1. 11 SPANISH EXPERIENCE IN CLINICAL RISK MANAGEMENT AEGRIS (Spanish Society of Clinical Risk Management) Department of General and Digestive Surgery Clinical Risk Management Unit Complejo Hospitalario de Ciudad Real. Spain AEGRIS (Spanish Society of Clinical Risk Management) Department of General and Digestive Surgery Clinical Risk Management Unit Complejo Hospitalario de Ciudad Real. Spain EUROPEAN WORKSHOP ON HEALTHCARE RISK MANAGEMENT Roma, June 13th 2005 EUROPEAN WORKSHOP ON HEALTHCARE RISK MANAGEMENT Roma, June 13th 2005

2. THE SPANISH EXPERIENCE IN RISK MANAGEMENT….. FROM A NATIONAL AND REGIONAL POINT OF VIEW… TO THE PRACTICAL REALITY IN A TERTIARY HOSPITAL THE SPANISH EXPERIENCE IN RISK MANAGEMENT….. FROM A NATIONAL AND REGIONAL POINT OF VIEW… TO THE PRACTICAL REALITY IN A TERTIARY HOSPITAL

3. 17 REGIONS + 2 CITIES 18 HEALTH AUTHORITIES Ciudad Real

4. Spanish Legal System Criminal Court Administrative Court. In a public Health System all the compensation claims are against the institution, not the individual (Laws: 30/1992, 4/1999, 19/2003) Spanish Legal System Criminal Court Administrative Court. In a public Health System all the compensation claims are against the institution, not the individual (Laws: 30/1992, 4/1999, 19/2003)

5. Since there are 18 different Health Authorities it is nearly impossible to obtain global data on the number and economical impact of claims. All public data available are those from the INSALUD between 1995 and 2000

6. INSALUD: 13 million population 1995-1998: 6,000,000 € 1998 – 2000: 9,000,000 € 2000 – 2002: 18,000,000 € 2003 – 2004: 26,500,000 € 63 million € in 2003 for all the NHS. Number of claims from 1995 to 2000: 2.700 with an increase of 15% every year INSALUD: 13 million population 1995-1998: 6,000,000 € 1998 – 2000: 9,000,000 € 2000 – 2002: 18,000,000 € 2003 – 2004: 26,500,000 € 63 million € in 2003 for all the NHS. Number of claims from 1995 to 2000: 2.700 with an increase of 15% every year

7. ACCIDENT/ 100 BEDS: 2,1 COST/BED: 310 € COST/ACCIDENT: 15.000 € ACCIDENT/ 100 BEDS: 2,1 COST/BED: 310 € COST/ACCIDENT: 15.000 €

8. GOVERNMENT… NHS Quality Agency. Four step policy: 1.Prioritize 2.Improve reporting systems 3.Improve professional competence 4.Improve common strategies in all the different organizations GOVERNMENT… NHS Quality Agency. Four step policy: 1.Prioritize 2.Improve reporting systems 3.Improve professional competence 4.Improve common strategies in all the different organizations NATIONAL INITIATIVES

9. GOVERNMENT… NHS Quality Agency. Four step policy: 1.- PRIORITIZE Patient Safety Meeting (Feb 8th, 2005) Experts Workshop Technical Group involving all regions Proposals to the National Health Authorities GOVERNMENT… NHS Quality Agency. Four step policy: 1.- PRIORITIZE Patient Safety Meeting (Feb 8th, 2005) Experts Workshop Technical Group involving all regions Proposals to the National Health Authorities NATIONAL INITIATIVES

10. GOVERNMENT… NHS Quality Agency. Four step policy: 2.- REPORTING SYSTEMS Still doubts to be resolved…… Confidentiality Independence from Insurance companies and Justice Not punitive… GOVERNMENT… NHS Quality Agency. Four step policy: 2.- REPORTING SYSTEMS Still doubts to be resolved…… Confidentiality Independence from Insurance companies and Justice Not punitive… NATIONAL INITIATIVES

11. GOVERNMENT… NHS Quality Agency. Four step policy: 4.- IMPROVE COMMON STRATEGIES With Professional associations With patient’s associations With judges Create a safety policy…. GOVERNMENT… NHS Quality Agency. Four step policy: 4.- IMPROVE COMMON STRATEGIES With Professional associations With patient’s associations With judges Create a safety policy…. NATIONAL INITIATIVES

12. GOVERNMENT… NHS Quality Agency. Four step policy: SAFETY POLICY 6,000,000 € BUDGET. 4 objectives 1.Study the incidence of adverse events 2.Training for medical and non medical staff 3.Identification systems for in- patients 4.Improvement of Nosocomial infection rate GOVERNMENT… NHS Quality Agency. Four step policy: SAFETY POLICY 6,000,000 € BUDGET. 4 objectives 1.Study the incidence of adverse events 2.Training for medical and non medical staff 3.Identification systems for in- patients 4.Improvement of Nosocomial infection rate NATIONAL INITIATIVES

13. GOVERNMENT… NHS Quality Agency. Four step policy: SAFETY POLICY 6,000,000 € BUDGET Allocated to the Regional Health Authorities to complete the four objectives GOVERNMENT… NHS Quality Agency. Four step policy: SAFETY POLICY 6,000,000 € BUDGET Allocated to the Regional Health Authorities to complete the four objectives NATIONAL INITIATIVES

14. 1.AEGRIS Training in Clinical Risk Management. Publications. Courses. Annual Congress dedicated to CRM 2.Patient Safety Centre (Avedis Donavedian Foundation) 1.AEGRIS Training in Clinical Risk Management. Publications. Courses. Annual Congress dedicated to CRM 2.Patient Safety Centre (Avedis Donavedian Foundation) NON GOVERNMENTAL INITIATIVES

15. 1.IDEA project. San Juan University. Prof Aranaz. 2.Medication errors, ISMP Spain. Universities of Salamanca, Barcelona, Madrid, Pais Vasco 3.Adverse events incidence. Cataluña hospitals. MAPFRE foundation 4.And so on……. 1.IDEA project. San Juan University. Prof Aranaz. 2.Medication errors, ISMP Spain. Universities of Salamanca, Barcelona, Madrid, Pais Vasco 3.Adverse events incidence. Cataluña hospitals. MAPFRE foundation 4.And so on……. SCIENTIFIC RESEARCH

16. REGIONAL HEALTH AUTHORITY REGIONAL INITIATIVES MURCIA

17. MURCIA HEALTH AUTHORITY REGIONAL INITIATIVES 1.- Creation of a Central Patient Safety Regional Unit Run by experienced professionals in Clinical Risk Management All the background and information from previous claims Support for Risk Management Programmes Drive Adverse Events studies Create an Incident Reporting System Analyse Incidents reported centrally and propose corrective measures in collaboration with the Local CRM Units Training of medical and non medical staff in CRM Appoint Clinical Risk Managers 2.- Creation of Local Clinical Risk Management Units In one years time

18. CASTILLA LA MANCHA HEALTH AUTHORITY (SESCAM) LOCAL INITIATIVES CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL. SEPTEMBER 2004

19. CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL GENERAL HOSPITAL 2004 1.SUPPORT FROM THE CHIEF EXECUTIVE OF THE SESCAM 2.SUPPORT FROM THE HOSPITAL MANAGER 3.SUPPORT FROM THE HEAD OF DPTS 4.STAFF (MEDICAL, NURSES, AUXILIARY NURSES, ADMINISTRATIVE, PORTERS….)WHO WANTED TO VOLUNTARILY COLLABORATE IN THE PROJECT ……remunerated with days CREATION OF A CLINICAL RISK MANAGEMENT UNIT IN CIUDAD REAL GENERAL HOSPITAL 2004 1.SUPPORT FROM THE CHIEF EXECUTIVE OF THE SESCAM 2.SUPPORT FROM THE HOSPITAL MANAGER 3.SUPPORT FROM THE HEAD OF DPTS 4.STAFF (MEDICAL, NURSES, AUXILIARY NURSES, ADMINISTRATIVE, PORTERS….)WHO WANTED TO VOLUNTARILY COLLABORATE IN THE PROJECT ……remunerated with days HOW TO IDENTIFY RISKS IN A PRACTICAL WAY?

20.  Mainly by clinicians  3 area supervisors (surgical, medical and central sevices) and 2 nurses from A&E  3 surgeons  Medical staff, nurses, auxiliary nurses who want to participate from:  GENERAL SURGERY  A&E  THEATRES  NUCLEAR MEDICINE  GYNAE AND OBST  NEPHROLOGY  ENT…  Mainly by clinicians  3 area supervisors (surgical, medical and central sevices) and 2 nurses from A&E  3 surgeons  Medical staff, nurses, auxiliary nurses who want to participate from:  GENERAL SURGERY  A&E  THEATRES  NUCLEAR MEDICINE  GYNAE AND OBST  NEPHROLOGY  ENT… CLINICAL RISK MANAGEMENT UNIT

21.  All work full time in their clinical work and help in the Unit as volunteers the time they can  Unit situated on the 7th floor, 24 m 2 ….…far from the Executive Management of the Hospital  All work full time in their clinical work and help in the Unit as volunteers the time they can  Unit situated on the 7th floor, 24 m 2 ….…far from the Executive Management of the Hospital CLINICAL RISK MANAGEMENT UNIT

22. OBJECTIVES  Risk Assessment of the Units  Implementing an incident reporting system  Analysis of incidents  Identification, common proposals for changes in close collaboration with the Head of Dpt, follow up of actions taken  Cooperation in how to develope and produce reports reports after receiving a claim  Risk Assessment of the Units  Implementing an incident reporting system  Analysis of incidents  Identification, common proposals for changes in close collaboration with the Head of Dpt, follow up of actions taken  Cooperation in how to develope and produce reports reports after receiving a claim

23. OBJECTIVES  Advise in high risk situations  RM Continuous Education for staff  Help in the design of RM Programmes for the Dpts that want to collaborate  Establish a“zero tolerance” policy related to agression against staff  Advise in high risk situations  RM Continuous Education for staff  Help in the design of RM Programmes for the Dpts that want to collaborate  Establish a“zero tolerance” policy related to agression against staff

24. ACTIONS PERFORMED  73 actions…..  Presentation of the CRM Unit at the General Session of the Hospital  Presentation of the Law 41 at the General Session of the Hospital  All Informed Consent forms from the Dpt of General and Digestive surgery were adapted to comply with the new Law 41  Creation of an Informed Consent process for sedation in terminal patients  73 actions…..  Presentation of the CRM Unit at the General Session of the Hospital  Presentation of the Law 41 at the General Session of the Hospital  All Informed Consent forms from the Dpt of General and Digestive surgery were adapted to comply with the new Law 41  Creation of an Informed Consent process for sedation in terminal patients

25.  Confidentiality in the Pathology results circuit  Assessment of high risk situations when asked by nurses or physicians involved  Confidentiality for admitted patients  New circuit for pathology specimens obtained in theatre  Confidentiality in the Pathology results circuit  Assessment of high risk situations when asked by nurses or physicians involved  Confidentiality for admitted patients  New circuit for pathology specimens obtained in theatre ACTIONS PERFORMED

26.  Claim reports (11 cases)  Intervention in risk situations when the family or relatives are not happy with medical care given (internal medicine, urology, A&E)  Reports about capability of medical and non medical staff….that can affect patient safety….can this resident, doctor, nurse take care of the patient??  First step after physical and non physical violence against staff  Claim reports (11 cases)  Intervention in risk situations when the family or relatives are not happy with medical care given (internal medicine, urology, A&E)  Reports about capability of medical and non medical staff….that can affect patient safety….can this resident, doctor, nurse take care of the patient??  First step after physical and non physical violence against staff ACTIONS PERFORMED

27.  Modification of the diagnostic imaging contrast medium injection protocol at the Nuclear Medicine Department (double cheking)  Assessment of Medication errors on the wards  Creation of a “Patient Safety Comission” with the participation of all the directors of the hospital and Health and Safety  Clinical Risk Management 50 hours course ready to start  Modification of the diagnostic imaging contrast medium injection protocol at the Nuclear Medicine Department (double cheking)  Assessment of Medication errors on the wards  Creation of a “Patient Safety Comission” with the participation of all the directors of the hospital and Health and Safety  Clinical Risk Management 50 hours course ready to start ACTIONS PERFORMED

28.  Adverse Incident Review of Medical records. Clinical application of the research project. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent  Effect of Distractions in theatre related to Patient Safety. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent  Adverse Incident Review of Medical records. Clinical application of the research project. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent  Effect of Distractions in theatre related to Patient Safety. In collaboration with the Patient Safety Unit at St Mary’s Hospital, Imperial College, London directed by Professor Charles Vincent NEW RESEARCH PROJECTS

29. NURSES ACTIONS PERFORMED  Creation of an information leaflet for auxiliary nurses who are new starters to theatre explaining Pathology specimen circuit…and what to do with them  Design of Induction Programmes for nurses working in A&E, Surgical Area and ICU  Identification band for patients admitted to A&E  New counting system for swabs in theatre  Pilot project for a new medication system (Surgical Department)  Collaboration with Haematology in the design of the transfusion process/policy circuit  Organizational changes in A&E aiming to improve Patient Safety  Creation of an information leaflet for auxiliary nurses who are new starters to theatre explaining Pathology specimen circuit…and what to do with them  Design of Induction Programmes for nurses working in A&E, Surgical Area and ICU  Identification band for patients admitted to A&E  New counting system for swabs in theatre  Pilot project for a new medication system (Surgical Department)  Collaboration with Haematology in the design of the transfusion process/policy circuit  Organizational changes in A&E aiming to improve Patient Safety

30. MAJOR PROBLEMS FOR THE UNIT

31. LACK OF TIME..........

32. SCEPTISCISM.........

33. IT IS NOT A PRIORITY NOW…..

34. I DO NOT COLLABORATE WITH THE MEDICAL DIRECTORS……

35. IF IT IS RUN BY SURGEONS I DON’T WANT TO KNOW ANYTHING ABOUT IT........

36. THE FUTURE IS NOT EASY, BUT NOBODY SAID IT WAS GOING TO BE AND A FINAL CONCLUSION… THE FUTURE IS NOT EASY, BUT NOBODY SAID IT WAS GOING TO BE AND A FINAL CONCLUSION…

37. THE SUCCESS OF CLINICAL RISK MANAGEMENT DEPENDS DIRECTLY ON THE INVOLVEMENT OF ALL MEDICAL AND NON MEDICAL STAFF WORKING IN A HOSPITAL….

38. ….IT DOES NOT DEPEND ONLY UPON THE POLITICAL DESIRE….. “DO IT…….IT WILL WORK” ….IT DOES NOT DEPEND ONLY UPON THE POLITICAL DESIRE….. “DO IT…….IT WILL WORK”

39. PATIENT SAFETY POLICIES WE ALL DREAM OF.........

40. DON QUIJOTE RULES….

41. If you follow these rules, Sancho,. Your days will be long,. Your fame eternal,. You will receive many gifts,. Your happiness will be impossible to describe,. Your children will marry as you desire. You will live in peace with your people. And you will improve patient safety…. If you follow these rules, Sancho,. Your days will be long,. Your fame eternal,. You will receive many gifts,. Your happiness will be impossible to describe,. Your children will marry as you desire. You will live in peace with your people. And you will improve patient safety….

42. “2005. IV CENTENARY” EL INGENIOSO HIDALGO DON QUIJOTE DE LA MANCHA PART II CHAPTER XLI “2005. IV CENTENARY” EL INGENIOSO HIDALGO DON QUIJOTE DE LA MANCHA PART II CHAPTER XLI