How to Change Adverse Event Reporting into Risk Management Practise

1. How to Change Adverse Event Reporting into Risk Management Practise Ritva Inkinen, project manager, patient safety ritva.inkinen@pshp.fi Tanja Lönnberg, spesialized nurse in nephrology tanja.lonnberg@pshp.fi 1st Nordic Patient Safety Conference Stockholm, May 20th- May 21st 2010

2. Finnish Patient Safety Strategy 2009- 2013 • Mission: We are promoting patient safety together • Vision: Patient safety will be embedded in the structures and methods of operation: care and treatment is effective and safe • Perspectives: culture, management, legislation and responsibility • Objectives: learning, management, patient involving, reporting

3. Patient Safety Development in Tampere University Hospital • Strategy for the executive program years 2008-2012 is to increase patient safety through development projects • Focus of projects is based on: - the strategy - use of data from adverse event reporting - self evaluation (EFQM) - changes in structures and practise

4. Planning and Creating the New Nephrology Expertise Center in TAUH • Foundation for safety culture: - patient safety - safe working conditions - employee welfare - risk management

5. ”renal disease” home/emergency policlinic - appointment - Peritoneal dialysis - pre- dialysis - procedures Peritoneal dialysis New appointment General practitioner Hemodialysis Follow-up care Home nursing Care institutions examinations Refer- ral Renal replacement therapy Discharge Home Policlinic Of Internal med. inpatient care Regional hospitals Health centers Home hospitals Policlinic Of Vascular surg. Possible kidney transplant

6. What has been done • Analysis of AE-reporting data (2007-2009, n=316 in nephrological unit) • Medication prevalence, quidelines for minimum regisration, checklist for patient discharging • Existing and possible risks evaluated by staff 2010 • Large survey about working conditions and employee welfare 2009 • Questionnaire for patients 2010 • FMEA

7. Improving the care of a kidney patient • Identification of potential risks in the nephrolgy units • Patient inquiry on theneeds for improvement • Mapping the current process of a kidney patient • critical points based on the risks identified • elimination of waste • Mapping the future process of a kidney patient • Formulation of an operational plan for the new nephrolgy centre • Mapping the current process of a kidney patient • Outpatient clinic • Ward • Peritoneal dialysis, hemodialysis Mapping the current process of an emergency patient in Internal Medicine Defintion of the minimumrequirements for recordingpatient data Checklist for the discharge of a patient Survey for the personnel on the employee welfare Recommendations for safe medication practise Risk identification of medication practise Adverse event reporting, kick-off 1.10.2007 • Plans for medication safety • Adverse event reporting • establishment of the practise • analysis of the incidents 2010 2007 2008 2009

8. Where do we find the risks? Critical phases in order to keep the service statement Primary care 4 10 Referral Service statement 7 1 2 3 8 9 5 11 6 13 Specialised care 12 14 Phramacy Labservices Technicalservices Admin.services Imagingservices

9. Equipment Working conditions Organisation Tasks Hygiene- unclear separation Between clean and unclean Resposibilities forregular and fault maintenance Lack in perceiving the Entity of care Insufficient room for Patien moving (with or without aids) Shortage of spare devices Problems are not Acknowledget or addressed Insufficient room for silence work Roles described – task Sharing does not work in practice Education and instructions for use Lack of recources inhibits Implementation of introduction Access of outsiders into Care facilities Lack of common documenting practice Inventories are notclose to the point of use Working solo because of Insufficient personnel Noise Acute dialyses The good care ofa kidney patientis compromised Know- how consentrated on few Information does notgo with the patient Lack of skilled staff for teaching patients Sufficiency of Isolation facilities Data is recorded in too many places Following hygiene regulations (MRSA) Number of patients/ Patient room (Washroom/ Toilet) Set policies are not always followed Communication between Professional groups Large number of temporary workers Lack of common policies for communication Limited protection of privacy Insufficient introduction Slowness and blocks in patient Database software Lack of common set of rules Suffiency of skill- holiday season/ Sudden leaves of absence Insufficient storage space Team work Education and skills Patient Communication

10. AN EXAMPLE OF FAILURE MODE AND EFFECTS ANALYSIS (FMEA) System name: Kidney patient care/adverse event reporting Responsible: Nephrology Unit/ Tampere University Hospital FMEA responsible: Ritva Inkinen Values of S between 1 and 10; values of O between 1 and 10; values of D between 10 and 1

12. Goals • Safety culture is the basis for patient care • Improving kidney patient process (PDCA) • Patients participate in improving patient safety • Staff learn to identify problems and harms in processes and systems • Patient safety is included in managemet and decision- making

13. Conclusions • Project is ongoing until 2012 • At the moment harms and risks in patient care are identified from individual point of view • Open patient safety culture must develop step by step • Management and funding must always be in evidence