Patient Safety – The Danish Experience. Torben Mogensen. Presentation of the National Study of Adverse Events (Madrid, Ministry of Health and Consumer Affairs, 2006)

1. Patient Safety – The Danish Experience
Torben Mogensen, Medical Director
Hvidovre Hospital, Denmark

3. Aim of the preliminary
study
Calculation for full scale investigation
Test of method
Question:
The number of adverse events in Denmark =
number of adverse events in other countries ?
Estimation of the cost of adverse events
Estimation of the potential for prevention

4. Expected results of the
preliminary investigation
÷
+
Number of adverse
Number of adverse
events at each hospital
events in Denmark
or department
The price for adverse
Disability
events
Number of death
Potential for prevention
Which speciality
Test of method
Causation
Calculation for full
scale investigation Identification of
patients with risk
Comparison of hospital

5. 1.1
inp 07.6 Adverse Events Studies
ati 32
en
ts
England Harvard Australia Utah/Colorado
10,8 %
Number of AEs 40.982
3,7 % 143.992
13,0 % 32.121
2,9 %
AE’s 119.624
66 % AEs
Mild 56,8 % 46,6 % 53,3 %
Mild
19 %
Modera. Moderate AEs 13,7 % 30,5 % 31,6 %
6%
Severe AEs 2,6 % 13,7 % 8,4 %
Severe
Deaths 8% Deaths 13,6 %
5.574 4,9 %
7.056 6,6 %
2.120
9.787

6. Index admission
Index
admission
Event Found
Time

7. Definitions
Adverse event
Not preventable Ae Preventable Ae
(complication) (error)
Technical error Human error
Latent failures Active error
Error of
Error of action
omission

8. Latent and active error
-Human factor analyses
Stanhope et al: Br J Obst and Gyne ,
nov 97, 104, 1225 -1232

9. Investigators
• Experienced nurses
• Senior doctors

10. Education
• 2 day course
• Continuous evaluation

11. Method In-patients
Representative sample
1. step
Nurse screening
Positive screening
Medical evaluation Medical evaluation
2. step
Comparison of answers
Possible adverse event
3. step
Senior medical evaluation Senior medical evaluation
Conference

12. 1.107.632
In-patients
Results
1.097
Representative sample
Record not useful Nurse screening 1033
622 411
Negative screening Positive screening
Medical evaluation Medical evaluation
Comparison of answers
No adverse event Adverse event
Possible adverse event
64
Senior medical evaluation Senior medical evaluation
282
Conference
No adverse event Adverse event
No conclusion
904 15 114

13. Results
• 176 adverse events (complications & error)
• 114 admissions with adverse events
• 46 preventive adverse events (error)
• Risk of adverse events and complications 5,3 % (54/1018)
• Risk of adverse events due to error 2,1 %(22/1018)
• Number of admissions with adverse events 9,0 %(92/1018)
• Number of admissions with adverse events
due to error 3,6 %(37/1018)
• Increase in length of stay due to adverse events 7,0 days

14. Results – reduced ability to function
40
39
30
25
20
14
10 12
9 8
7
0
0-1 month 1-6 month 6-12 month Permanent Permanent Death Unknown
1-50% 50-100%

15. Preliminary investigation of adverse events
2001
No adverse events 91%
”Error” 40%
Standard treatment 60%
Adverse events 9%
www.dsi.dk/publikationer

16. 1 .1
pa 07.63 Adverse Events Studies
tie
nte 2
r
Denmark
Harvard Australia Utah/Colorado
1998
Number
3,7 % 13,0 % 2,9 %
40.982 143.992 32.121 115.104
of AEs
46,6 % 53,3 %
56,8 %
Mild AEs
Moderate
30,5 % 31,6 %
13,7 %
AEs
13,7 % 8,4 %
2,6 %
Severe AEs
4,9 % 6,6 % 7.067
13,6 %
5.574 7.056 2.120
Deaths

17. Conclusions
• The total amount of adverse events in Denmark
are comparable with previous studies from other
countries.
- Not better – not worse -
• The number of preventable adverse events are
the same as in previous studies.
• The investigation too small to evaluate the
number of death due to adverse events.

18. The Magic 3 Years
Danish Society for
Patient Safety
Law on Patient
Danish A.E.
Safety
Study
published
H:S Unit of
Study with
Patient Safety
Recommendations
What is Patient
Safety?
2000 2001 2002 2003

19. Teamwork
Danish Society for Patient Safety
• Established December, 2001
• Stakeholders represented in the board by their
president (hospital owners, professions, industry,
research & patient organisations)
• Gathers, spreads and develops knowledge and
initiatives
• Has become an important political factor

20. Law on Patient Safety
Law on Patient Safety
passed in the
ion
Parliament June 2003
sat
Learning
t
lain
en
mp
mp
Co
Co

21. Law on Patient Safety,
June 2003
Frontline Personnel obligated to report
Hospital Owners are obligated to act
Board of Health are obligated to
communicate

22. §6 in Law on
Patient Safety
A health care professional reporting an
adverse event shall not as a result of such
reporting be subjected to disciplinary
investigations or measures by the
Employing Authority, Supervisory
Reactions by the National Board of Health
or Criminal Sanctions by the Courts.

23. The hard work is yet to come

24. What can you expect in Spain?

25. 54.
835
. 76
0 in Adverse Events Studies
pat
i en
ts*
England Harvard Australia Utah/Colorado
10,8 %
Number of AEs 2.028.904
3,7 % 7.128.641
13,0 % 1.590.221
2,9 %
5.922.262
AE’s
66 % AEs
Mild 56,8 % 46,6 % 53,3 %
Mild
19 %
Modera. Moderate AEs 13,7 % 30,5 % 31,6 %
6%
Severe AEs 2,6 % 13,7 % 8,4 %
Severe
Deaths 8%Deaths 275.953
13,6 % 349.323
4,9 % 104.955
6,6 %
473.781
*) excl. Greece and UK. Numbers are from 2000, except Germany where the number is from
1999, OECD Health Data 2003, 3rd ed.

26. 4 .5
02.
740
Adverse Events Studies
i np
atie
n ts*
England Harvard Australia Utah/Colorado
10,8 % 166.601
Number of AEs 3,7 % 13,0 % 2,9 %
486.296 585.356 130.579
AE’s
66 % AEs
Mild 56,8 % 46,6 % 53,3 %
Mild
19 %
Modera. Moderate AEs 13,7 % 30,5 % 31,6 %
6%
Severe AEs 2,6 % 13,7 % 8,4 %
Severe
Deaths 22.658
8%
38.904
Deaths 13,6 % 4,9 % 6,6 %
28.682 8.618
*) Number is from 2000, OECD Health Data 2003, 3rd ed.