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Patient safety - what works? 4 th  June 2009 See safety folder on web site  http://homepage.mac.com/johnovr/FileSharing2.html ,[object Object],[object Object],08/03/09
. ,[object Object],08/03/09 Once upon a time
 In a parallel universe
 Not so far from here
..
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
Don’t complicate things – what works 
? Proven safety solutions recommended or mandated by authoritative bodies  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical safety practices: changes for common problems ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Katolinska Sjukhus toilets – quick/low cost  video cams & poster 08/03/09
Katolinska Sjukhus 08/03/09
Good cost/effectiveness – direct communication with patients 08/03/09
We will do these 2 because these are a problem for us ,[object Object],[object Object],08/03/09
How do you know these work? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Sven Angstrom: the Dr Darth Viking of Shockholm sjukus & the Local Context King ,[object Object],[object Object]
Can you grow pineapples in Shockholm? 08/03/09 Seed Gardener/planting & nurture Climate / soil The point is, choose plants you see growing in similar environments – and change which aspects of climate you can  Can Darth change  the micro or macro climate? Anna, supported by Darth
Say again Jon? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Later
 back at the Katolinska Research Centre 
Jon calls together the research group 08/03/09
Jon enthuses the research team  - we can make a difference
 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
Other points about safety – post modernist writer in residence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
Research points - 2 ,[object Object],08/03/09
08/03/09 1994  1995  1996 1997 1998  1999  2000  2001  2002  2003  2004  2005  2006  2007  2008  2009 Theory informed evaluation – safety interventions evolve in context Actions:  planning and preparations Result: agreed care goals,  three shared centres and joint management Planning  Innovation  Further development actions Established  Actions to develop coordinated  client/patient care planning system  & other systems & procedures >>>>>>>>>>>>  Context factors  help and hinder implementation at different times Government policy  helps planning Intermediate results : coordination structures  and changes in personnel behaviour 1996  2000   2004    2008 Results : Consequences for personnel Results: Consequences for clients
Hindrances for us researchers: ,[object Object],[object Object],[object Object],[object Object],08/03/09
Johns safety research wish list ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
Other points about safety research – 3  – address the 4 challenges ,[object Object],[object Object],[object Object],[object Object],08/03/09
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
What works? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],08/03/09
What does not work? 08/03/09 “ be more careful”
Patient safety - what works? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Researchers may need guidance 
 08/03/09
Questions to you  
 ,[object Object],[object Object],[object Object],[object Object],08/03/09
. ,[object Object],08/03/09

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Ovret Sdo Patientsafety4 June09

  • 1.
  • 2.
  • 3.
  • 4.
  • 5.
  • 6. Katolinska Sjukhus toilets – quick/low cost video cams & poster 08/03/09
  • 8. Good cost/effectiveness – direct communication with patients 08/03/09
  • 9.
  • 10.
  • 11.
  • 12.
  • 13. Can you grow pineapples in Shockholm? 08/03/09 Seed Gardener/planting & nurture Climate / soil The point is, choose plants you see growing in similar environments – and change which aspects of climate you can Can Darth change the micro or macro climate? Anna, supported by Darth
  • 14.
  • 15. Later
 back at the Katolinska Research Centre 
Jon calls together the research group 08/03/09
  • 16.
  • 17.
  • 18.
  • 19. 08/03/09 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Theory informed evaluation – safety interventions evolve in context Actions: planning and preparations Result: agreed care goals, three shared centres and joint management Planning Innovation Further development actions Established Actions to develop coordinated client/patient care planning system & other systems & procedures >>>>>>>>>>>> Context factors help and hinder implementation at different times Government policy helps planning Intermediate results : coordination structures and changes in personnel behaviour 1996 2000 2004 2008 Results : Consequences for personnel Results: Consequences for clients
  • 20.
  • 21.
  • 22.
  • 23.
  • 24.
  • 25. What does not work? 08/03/09 “ be more careful”
  • 26.
  • 27. Researchers may need guidance 
 08/03/09
  • 28.
  • 29.

Hinweis der Redaktion

  1. Goal: Identify Patients Correctly ïżœ Requirement 1: Use at least two (2) ways to identify a patient when giving medicines, blood or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures. The patient's room number cannot be used to identify the patient. Goal: Improve Effective Communication ïżœ Requirement 2: Implement a process/procedure for taking verbal or telephone orders, or for the reporting of critical test results that requires a verification "read-back" of the complete order or test result by the person receiving the information. NOTE: Not all countries permit verbal or telephone orders. Goal: Improve the Safety of High-alert Medications Requirement 3: Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units. Goal: Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery Requirement 4: Use a checklist, including a "time-out" just before starting a surgical procedure, to ensure the correct patient, procedure and body part. Requirement 5: Develop a process or checklist to verify that all documents and equipment needed for surgery are on hand and correct and functioning properly before surgery begins. Requirement 6: Mark the precise site where the surgery will be performed. Use a clearly understood mark and involve the patient in doing this. Goal: Reduce the Risk of Health Care ïżœ acquired Infections Requirement 7: Comply with current published and generally accepted hand hygiene guidelines. NOTE: This should recognize that not all countries have a CDC (Centers for Disease Control and Prevention) or may not recognize the US CDC. Goal: Reduce the Risk of Patient Harm Resulting from Falls Requirement 8: Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to decrease or eliminate any identified risks.
  2. K eep it simple, Sven believes in green leadership
  3. I ts one thing in hot house study conditions, another out in the wild
  4. t
  5. t
  6. t