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 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 Mission: We are promoting patient safety together Vision: Patient safety will be embedded in the structures and methods of operation: Vision: Patient safety will be embedded in the structures and methods of operation: care and treatment is effective and safe care and treatment is effective and safe Perspectives: culture, management, legislation and responsibility Perspectives: culture, management, legislation and responsibility Objectives: learning, management, patient involving, reporting 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 Strategy for the executive program years 2008-2012 is to increase patient safety through development projects Focus of projects is based on: Focus of projects is based on: - the strategy - the strategy - use of data from adverse event reporting - use of data from adverse event reporting - self evaluation (EFQM) - self evaluation (EFQM) - changes in structures and practise - changes in structures and practise

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

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

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

7. Identification of potential risks in the nephrolgy units Patient inquiry on the needs 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 an emergency patient in Internal Medicine Defintion of the minimum requirements for recording patient data Checklist for the discharge of a patient Survey for the personnel on the employee welfare Improving the care of a kidney patient 2007 2008 2009 Mapping the current process of a kidney patient - Outpatient clinic - Ward - Peritoneal dialysis, hemodialysis 2010 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

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

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

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

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