3rd Seminar. Medication errors with vaccines: improving with the professionals

Problem description:

The objective of the 2009 program-contract in our area on medication errors reporting was to report at least 109 errors, which means a 5% of the expected in an area like ours.

The total in 2009 was 192 errors reported. The 26% of these was related to vaccine administration.

Analysis of causes:

A working group is formed with 12 professionals involved in immunization and motivated on patient safety: a pediatrician, nurses and immunization managers. Members of the risk unit of the area coordinate the group.

The group performs an analysis of causes of vaccine-reported errors.

Professionals: lack of training, unclear labeling, bad registration on patient's medical records, bad anamnesis, more than one professional to vaccinate a patient.

Organizational: lack of information in the admission of new professionals and substitutes, neither clear labels nor clear information on vaccine refrigerators, no registration of the vial opening date, failure to follow protocols and institutional advices.

Agents and resources: Errors in OMI drug list, frequent changes in laboratory supplier, multi-dose vaccines, different vaccines with similar labeling, prescribing information in other language, small print on the packaging.

Improvement actions:

Elaboration of an informative brochure and poster on the most common mistakes with vaccines.

The brochure will be given to new professionals and substitutes who will work with vaccines at their welcome, and there will be named a manager for this task in each facility.

The poster will be located in all offices at the primary care facility.

Rearrangement of vaccines in the refrigerator by age of administration.

Development of visible reminders in the refrigerator on the identification and proper placement of vaccines.

Results:

We improve the involvement of professionals in the security ambit.

A professional group makes improvement proposals, which will facilitate its acceptance.

We will assess the impact of these measures with the report of the errors with vaccines throughout 2010.

Presentation by María Dolores Martínez Patiño, UFGRS of the 5th Area of Madrid.

+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20030.pdf


Posted by Fernando Palacio
English version by Erika Céspedes

3rd seminar. Safety incident with the defibrillator gel in health centers. Root cause analysis

Problem description:

There are CPR training courses at primary care facilities in the 5th Primary Care area of Madrid. In reviewing the crash cart, the teacher finds in some facilities the presence of an alcohol gel bottle next to the defibrillator.

The gels for manual defibrillator must be alcohol free, because its use could burn patients.

Analysis of causes:

Professional causes: ignorance, not reviewing the composition of the gel, the defibrillator’s instruction manual and the provision of the crash cart, the coexistence of a semi-automated defibrillator that does not need gel.

Organizational causes: inexistence of a crash cart manager, rotative reviewing among the professionals, not separating the ultrasound gels (for ultrasonography and physical therapy) with alcohol.

Agents and resources: the trading house that provides the gel submits to the competitive acquisition a container identified with a sticker "for ECG and defibrillator”, but brought an alcohol gel, with the sticker "gel for ultrasound".

Working conditions: In some cases, the sonographic instrument and the crash cart are in the same room, and gels are exchanged.

Improvement actions:

Verification the competitive acquisition of the correct gel. Sample: the bottle says "ECG and defibrillator", without alcohol. Current product says "ultrasound transmission gel”, containing alcohol.

Appointment with the trading house, to clarify the supply of a product other than awarded.

Reporting the incident by fax, internal mail and e-mail to all professional; publishing on the website; notifying that there is defibrillator gel available in crash carts.

Sending the centers a correct gel container with a newsletter.

Edition of the book "Quality assurance in the use of health material and apparatus".
That includes a specific section on use and maintenance of defibrillators.

Although no damage has occurred, it is crucial the deployment of measures to prevent it in the future.

Oral presentation by Mercedes Martínez

+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20029.pdf


Posted by Fernando Palacio
English version by Erika Céspedes

3rd Seminar. Adverse effects detection, a way of sensitizing the professionals to Patient Safety

The interest and promotion of Patient Safety (PS) by National and International agencies in health services, motivated us to make this report with the following objectives:

• To assess the sensitization on PS through educational workshops, measured by the statement of adverse effects (AE) in all teaching units of the autonomous community of Galicia

• To study the frequency, severity and characteristics of the AE reported

The method was developed in two phases. Initially all Teaching Units of Family and Community Medicine of Galicia (senior residents and their tutors) were invited to participate. In the first phase there had place training workshops on PS concepts, types, error analysis and knowledge of the questionary APEAS1. In a second phase the professionals registered the AEs for 15 days, in their daily activities according the APEAS methodology.

During the registration period, 9,024 patients participated in 27 primary care facility. The prevalence of AE was 15.37 ‰: (5.97 ‰ incidents and 9.40 ‰ adverse effects), of which 76.7% were mild, 17.5% moderate and 5.8% severe. The 72% of the AEs were considered avoidable.

The 36.2% of cases the causal factors of the AE were related to medication, 34.2% with communication, and 25.6% to management, followed by other causes.

When we studied the origin of the AEs we found that 65% of them occurred at a primary care facility, 20% at specialized care, 4% at emergency departments, 3% at pharmacy offices and the remaining 8% at "others" as herbalist shops or private practice.

With regard to the care the patient received as a result of the AE, in the 63% the health care was not affected, in a 26% the AE was solved at primary care, the 10% required further consultation or a specialized care and the 1% required hospitalization.

Most professionals have reported at least one AE and its characteristics are similar to those published on other papers.

Reporting AE, with a previous training, may be a useful tool to assess the sensitization to PS, and teaching units, a resource in the development of a culture of PS.

Presented by Clara González-Formoso; M ª Victoria Martín Miguel; Antonio Rial Boubeta; Jose Luis Delgado Martín; M ª José Fernández Domínguez; José Luis Ramil Hermida; Fernando Isidro Lago Deibe; Ana Clavería Fontán; Margarita Pérez García.


+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20048.pdf


Posted by Fernando Palacio
English version by Erika Céspedes

3rd Seminar. Involving professionals in patient safety

Cristina Cedrún of the Primary Care Area 5 of Madrid, presented the interventions undertaken to improve reporting of incidents.

These interventions achieved the declaration of a 76% above the proposed objective.

The information and involvement were again the key.

The authors are: Cedrún Lastra, C; Martínez Patiño, M.D; Piédrola Martínez, M.


+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20028.pdf

Several posts on reporting adverse events have been published in this blog. Those can be accessed by typing in the search box on the right column the word “notification”.


Posted by Fernando Palacio
English version by Erika Céspedes

3rd Seminar. A project to systematize the communication in drugs administration at emergency situations

The Primary Care Management of Talavera de la Reina presented many presentations at the Seminar. In this one, they comment a very important topic, the risk of error in drugs administration at emergency situations.

Raised the issue, they developed a protocol on this subject that was presented with a video in all healthcare facilities.

The main author is Belen de La Hija.


+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20014.pdf


Posted by Belen de La Hija and Fernando Palacio
English version by Erika Céspedes

A brief synopsis on Patient Safety, WHO/Europe 2010

A brief synopsis on Patient Safety, WHO/Europe 2010.

“This document provides a simplified and non-exhaustive synopsis of the major international patient safety initiatives – past and present – undertaken in the WHO European Region. While patient safety is a complex issue spanning numerous public health and health-care domains, this document adopts a generic understanding of the subject in respect to avoidable harm.

As such, most of the patient safety interventions chosen for this document have a general and cross-cutting character and do not include the many complementary and dedicated actions developed at various levels of the health system and beyond. Moreover, as patient safety is constantly developing better ways to respond to health, economic, social and environmental challenges, the document is to be seen as a 'snapshot' of the current state of affairs in the WHO European Region, and as a work in progress”.

We can find in this document contents related to taxonomy, legislation, initiatives and consensus on safety in the WHO European region, and the list of initiatives related to patient safety, arranged chronologically from 2004 until this moment.

+Info: A brief synopsis on Patient Safety, WHO/Europe 2010 (pdf file)


Posted by Lola Martín
English version by Erika Céspedes

Interview with Pilar Vicente García, nurse, member of the Spanish Association of Latex Allergy

Latex allergy, although currently very common, is still little known. According some studies, in Spain a 2% of the general population has developed it and in risk groups the number may reach a 15%. Once it appears, any area of a person’s life is involved because, where there is no latex?

We interviewed Pilar Vicente García, a member of the Spanish Association of Latex Allergy (Asociación Española de Alérgicos al Látex), and nurse.

S. & H.: Do you think that health professionals are sensitized or trained in this problem?

P.V.G.: Although the situation has improved in the last two or three years, much remains to be done. Nowadays there are many health professionals that do not know what to do when a latex allergic person arrives to their offices o divisions.

What aspects should be improved?

Basically, two things: information and training. It is a disease partially unknown for many health care professionals.

Could you give us some examples?

Well, one would be when a professional see us with elastic underclothes, and says: "Come on, you are allergic to latex and you wear latex elastic!". It is a very uncomfortable comment for the patient. The first thing you think is that they do not believe you are allergic to latex. Fortunately, patients are increasingly trained in patient safety. Then, as calmly as you can, you explain that there are clothes with synthetic materials elastics that do not harm us.

Another example would be the administration of a drug that comes in a glass vial and has a rubber plug; you instinctively ask "the plug is of natural latex?". Answers may be very different... "but I will not touch the plug" or "so I remove the plug and you're done". And there is an answer more and more frequent "I am going to ask, I will make sure". In the first two cases the patient has to explain that the liquid may contain latex proteins and, even though you remove the plug or not touch it, it can cause a reaction. So what occurs is an estrangement between the professional and the patient that does not benefit either party. The third answer may start a rapport with the professional who shows more interest for the problem and investigates whether the plug is natural or synthetic latex. This situation really benefits both parts.

Another situation that causes surprise is when you explain that there are foods that, having proteins similar to those of natural latex, can cause reactions similar to those caused by latex itself. This is what we call “latex-fruit syndrome", since tropical fruits are the most concerned: kiwi, pineapple, banana... but also tomatoes, oranges, melons...

So, no latex-allergic people can eat these foods?

No, according to reports only the 50% of those latex-allergic people develop the “latex-fruit syndrome", and not to all fruits, but the truth is that when the reaction to any of these foods appears, the list often starts to grow.

In addition to training and information, as you mentioned at the beginning, what could be done to improve the situation?

We think that it would be desirable that health care professionals invite patients to their meetings, seminars, etc. and give them the opportunity to explain their day-to-day routine, the obstacles they have to overcome because of their latex allergy, their feelings in relation to health care situations. It is not about confronting or criticizing; it is about intercommunicating and listening to each other, it is about gradually changing the current culture.

Patients know that health care professionals and we have a common goal, our safety, patient safety. Strangely we both walk toward that goal but in parallel and with and askance look, and so, we will never meet. We must learn to walk together, side by side.

What would you emphasize of the actions of your organization, the Spanish Association of Latex Allergy?

The spread of the disease has been very important. We have carried out a number of seminars in different regions specifically directed at health professionals, many of which had recognized health interest. Accurate information has been given to all patients allergic to latex. We have conducted studies in which realization we had always the support of the Ministry of Health and Social Policy, the professionals from different disciplines such as chemists, engineers, biochemists, dermatologists, allergists, etc. and the different areas such as universities, hospitals, nursing schools, research centres in biotechnology, etc.

You may see all this on the Association’s website, www.alergialatex.com. The studies mentioned can be downloaded for free from the Web.

Thank you very much for thinking of us and giving the latex-allergic people the opportunity of being present in the Safe and Healthy blog, which is very interesting.

Thank you very much for your attention.


Interview by Clara Formoso for Safe and Healthy
English version by Erika Céspedes

3rd Seminar. Design and implementation of a protocol on users’ unequivocal identification in primary care

The topic of the unequivocal identification of patients was also present at the Seminar, through this presentation of the Guadalquivir Sanitary District, Córdoba. The authors are Hervás Vargas, A. and Gutierrez Sequera, J.L., who summarize their work thus:

Problem Description: In the provision of health care, the identification of patients involves risks that may result in misdiagnosis, testing, surgery or giving medications or blood products to wrong patients.

Proposal for improvement: The Strategy for Patient Safety of the Andalusian Autonomous Government includes among its objectives the unequivocal identification of citizens that contact with the Andalusian Public Health System and says explicitly that all citizens treated in primary care must be unequivocally identified by at least two data, one of them, the Unique Andalusian Health Record Number (NUHSA). Therefore, we have developed a protocol which aims to establish a policy for secure identification of patients that lets identify reliably the patient as the person to whom the treatment, care or service is focused and, in turn, relate the treatment, care or services with that patient.

Strategy: The scope of our work covers all health services that integrate the eight Clinical Management Units of our Health District: primary care centres, emergency departments, domiciliary care, critical care units, minor surgery, etc., and so to all health and non health professionals who have direct care contact at any time with the patient.

The following tools will be used for diffusion:
1. Sessions/Workshops for health and non health professionals.
2. Brochure for the Citizen Advice Service Professionals.
3. Publication of the document on safety and unequivocal identification of patients in local magazines, aimed at citizens.
4. Publication of the document on safety and unequivocal identification of patients, aimed at professionals in newsletters.

+ Info: http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20020.pdf


Posted by Fernando Palacio
English version by Erika Céspedes

Time to listen: a review of the methods to solicit patient reports of adverse events

As patient participation is a relatively new addition to patient safety reporting systems, the techniques that are most successful and efficient are not yet known.

The journal Quality & Safety in Heath Care has published this literature review on reporting systems used by patients: populations, contact methods, verification, reporting, incentives, incident rates and reporting terminology.

Two databases were searched: PubMed and MEDLINE (English publications only), obtaining finally 17 publications for review. Of these publications, four focused on Primary Care (PC), and one included both primary and hospital care.

PC patient reporting studies used a combination of methods to collect patient reports: telephone recruitment with a follow up in-person interview, patient’s choice of reporting method (online, written or telephone reporting) and telephone survey. The terminology used to ask the patient about the events has also been variable.

Adverse events were corroborated only in three publications, none of PC. The incidence of nosocomial infections, pressure ulcers and drug-related events reported by patients was shown to be comparable to rates documented by healthcare providers in hospitals and to rates reported in patient safety literature.

The incidence rate for adverse events across settings and populations varied considerably, ranging from less than 0.1 to 5.8 per patient. The results are not comparable. The same happens with the classification of reports.

Thus, the variability found among the publications reviewed is extensive in terms of healthcare settings, method of reporting, time span, terminology, criteria for assessment and response rates, which makes establishing definitive conclusions impossible. It seems that higher response rates are achieved with open questions and solicitation techniques based exclusively on personal experiences by interview. Further research is required to determine the optimal language, method, format and tool for patient reporting. The utility of the incentives should also be studied.

In short, the participation of patients in reporting adverse events is a very interesting field, which represents a valuable new perspective to improve their security, but is soon to offer final conclusions. Further research is required to reach its implementation and to achieve its potential benefits.


A King, J Daniels, J Lim, et al. Time to listen: a review of Methods to request patient reports of adverse events. Qual Saf Health Care 2010 19: 148-157


Posted by Marisa Torijano
English version by Erika Céspedes

Interview with Miguel Angel Máñez. Can we sell better the safety culture?

We met Miguel Angel Máñez at the Security Master developed by the Spanish Ministry of Health and Social Policy and the Miguel Hernández University. We felt he provided a new –and very necessary- point of view respecting safety culture. That is why we asked to interview him and he has kindly answered.

Miguel Angel Máñez is an economist. He is currently the Deputy Manager of Economic and Human resources of the Alicante-Sant Joan Health Department. He is the author of Salud con Cosas, a blog on healthcare management, since 2007. His areas of interest are leadership and clinical governance, innovation, social marketing applied to healthcare organizations, health 2.0 and change management. He has participated in courses and seminars on Internet and health, healthcare management and marketing; and he has also written articles in various media on these topics.

- S & H: Why, if we all agree on the "primun non nocere", in the ethical principle of nonmaleficence, are there difficulties for health professionals to take on the problems on patient safety?

- M. A. M.: The custom and culture of each organization play an important role in how professionals behave. To generate a behaviour change is complex in humans and that is why incentives or rewards are often used to make this change not only fast but also durable. However, in the healthcare environment, the incentives associated with the implementation of a new culture based on patient safety are not very effective (in the case of economic incentives) and difficult to apply (the non-economic).

A clear comparison is the behaviour change in business environment, since to get a consumer buy a product is to create a purchase impulse that can produce positive results in just three minutes, but to change behaviour is something very long.

Finally, in the case of patient safety, the benefits are invisible to the professional, as they directly affect third parties, making the change difficult.

And counting on it, from your point of view, what are the strategies to succeed in introducing this culture? How can we “sell” it?

First, we must show that there is a direct benefit for the professional. Without demonstrating that the change creates value for both professionals and their activities, we can not move forward. Social marketing techniques seek to modify behaviour based on an exchange, analyzing the attitudes of members of the organization to the proposed behaviour, and providing each professional skills and motivation both necessary to understand he can make that change.

We have to dissociate the "sale" of that culture of the monetary concept of the term "sale." Economic incentives only work in the short-run and, indeed, any change brought whit an economic incentive disappears when the incentive disappears. The design of incentives should be conducted in a manner that achieves a long-term change, appealing to professional values, beliefs and their abilities to overcome obstacles.

Moreover, a new culture implies that we must know exactly how the professionals of the organization are in order to detect the leaders, innovators and "early adopters" (in Rogers’s terminology) who are going to serve as engine and example. In addition, managers must act according to the new culture, to keep the professional look at their own bosses trying to implement a new way of doing things that they do not follow.

Finally, we need a consistent and innovative training base: workshops in the workplace, courses, training for managers of each unit, reminders, etc. Any support material is welcome, but also the originality and innovation will be appreciated to reach the professional’s attention.

Finally, what role do patients play in this topic?

The patient plays a central role, because if healthcare organizations seek to generate a cultural change aimed at the improvement in security, is because it has been shown that there is improvement in patient care: more quality, more safety. Perhaps we have gone through a culture of wellness and safety time for the professional, sometimes forgetting, in the process design, that the ultimate objective of health services is to provide a range of patient cares.

One way that lately has been used to achieve these changes in the culture we are discussing is to use the patient as a means of transmitting the professional the need to make things differently. Within the National Health Service (NHS) it has been much criticized, as there are professionals very reluctant to the idea of a patient requiring them to perform a task one way or another, but it is usually very effective. In fact, we are conducting in our center a project in social marketing and hand washing aimed to relate each type of marketing strategy with a change in professional’s behaviour.

Thank you very much for talking to us. Now it is time to reflect on what we have expressed and to work, more focused, to keep trying to create that culture of safety.

Thank you very much


+ Info: a very interesting link, his class in the Patient Safety Master of the Spanish Ministry of Health and Social Policy and the Miguel Hernández University, where Miguel Angel Máñez develops some of the ideas reviewed in the interview.


Posted by Safe and Healthy
English version by Erika Céspedes

3rd Seminar. Safe practices presented by the Functional Unit of Health Risks Management, 4th Area of Madrid

The Functional Unit of Health Risks Management of the 4th Area of Madrid presented the safe practices identified in the last four years.

They define a safe practice as "an action, according to the evidence and knowledge available, to avoid or reduce health risks or adverse effects. It may respond to a particular health care situation or may be useful and/or generalizable to other facilities because of their potential impact on patient safety, frequency or importance. "

In their presentation there is a list of safe practices that are widespread. It is a very interesting list for those who want to implement them in their area of influence.

The authors are Asunción Cañada Dorado, Inmaculada García Ferradal, Carmen García Cubero, Sergio Serrablo Requejo, María Antonia Sánchez Márquez y María José Montero Fernández.

+ Info: http://www.seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20059.pdf

See also in this blog: Entrevista a Asunción Cañada a propósito de las Unidades Funcionales de Gestión de Riesgos Sanitarios (Interview with Asunción Cañada about the Functional Units of Health Risks Management)


Posted by Fernando Palacio
English version by Erika Céspedes

Atención Primaria Editorial: semFYC adapts the WHO recommendations on hand hygiene for Primary Care

The journal Atención Primaria publishes in its last number an editorial with the title: La Sociedad Española de Medicina Familiar y Comunitaria adapta las recomendaciones sobre higiene de las manos de la Organización Mundial de la Salud para atención primaria (The Spanish Society of Family and Community Medicine adapts the World Health Organization recommendations on hand hygiene for Primary Care).

The editorial is about why and how the semFYC’s Patient Safety Group, which manages this blog, made recommendations on that subject as well as a summary of its contents.

The full text of the Recommendations on hand hygiene for Primary Health Care workers and for Health Services in Spain can be downloaded here (html) and here (pdf)


Palacio J, Aibar C, Marec R. La Sociedad Española de Medicina Familiar y Comunitaria adapta las recomendaciones sobre higiene de las manos de la Organización Mundial de la Salud para atención primaria (The Spanish Society of Family and Community Medicine recommendations on adapting the hand hygiene of the World Health Organization for Primary Care). Aten Primaria. 2010; 42:401-2.


Posted by Safe and Healthy
English version by Erika Céspedes

3rd Seminar. Assessment of the Registration System of falls in nursing home residents and identification of improvement strategies

This oral presentation was considered the best of its work group (they chose the best presentation in each work group).

This presentation studies the falls in elderly residents of nursing homes in the Granada Sanitary District, and has three main objectives:


1. To determine the incidence of falls in nursing home residents.

2. To perform an analysis of the most common causes of falls.

3. To categorize the identified improvement areas to plan intervention strategies.

4. To assess the impact of the registration system in the professionals.


The results are very interesting. Among them, for example:

- One thousand and two patients of the total of 3142 had one or more falls in a period of less than three years.

- About 12% of the patients who fell went to the Emergency, and 3% of the total was hospitalized.

An ambitious and very well described project, on a topic often overlooked. The first author is Eugenio Vera.


+ Info http://seguridadpaciente.com/Jornadas10/comunicaciones/Resumen% 20032.pdf


See also in this blog:

Evaluación multifactorial del riesgo en la prevención de caídas y lesiones en atención primaria y urgencias destinadas a personas mayores (Multifactorial risk assessment in the prevention of falls and injuries in primary care and emergency care for elderly).


Los programas de ejercicio son efectivos para la prevención de las caídas en ancianos (Exercise programs are effective in preventing falls in elderly).


Posted by Fernando Palacio
English version by Erika Céspedes