1. 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

2. 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

3. 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

4. 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

5. 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 ( )
(Charles 5

6. 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

7. 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

8. …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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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 PILOT TESTING
- Medication errors
- Medical paradigm
- Nursing paradigm
- Patient care-givers
Guideline for PS education 15

16. 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

17. 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

18. 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

19. WP 4 Medication Safety Description of the work:
Identification and selection of good practices in 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

20. 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

21. 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

22. EUNetPaS communication tools
EUNetPaS logo, graphical chart and design of the website
EUNetPaS website: 22

23. 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

24. 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

25. EUnetPaS 46 partners! 25