1. Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience

2. Danish Society for Patient Safety “Something is rotten in the state of Denmark”

3. Danish Society for Patient Safety Act on Patient Safety Frontline Personnel obligated to report Hospital Owners are obligated to act Board of Health is obligated to communicate

4. Danish Society for Patient Safety §6 in Act on Patient Safety A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice

5. Danish Society for Patient Safety The organization of the Danish Reporting System National Board of Health Regional Patient Safety Units Hospitals The regional level

6. Danish Society for Patient Safety Reported adverse events Example from Copenhagen Hospital Corporation (H:S) Regional level

7. Danish Society for Patient Safety NCPS’ 5 steps for ensuring correct surgery JCAHO’s Universal Protocol Known Solution Regional level

8. Danish Society for Patient Safety Wrong site event # 1 Patient operated on the wrong side of the head Regional level

9. Danish Society for Patient Safety Wrong site event # 2 Patient operated on the wrong finger Regional level

10. Danish Society for Patient Safety Wrong site event # 3 Patient operated on the wrong side of the head Regional level

11. Danish Society for Patient Safety Head Office calls for Action: Pilot test of a Danish version of NCPS’ 5 steps Departments without reported wrong site events 410 procedures More than 90% of the surgeons made positive comments Participating departments Gynecology Urology Orthopedic surgery Surgical gastroenterology Regional level

12. Danish Society for Patient Safety During this time 12 wrong site surgical events 5 was prevented before incision 7 RCA (all with incision) 1:32.500 surgical procedures Root causes: Wrong site surgery is more likely to happen when: Number of occurrence in the 7 RCA’s The surgeon doesn’t participate in the preoperative identification of the patient 7 Scanty/obscure communication between OR personnel 4 Due to work pressure interruptions in the preoperative procedures 3 Significant differences between the operation schedule and the anaesthesia schedule 2 Regional level

13. Danish Society for Patient Safety Procedure to be used by all hospitals in the Copenhagen Hospital Corporation News Letters Power Point Presentations Literature Review FAQA Posters www.de5trin.dk Regional level

14. Danish Society for Patient Safety Regional level

15. Danish Society for Patient Safety Regional level

16. Danish Society for Patient Safety Baseline – April 2005 66% response rate, 40 out of 65 questionnaires fully completed (29 doctors, 11 nurses) Full knowledge of guideline Two more wrong site events identified Questionnaire survey to 65 head of departments Regional level

17. Danish Society for Patient Safety The organization of the Danish Reporting System National Board of Health Regional Patient Safety Units Hospitals The national level In 2004 additional 9 wrong site events reported to the national reporting system.

18. Danish Society for Patient Safety Epidemiology of wrong site surgery 57 wrong site surgical procedures reported to The Patient Insurance in 6 years 1:12.292 knee operations 1:8017 Neurosurgical procedures National level

19. Danish Society for Patient Safety Lessons learned Ownership to the problem requires ownership to the solution It makes good sense to share solutions tested and proved effect full elsewhere

20. Danish Society for Patient Safety Reporting