NATIONAL INITIATIVE FOR IMPROVED PATIENT SAFETY

From blaming to improvement
Working together for the safest healthcare in the world

The Swedish Associations of Local
Authorities and Regions (SALAR) We act as an employer’sorganisation, and defend
and promote the interests ofour members.

JapanPopulation2012 estimate
DensityArea
Total

126,659,683
337.1/km2

377,944 km2
145,925 sq mi
GDP (PPP) 2012 estimate
Total$4.628 trillion
Per capita$36,266
Gini (2008)
37.6
HDI (2013)
0.912

SwedenPopulation2012 census
DensityArea
Total

9,555,893
20.6/km2

449,964 km2
173,745 sq mi
GDP (PPP) 2011 estimate
Total$381.719 billion
Per capita$40,393
Gini (2005)
23HDI (2013)
0.916

From blaming culture toimprovement culture- Patient safety is about how to prevent adverse events- The purpose of this shift in culture is to learn from mistakes

Adverse event- Adverse event- Suffering, physical or mental harm or illness and death that
could have been avoided if adequate measures had been takenin the patient´s contact with healthcare services- Serious adverse event- An adverse event that is lasting and not minor or has led to asignificant increase in the patient´s need of healthcare or to
the death of the patient
Patient Safety Act, SFS 2010:659

Reduce adverse events
To err is human - buildning a safer health system(Harvard 1999)
Swedish study, 2008
Huge problem-

Affect many – 105 000 patients
Cause suffering – 10 000 patients suffered lasting harm
Cost a lot of money – 630 000 care days

Knowledge exists-

70 % could probably have been prevented

Huge potential for improvement

Adverse events are theconsequences of••••Missed or delayed diagnoses
Incorrect surgical procedures and treatments
Medication errors
Poor hygiene leading to severe infections

Types of adverse events
Allergic reaction
2%

Obstetric injury
1%

Medical device
related injury
0%

Thrombosis
3%

Bleeding
3%

Anaesthesia related
injury1%

Fall
6%

Pressure ulcer
8%

Hospital acquired
infection
40%

Surgical injury
11%

Medication related
injury
12%

Other
13%

Before the Act- Blaming culture- Healthcare professionals could be given a warning and areminder (disciplinary sanctions) – Medical Responsibility Board- People were afraid to admit their mistakes- Changes and improvements were difficult to achieve

Why a new act?
- The former Healthcare Professionals Act was not effective
enough to reduce adverse events- Wish for a more proactive Act- Wish for more of a system perspective instead of an individual
perspective- Strengthen patient rights

What does the new Act involve?
- To make healthcare safer- The healthcare provider is given a clear responsibility to conduct
systematic work on patient safety- Preventive approach - prevent adverse events- Patients and their close relatives will be invited to take part in the work
to improve patient safety- The disciplinary sanctions of a warning and a reminder are removed
and replaced by the possibility of directing more criticism at and taking
action against both healthcare providers and healthcare professionals.
- Expands the possibilities of ordering a three-year trial period which
includes support for licensed healthcare professionals and can order thewithdrawal of licences to practice - The Medical Responsibility Board- Complaints – the whole event is investigatedSystems thinking- An adverse event is a result of deficient interaction between individuals
and systems. It is when the interaction between humans, technology
and organisation is inadequate that near accidents and adverse events
can occur- In a good safety culture , professionals are encouraged to conduct risk
analyses and report incidents that could have led to an adverse event- This approach encourages learning and increases risk awereness- ”It should be easy to do the right thing and hard to do the wrong thing”
captures an important aspect of the term safety cultureImprovement culture-Management engagement
Knowledge about the problem
Measurements
Openess regarding results
Aims
Improvements

Patient Safety Culture
Healthcare is a high-risk sector- a dynamic and complex system- The approaches and attitudes which an organisation and its
professionals have towards risks

Improved culture presupposes agood Patient Safety Culture
A good patient safety culture is characterised by: ..the professionals and the management admitting that errors can bemade in the organisation
 ..the professionals feel that they can report errors and risks without
fear of ”blame and shame”

 ..there is good cooperation between all levels to find solutions topatient safety issues
 ..there is specific provision of resources

Patient Safety Culture in 2011
Information and support to staff inconnection with an adverse event
Information and support to patientin connection with an adverse
event
Transfer of patients andinformation

Collaboration between careunits

Willingness to report events
90807060504030
20100

Total safety awerness
Self-assesment of patient
safety level
My line-managers behavior
towards patient safety

Learning organisation

Collaboration within the care unit

The management´s support ofpatient safety work

Workload staffing levels
A non-blame and shame culture

Openess in comunication
Feedback and communication of adverse
eventsPatient Safety Agreement
2011-2014
The agreement between the Government
and SALAR on improved patient safetyAim To reduce the number of adverse events bystrengthening and intensifying the patient safety
work To support implementation of the Patient SafetyAct Structure – process – result- context

Model for financial incentives for
improved performance – 380 million
dollars in four years
Basic requirements to be eligible
for funds
Indicators to ensure a broad patient
safety workIndicators for specific areas

Level 1

Level 2linked toperformance-based
remuneration

Patient Safety Agreement
 Patient safety annual report Quality of care experienced bythe patient National patient overview
 Patient safety culture Structured record review

 Hygiene routines and clothingrules Reduced prescribion ofantibiotics
 IT-support, the Infection tool Drugs
 Pressure ulcers
 Overcrowding

Hygiene Compliance 2010-2013 inpatient wards
100%
90%
80%
72%

70%

69%
66%
60%

60%

62%

55%

50%
40%
30%
20%
10%
0%
HT10

VT11

Compliance with hygiene routines and dress code

HT11VT12
Compliance with hygiene routines

HT12VT13

Compliance with dress codePrevalence of healthcare associatedinfections in inpatient wards
14%

12%

11.2%

11.0%
9.7%

10%

9.6%
8.9%

9.4%

9.2%

9.3%

Spring11

Autumn11

8.9%

9.0%

9.0%

Spring12

Autumn12Spring138%

6%

4%

2%

0%
Spring08

Autumn08

Spring09
TotalAutumn09

Spring10

Länsdelssjukhus

Autumn10

Länssjukhus

Regionsjukhus

Prescriptions/1000 citizens and month

Outpatietns prescriptions ofantibiotics – National

Measures to prevent adverse events- SALAR has commissioned a number of experts to compile
measures based on scientific and proven experience- Applied consistently, they reduce the risks of adverse events

Care bundles, handbooks, management andleadership for improved patient safety

Prevention of healthcare associated infections, pressure ulcers, medication errors, drug-related problems, fallinjuries, malnutrition
Structured record review, root and cause analysis, Measuring patient safety cultureTools for increased patient involvement
within patient safety work

When an injury occurs, information for the healthcare professionals, information for the patients, patient involvement inrisk analysis, Handbook for both patient and healthcare professionals about how to omprove and develop healthcare, advise
for better communication between patients and professionals, what can you do yourself, The difference between bacteria
and viruses, when it is appropriate to take antibiotica

Surgical Safety Checklist - WHOA model for implementation based on
making improvements
How schould
we continue
working?

Reflect on
how it went1

do we work
2 Why
as we do?

6

Try out thenew solution

How do we work today?
What is pos/neg?

53 What alternatives are
4Suggestions for new ways ofworking

there?
What can we do instedad?

Today- Increased commitment to patient safety
From 300 to 2 400 participants at the Swedish Patient Safety Conference (2003 -2013)- Patients Safety Act
The Act has strengthened patient rights, stressed the importance of system perspective
and a proactive approach- The Agreement between the Government and SALAR
The agreement between the Government and SALAR has been successful and all
counties have improved their performance.

- Structure – process – result
We have built structures for patient safety in Sweden. The measures are being appliedconsistently in a systematic way to prevent the risks of adverse events and for safer
processes which in turn leads to better results for the patients. It requires a continued
purposeful and sustained work.

Challenges now and in the future- Patient involvement- Management and leadership for improved patient safety- Use the results of the measurements to make healthcare safer- Training and education in patient safety- Continued development and research in the field

Gains – from blaming toimprovement-Reduced suffering for the patients
Better improved culture
Improved patient safety
Reduced costs
Better working environment
Increased confidence in the health care system

SALAR´s Patient Safety Work
Keep updated– SALAR`S website about patient safety– www.skl.se/patientsakerhet

Order publications– www.skl.se/publikationer

Healthcare doesn´t become safer byitself – it needs action
We have to start working in a different, better and safer way on alllevels!
Create a safe day every day!
Thank you for your attention!
Eva Estling
eva.estling@skl.se