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Patient safety culture at Landspitali
1. NURTURING PATIENT SAFETY
CULTURE AT LANDSPÍTALI
Ólafur Baldursson, chief medical officer
Sigríður Gunnarsdóttir, chief nursing officer
Elísabet Benedikz, director, division of patient safety/infection control
Landspítali – The National University Hospital of Iceland**
2. LANDSPÍTALI
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107.000 individuals
~400.000 patient visits
98.000 A&E visits
315.000 ambulatory visits
14.000 surgical operations
3.200 births
27.000 admissions
7,3 days, mean length of stay
4800 employees
A Third of the Icelandic Population is
Served by Landspitali each Year (2013)
~ 40 medical specialities
Cardiothoracic surgery
Kidney transplantation
Radiation therapy
High security psychiatry unit
NOT:
Transplantation in general
PET scan (under way)
3. LANDSPÍTALI
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A TYPICAL DAY AT LANDSPITALI (2013)
• 600 inpatients
• 1.300 ambulatory patients
• 5.300 clinical tests
• 550 pts. in physio and rehab.
• 300 pts. to A&E
• 75 new admissions
• 55 pts. undergo surgery
• 1600 students/Year
• 9 births
• 166 ambulatory pshych. pts.
• 40 to childrens A&E
• 7 card. cath. procedures
• 30 dialysis procedures
• 11 in intensive care
• 3.700 employees at work
• 3 ,7 tons of waste
• Electricity utilized
=4.000 homes
5. LANDSPÍTALI
THE “OLD” VISION
• More medical knowledge
• More efficient therapies
• Less morbidity and mortality
• We´re doing great!
• Required – not nearly sufficient
• New ways of measuring the service
6. LANDSPÍTALI
INCIDENTS REPORTED 2014 AND ´15
~ 3000 incidents per year
~ 25% due to falls
~ 18% due to medication errors
Patient surveys:
Discharge quality
Complaints from our website:
Lack of service culture
“No one greeted me”
9. LANDSPÍTALI
ONGOING, HOSPITAL WIDE, SAFETY IMPROVEMENT
PROJECTS
• “Huddles” - the daily security check – situational awareness
– Improved EMR, more real time individual patient data and patient flow data
– Patient flow data on large ward-monitors
• Streaming rounds – systematic ward rounds using check lists, role play according to
script and systematic flow of information
• SBAR – systematic exchange of clinical information (handover)
• The monitoring of vital signs protocol, including an incremental clinical response
• Skills lab/Sim training– training of teams, technical/non-technical
• Incident management / Root-cause-analysis
11. LANDSPÍTALI
ROOT CAUSE ANALYSIS TO PREVENT HARM
• Implemented in 2013
• Based on NHS (UK) methodology
• Two courses from the NHS, 2013 og 2014
• An additional course will be held in Nov. 2016
• 41 have received the formal training
5xwhy
12. LANDSPÍTALI
ROOT CAUSE ANALYSIS – THE CULTURE
J.REASON (2000)
Learning from incidents and preventing them !
–concentrates on the conditions
under which individuals work and
tries to build defences to avert
errors or mitigate their effects
– focuses on the errors of
individuals, blaming them for
forgetfulness, inattention, or
moral weakness
13. LANDSPÍTALI
REPEATED PROBLEMS FOUND IN ROOT CAUSE ANALYSES
1. Insufficient patient monitoring
2. Insufficient response to a worsening clinical state
3. Communication/Information breakdown
4. Lack of documentation and a segregated EMR, lacking
overview
5. How work is organized
6. Team skill mix
7. Dysfunctional teams
8. Lack of realistic patient involvement – “high hopes”
14. LANDSPÍTALI
LESSONS LEARNED
• RCA is efficient to define underlying causes of incidents
– System failures
– The “inner” nature of incidents
– Better focus on improvement efforts
– Supports those involved
• A tool, not a comprehensive solution
• Physician participation and involvement is crucial
• “Culture eats process for breakfast”
15. LANDSPÍTALI
IMPROVEMENT CULTURE
• Honest and organized conversations
– Handover
– 200% accountability
• Incident reporting and analysis
– 5 x Why ?
• Make it easier to do things right
• Learn from mistakes
16. LANDSPÍTALI
CULTURE – THE HUMAN FACTOR
• Do we acknowledge our mistakes/shortcomings ?
• Do we change to become better ?
• Do we correct our coworkers when they do the wrong
thing?
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17. LANDSPÍTALI
CURRENT CHALLENGES – “INTERNAL”
• “Spread the word” – Involve staff
• Discipline / Normalization of deviance
• Write, discuss, “film” and tell stories to support the culture ?
• Communication and team work
• Involve the biggest untapped resource of all: The Patients !
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18. LANDSPÍTALI
CURRENT CHALLENGES – “EXTERNAL”
• Politics at the national level
• A large scale effort is required
– Ministry of Health, The surgeon general, The Health sciences school, The health professional
bodies, The public, Patient organizations etc.
• The nurse-workforce
– Great potential to be the crucial factor increasting pt. safety
– Shortage
• The physician workforce is scattered and disorganized, and only partially under the
direction of the hospital
– Part time employment is common at the hospital
– The State pays physicians better salary in their “private offices”
• Physicians are preoccupied with “their own agenda”
– The Icelandic Medical Association
– Physician shortage vs. task shift
– Change the physician-culture
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