16. Dutch Patient Safety Program (SMS) ‘Prevent
Injury, Work Safely’
Safety Management System in the Flevo Hospital
Objective Incident Reporting
17. Motivation
• The report `you work here safely or not at all` by
Rein Willems (2004)
• EMGO/Nivel-research avoidable adverse events
and mortality in Dutch hospitals commissioned by
the Order of Medical Specialists (2007)
• A Pilot project launched in 9 hospitals
succesfully
18. Context SMS
The SMS systeem:
• Continuously signals risks
• Implements improvements
• Secures hospital policy
• Evaluates and improves
Using this system:
1. To controle the risk for patients
2. To reduce (unintentional) damage to the patient
•
19. Objectives
The Safety Management system:
• Supports all Dutch hospitals by offering knowlege
and offering a cooperation structure
• 50% reduction of preventable unintentional injury
• All hospitals are SMS accredited or certified by
December 31 2012 and have achieved the ten
themes goals
• Objectives 10 themes achieved
•
20. Promoters
• The Dutch Hospital Association (NVZ),
• Netherlands Federation of University Medical
Centres (NFU),
• Order of Medical Specialists (OMS),
• The Netherlands Centre for Excellence in
Nursing (LEVV)
• Nurses and Care Providers in the Netherlands
(V&VN).
21. Projectduration & finance
SMS Security program runs from January 2008
to December 2012 and is funded partly by a grant
from the Ministry of Health and partly by the
program promoters
22. Participants
• 93 Hospitals
• 9 Hospital Networks
• Participation in the SMS Safety Program is open
to all Dutch hospitals
• Specially developed training courses and
conferences and participation in the nine hospital
networks.
23. The approach
Two lines:
- Line 1: The further introduction of a Safety
Management System (SMS)
- Line 2: Specific interventions in which results can
be achieved quickly
24. Basic elements SMS
The basic elements for a certified SMS consist off
at least:
1. Formulating a security policy and strategy
2. Creating a 'safe' culture
3. Reporting incidents safely
4. Systematic Risk analysis
5. A process for continuous improvement of the
(patient) safety
25. 10 Interventions
1. Prevention of hospital infections after an operation
2. Prevention of injury in patients with sepsis including a central venous line
(infection, blood poisoning)
3. Early recognition of patients with threatened vital functions
4. Prevention of medication errors, with attention mainly on transfer times
5. Prevention of accidental avoidable harm to elderly patients
6. Prevention of death through a sudden unexpected heart attack (acute
myocardial infarction)
7. Prevention of unnecessary patient suffering as a result of pain
8. Prevention of incidents associated with the preparation and administration
of high-risk medication
9. Prevention of mix-ups in and among patients
10. Prevention of renal insufficiency (inadequate kidney function) through the
use of contrast agents and medication
26. Know your risk
Reporting and analysing incidents and
riskmanagement is an important part of the SMS.
Objective:
To understand the functioning of the care
process. The focus is not on the mistake a person
makes but on the conditions under which people
work and how care is organized
27. DTA 8009
• In 9 pilot hospitals the basic elements for the
SMS system had been laid down, tested and,
where necessary, further developed.
• The basic requirments have now been laid down
in a Dutch Technical Agreement (DTA 8009)
28. The DTA and incident
reporting
• Management should be responsible for a good
reporting system
• Information from the incidents should be used to
identify the main risks.
• Information from incident reports should be used
for performing retrospective risk assessment to
prevent similar incidents in the future.
29. Objective for our Hospital
• Starting Incident reporting Better Faster 2006
• Manual reporting vs Digital reporting
• Designing a Report form
• Formulating conditions for Local Reporting
Committee
• Transforming Central Reporting Committee
• Statutes
30. Objective
• Implementation in all hospitals, incident reporting
in all departments
• Safe reporting means that employees are
confident that there is no blame if they report an
incident
• Employees are encouraged to report
31. What to report?
• Anything that is not carried out as
specified in regulations
• Any adverse event
32. Results
A Digital reporting systeem
• Most flexible and comprehensive system
• Also Benchmark solution available!!
• Solution which is fully customizable to the smallest details
• Point-and-click configuration (no programming)
• 100% web based, no client side installations
• Platform & database independent
• Highly connectable
• Modular and scalable
• Very user-friendly
33. Results
• 20 Local reporting committies on patiëntwards
incl laboratory, pharmacy, radiology and out
patiënt departments
• Rollout to other departments (kitchen, reception
and security)
• 2573 Incidents 2009 (2119 in 2010)
- 1933 near-incidents (1635 in 2010)
- 640 incidents (484 in 2010)
• Transform Central Reporting Committee
• Statutes
35. Results
• Quick response
• Improvement program
• Team involvement
• Awareness
• no head of department as a member of the incident
commission (conflict of interest)
• Seperate system for analysing dysfunction of
employee
36. Responsablity SMS Flevo
Hospital
• Chairman of Board of Directors
• Representative Medical Staff
• Representative Nursing Staff
• Quality & Organisation Consulting
