduce (unintentional) damage to the patient•
ObjectivesThe Safety Management system:• Supports all Dutch hospitals by offering knowlege and offering a cooperation structure• 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•
Promoters• The Dutch Hospital Association (NVZ),• Netherlands Federation of University Medical Centres (NFU),• Order of Medical Specialists (OMS),• The Netherlands Centre for Excellence in Nursing (LEVV)• Nurses and Care Providers in the Netherlands (V&VN).
Projectduration & finance SMS Security program runs from January 2008to December 2012 and is funded partly by a grantfrom the Ministry of Health and partly by theprogram promoters
Participants• 93 Hospitals• 9 Hospital Networks• Participation in the SMS Safety Program is open to all Dutch hospitals• Specially developed training courses and conferences and participation in the nine hospital networks.
The approachTwo lines:- Line 1: The further introduction of a Safety Management System (SMS)- Line 2: Specific interventions in which results can be achieved quickly
Basic elements SMSThe basic elements for a certified SMS consist off at least:1. Formulating a security policy and strategy2. Creating a safe culture3. Reporting incidents safely4. Systematic Risk analysis5. A process for continuous improvement of the (patient) safety
10 Interventions1. 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 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
Know your riskReporting and analysing incidents andriskmanagement is an important part of the SMS.Objective: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
DTA 8009• In 9 pilot hospitals the basic elements for the SMS system had been laid down, tested and, where necessary, further developed.• The basic requirments have now been laid down in a Dutch Technical Agreement (DTA 8009)
The DTA and incident reporting• Management should be responsible for a good reporting system• 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.
Objective for our Hospital• Starting Incident reporting Better Faster 2006• Manual reporting vs Digital reporting• Designing a Report form• Formulating conditions for Local Reporting Committee• Transforming Central Reporting Committee• Statutes
Objective• Implementation in all hospitals, incident reporting in all departments• Safe reporting means that employees are confident that there is no blame if they report an incident• Employees are encouraged to report
What to report?• Anything that is not carried out as specified in regulations• Any adverse event
ResultsA 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)• 100% web based, no client side installations• Platform & database independent• Highly connectable• Modular and scalable• Very user-friendly
Results• 20 Local reporting committies on patiëntwards incl laboratory, pharmacy, radiology and out patiënt departments• Rollout to other departments (kitchen, reception and security)• 2573 Incidents 2009 (2119 in 2010)- 1933 near-incidents (1635 in 2010)- 640 incidents (484 in 2010)• Transform Central Reporting Committee• Statutes
Results• Quick response• Improvement program• Team involvement• Awareness• no head of department as a member of the incident commission (conflict of interest)• Seperate system for analysing dysfunction of employee
Responsablity SMS Flevo Hospital• Chairman of Board of Directors• Representative Medical Staff• Representative Nursing Staff• Quality & Organisation Consulting