EUNetPaS European Union Network for Patient Safety European Patients’ Rights Day 2009 April 17, 2009, Riga , Latvia Rasa Terbetiene M.D. StaHeCCA, MoH, Lithuania EUNetPaS European Union Network for Patient Safety

DEFINITION Patient Safety: The avoidance, prevention and amelioration of adverse events or injuries stemming from the process of health care. Adverse event: an unintended injury caused by medical management rather than by a disease process. 2

EPIDEMIOLOGY OF ADVERSE EVENTS Every 10th patient in EU hospitals suffers from an unintended harm 2/3 of adverse events are preventabe There are efective interventions for reducing the effect of error on mortality and morbidity 3

EU CONSULTATION ON PATIENT SAFETY 2008 Respondents were asked about personal or family members’ first-hand experience of an adverse event in a healthcare setting: 4 4

EUNetPaS European Union Network for Patient Safety Funded and supported by European Commision Coordinated by HAS (French National Authority for Health) 24 Associated partners (MS and international organizations) Duration 30 months (2008-2010) (Charles 5

OBJECTIVES of EUNetPaS To produce European added value of Member States collaboration by mutual support, and exchange of ideas and materials for accelerating progress To set up a pan European NETWORK for patient safety involving stake holders organised around national coordinators (National platforms) To pilot tools to reduce medication errors as a first step To promote education, a change in culture and a learning environment To propose a basis for research projects for better safety. 6

EUNetPaS: an EU network… A platform at EU level for collaboration and networking between: - 27 Member States - international organizations - stakeholders in the field of Patient Safety (decision makers, health care professionals, patients, researchers …) 7

…of National Networks National platforms National Institutions on Patient Safety (PS): Health Care Quality agencies Dedicated PS agencies or Department Decision makers and financers Healthcare professionals Patient representatives Research teams on PS National platforms 8

Development of National Patient Safety platforms 13 National PS Patforms Austria Belgium Denmark Finland France Germany Greece Ireland Netherlands Poland Spain Sweden UK 9

DEVELOPMENT OF CONCEPTS INTERVENTION STRATEGIES PILOT STUDIES in SITUATION ANALYSIS DEVELOPMENT OF CONCEPTS INTERVENTION STRATEGIES PILOT STUDIES in FIVE COORDINATED NETWORKING AREAS Executive Agency for Health and Consumers Patient Safety and Quality of care Working Group EUNetPaS, 27 countries Coordinated network Medication Errors Dissemination Promotion Education & Training Reporting and learning systems Patient safety culture 10

EUNetPaS TOPICS Promoting a Culture of PS WP1 EUNetPaS focuses on four topics: Promoting a Culture of PS WP1 Education and Training in PS WP2 Implementing Reporting and Learning Systems WP3 4. Pilot implementation on Medication Safety WP4 11

WP1: PS Culture WP leader: CBO (Holand) Partners: ESQH, EFN, SMoH, StaHeCCA, OECD Definition: the way we do things around here, our approach to risk management and the way we think and believe in response to risks in our health care environment “First do not harm” Hippocratic oath 12

WP1: PS Culture Measuring patient safety culture and experiences and Focus of the WP1 activities: Measuring patient safety culture and experiences and integrating this measurement in a patient safety improvement Deliverables: Compendium of good practices and examples: legislation, regulation, organizations, indicators, actions and solutions in the PS Status report on PS culture in MS and instrument for measurement/ folow up 13

WP2 PS Education and Training WP leader: Greece Partners: Spain, Germany, Ireland, Lithuania, EPF, CPME, EFN, ESQH Deliverable: Guidelines for education in Patient Safety : - proposal for core competencies and curricula for health profesionals - guidance for basic training for patients and care-givers 14

WP2 PS Education and Training Work methods and milestones: Collection of best practices: basic competences and education programs in PS Developing PS generic programs for pilot testing Identification of institutions for pilot implementation June 2009 – June 2010 PILOT TESTING - Medication errors - Medical paradigm - Nursing paradigm - Patient care-givers Guideline for PS education 15

WP3 Reporting and Learning Systems Adverse event: an unintended injury caused by medical management rather than by a disease process. Reporting and Learning System: A system with the potential to improve patient safety through the analysis of reported events, disemination of recommendations for system improvements, and implementation of leading practices. 16

WP3 Reporting and Learning Systems WP leader: DK National Board of Health Partners: Sweden, Lithuania, Greece, Portugal, Netherlands, UK, Finland, Slovakia, Italy, Poland, Hungary, Norway, Latvia, Germany, Romania Objectives, deliverable Collection, analysis and sharing of information about reporting and learning systems and their implementation (34 from 10 MS) Web based library of methods for reporting and learning systems implementation Establish a rapid response mechanism for sharing PS issues or sollutions between all member states 17

WP 4 Medication Safety WP leader: HOPE European Federation of Hospitals Partners: Finland, Belgium, Austria, EFN (nurses), PGEU (pharmacists) Pilot testing: Lithuania, Denmark, Netherlands, France, Portugal, Greece, reland. Objectives and deliverables: - To identify good practices in reducing medication errors in hospital, select a number of those and implement them in hospitals (3 hospitals in each of the10 participating member states) - To create a community with those hospitals to exchange at the level of the health professionals directly involved in clinical care 18

WP 4 Medication Safety Description of the work: Identification and selection of good practices in 63 practices reducing medication errors in hospitals from 16 MS Selection of best practices for pilot testing (7 practices selected) Selection of hospitals for pilot testing (11 MS ) Apr. 09 – Feb.10 PILOT TESTING Evaluation of the pilot testing and final report 19

WP4 selection of good practices 7 good practices have been selected and transformed into implementation tools 1. The safety vest “Do not disturb” for nurse during medicine preparation in wards (reduces the risk to make a mistake) 2. “The sleep card” – a guide line for doctors and nurses (reduces unnecessary treatment by sleeping pills) 3. Bed dispensation :preparation and administration of medicine by the same person at the patient’s bed (reduces the risk of confusion) 4. Medication list for patient reconciliation at discharge (education of patients) 20

Hospital selection Hospitals have been selected in 11 MS: Austria Belgium Denmark (on going) Finland Greece Ireland Lithuania ( 4 hospitals) Netherlands (on going) Portugal Italy France 21

EUNetPaS communication tools EUNetPaS logo, graphical chart and design of the website EUNetPaS website: http://www.eunetpas.eu 22

EUNetPaS Outcomes and Deliverables Culture measurement tool Guidelines for education Library of methods for reporting and learning systems implementation Rapid response mechanism for sharing high priority patient safety issues or solutions between all member states Medication safety recommendations 23

provides a tremendous challenge… but a real opportunity EUNetPaS provides a tremendous challenge… but a real opportunity to improve Patient Safety at the EU level, 24

EUnetPaS 46 partners!         25