What to do if things go wrong: a guide for junior doctors

This National Patient Safety Agency's booklet is a guide for junior doctors to manage a patient safety incident.

It is organized in 6 sections.

First, a description of a personal experience of having a medical incident. Second, to document the incident in the patient’s medical records and to inform consultant and/or supervisor. Third, to communicate the incident to the patient, family and caregivers and apologise to all. Fourth, to report the incident in a local reporting system. Fifth, the guide enhance that junior doctors, on the frontline of care, are vital in the identification of learning from reporting. Finally, an algorithm is presented to deal with the complaints process in England.

Every section is introduced by an incident description from a relevant medical doctor in England.

It is easy to read and a good example to adapt in every country as a guide to promote good answers to incidents in practice for junior doctors.

Medical error. What to do if things go wrong: a guide for junior doctors


Posted by Pilar Astier
English version by Pilar Astier

Increased reporting of medication errors in a Healthcare Area

Virginia Greciano, of the Area 2 of Madrid, presented an interesting oral communication on medication error reporting, which is summarized below.

Given the necessity to extend definitively the culture of reporting medication errors (ME) and facing an increasing number of targets by the organization, the Functional Unit for Health Risks Management (FUHRM) proposed the Pharmacy Department to develop strategies to promote reporting.

Managers designed a training session on ME for healthcare centers in the Area 2. This session was directed at doctors, pediatricians and nursing, and other non-healthcare professionals. The main objective was to deepen the concept of ME and its differentiation from other adverse events. The content was also aimed at promoting reporting by simple steps, as well as illustrating the session with useful information and examples.

There were a few support messages based on 4 basic principles:

1. Curiosity: about any circumstance that cause surprise about a drug or pharmaceutical product at any time.

2. No doubt: "at the dilemma of whether it is an ME, an adverse reaction or other event, report it. An excess of notification does not hurt anybody and do so could get a risk to the patient ".

3. No blame: the ME is a part of the sanitary work. Reporting is anonymous, encourages a culture of risk and helps us grow as healthcare professionals.

4. Avoid bureaucracy: do not let papers paralyze you. To report a ME, just publicize it and ask for collaboration.

The results of the sessions were very interesting in terms of number of people attending and the number of notifications that have been received later. In less than six months reported a number of EM sufficient to achieve the goal of the year, reaching 42% report a higher than agreed. At the end of 2009, we were the third AP Management goal percentage and fourth in number of notifications.

Having identified the improvement areas and made the balance in the FUHRM, various measures have been proposed to maintain this line of work in the future.

To view the full presentation click here


Posted by Fernando Palacio
English version by Erika Céspedes

Learning from the successes. Safety Meeting’ 10

The Observatory for Patient Safety, of the Quality Agency of Andalusia, has organized this conference on 23 September in Seville.

There will have place roundtables with suggestive titles such as "Improving safety is simple", "Improving safety takes 2 minutes" or "Report of successes".

On the other hand they will project the safe practice experiences sent before 15 September.

The Observatory organized with our group the 2nd Seminar for Patient Safety, held in Granada in 2009, so we know their good job. Therefore we encourage you to go to Seville.

The program and registration are available on this webpage.


Posted by Fernando Palacio
English version by Erika Céspedes

Seminar of the Spanish Society of Preventive Medicine, Public Health and Hygiene: Patient safety, a shared commitment, a general interest

The next September 17 will take place in Alicante a Seminar of the Spanish Society of Preventive Medicine, Public Health and Hygiene (Sociedad Española de Medicina Preventiva, Salud Pública e Higiene), in which also participates the Spanish Society for Quality Healthcare (Sociedad Española de Calidad Asistencial, SECA) and the Spanish Association of Health Risks Management and Patient Safety (Asociación Española de Gestión de Riesgos Sanitarios y Seguridad del Paciente, AEGRIS).

Their slogan: "Patient safety, a shared commitment, a general interest”.

Some of the most committed to patient safety will participate, including our colleague Carlos Aibar, who manages a workshop.

It is useful to review the programme and participants and, if you can go, the registration is free, in order of application.


+Info on this web page


Posted by Safe and Healthy
English version by Erika Céspedes

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. 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

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

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

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

The Ministry of Health and Social Policy has posted on the network the presentations of the 5th Conference

Our readers will remember that the last June 3 and 4 was held in Madrid the 5th International Conference on Patient Safety, which has already been reviewed in this blog.

The Spanish Ministry of Health and Social Policy has posted on its Patient Safety Web Site, the presentations of that conference.

It is also an opportunity to visit -for those who have not yet done it- the specific Patient Safety Web which provides interesting and important contents.

Posted by Fernando Palacio
English version by Erika Céspedes

3rd Seminar. Assessment of the observance of Hand Hygiene in a Primary Care area of Madrid

With the aim of bringing good practices to our daily work, we start a little series where we will bring to the blog the oral communications presented at the last 3rd Seminar for the Improvement of Patient Safety in Primary Care.

And we start with a polemical topic, hand hygiene.

We know that hand hygiene, as the WHO recommends, is a controversial topic in Primary Care, where the famous five stages do not find a proper insertion. To approximate us to reality the Training and Research Unit of the 4th Area of Madrid designed an observational study whose results were presented at the Seminar. Those results are very interesting because they show a low level of observance, even after risk of exposure to body fluids. Although the WHO recommendations are not enterely applicable in Primary Care, this study provides evidence that our reality, on hand hygiene, may be well below than acceptable. Both at Hospitals and Primary Care, it seems to be great opportunities to improve a behaviour that affects patient and professional safety.

The researchers have been Carmen Martín Madrazo, Juan Carlos Abanades Herranz, Asunción Cañada Dorado, Miguel Salinero Fort and Sonia Soto Diaz.

+ Info: Summary of the Communication Evaluación del cumplimiento de higiene de manos en un Área de Atención Primaria de Madrid (Assessment of the observance of Hand Hygiene in a Primary Care area of Madrid)

See also in this blog: Recomendaciones sobre higiene de las manos en Atención Primaria (Recommendations on Hand Hygiene in Primary Care)


Posted by Fernando Palacio
English version by Erika Céspedes

Held the First Congress of the Health Blogosphere

As announced on this blog, last Monday June 14 was held in Madrid the 1st Congress of the Health Blogosphere.

We presented there our blog Safe and Healthy. The presentation can be downloaded here. It is a summary on what it is and what can be found in safeandhealthypatient.org (the English version of sanoysalvo.es).

The conference was a success of participation and contents, that is why we must thank the organizers.


Posted by Jesús Palacio
English version by Jesús Moreno

V International Conference on Patient Safety

Under the Spanish Presidency of the U.E. Madrid was held at the V International Conference on Patient Safety. Impeccable organization and excellent speakers at tables rather moderate.

A lot and very good. How to summarize? I chose to reflect what has impressed me most as a family doctor who has left these days its small and saturated query to continue learning to improve the safety of care patients receive.

I encourage the rest of the attendees to write their impressions on this blog from the same or from other points of view and thereby enrich my comment.

About infections associated with health care and antimicrobial resistance I noted: Over 50% of the Spanish adult population admitted having taken antibiotics in the last year (30% "with the flu").

Antibiotic consumption is associated with increased bacterial resistance which cause delays in the administration of effective treatments and therefore increase morbidity and mortality, prolonged hospital stay and high economic costs. Resistance increases with increased use. It is shown that less use increase complications in patients with infectious disease.
In Spain, 92% of antibiotics are acquired by prescription (in France 97%, with a European average of 95%).

Other data for comparison with the rest of Europe: we consume more broad-spectrum antibiotics and continues the upward trend in the prevalence of MRSA in our hospitals (the French show that this trend can be reversed).

Research on antibiotic therapy is virtually idle since the 60s (currently only a research compound against gram negative).

There is decrease in the supply of active ingredients while raising presentations. The EFG represent 43% of prescriptions.

What I can do?

Non-pharmacological interventions:

Prudent use of antibiotics: only when necessary, correct intervals and duration.

Optimization of empirical treatments. Prescribing based on evidence.

Help end the illegal practice of giving antibiotics without a prescription at the pharmacy (for example, not providing the same into the patient).

Ask to enhance research in antibiotics (eg, not favoring my requirements that the business is in selling so many drugs that do not represent steps)

Find information and training and quality transparent

Collaborate with health authorities in health education campaigns for proper use of antibiotics and other initiatives related to patient safety.

Regarding measures to be taken to prevent transmission of pathogens themselves that we use and abuse the most powerful tool to address infections associated with health care: hand hygiene. Compliance through this simple but effective measure is only 38% and fewer doctors that nurses meet.

I keep taking note of the representatives of our patients tell us they are in health care silence and concealment of errors, reactive actions to prevail against those aimed at preventing them.

We ask for proactive risk management, teamwork, improve communication with and among us, standardization of procedures based on best available knowledge to care "partnerships" with industry to establish and therefore we do not focus on the sophisticated technology in the pursuit of our interest but in the promotion of good practice and in them, our patients.

They in turn are considering what to do for health systems and better use of resources and effort to ask for and offer honesty, transparency and participation.

Already in the last speech heartened to hear that primary care matters a great deal, how to tell us so little!

But beyond the first moment of pride that we have to take rather this phrase as a warning: be so important in AP extent of the risk does not appear to be reaching for now strategies to achieve safer health care in the same So get to other levels of care.

I recommend to visit the website of the Linneaus project.

For my part I try, and this week in my small and saturated consultation, follow some concrete recommendations for action by his representative: Do not lose sight of the importance of good interaction with the patient to understand and follow my explanations, explanations should be improving day by day and manage my time so you can establish routines that allow me to advance the consultation of the patient if something can not go well and record, report, analyze and learn from the failures and errors.


Posted by Marian López Orive
English version by Jesús Moreno

The nursing organization, access to training and motivation are key to safety in hospitals.

The next day May 21 will be held in Madrid, at the Carlos III Health Institute, the symposium "Nurse staffing and its Impact on Patient Safety: towards a Better forecast of human resources in nursing needs", organized by Investen. During this event will be the study RN4CAST that although referred to hospitals, is worth seeing
for the uniqueness of your starting point: studies of Linda Aiken.

In 2002 and 2003, Aiken released his studies (see links at the bottom) on the so-called "magnetic hospitals,"those who attract the best medical and nursing professionals. They showed that nursing human resources influence the quality of the results of these hospitals, in aspects such as mortality or neglect of patient calls, in addition to its own welfare of nurses. Since then the concern for proper management of nursing resources and the design of planning models needs of these resources has been increasing. It should be noted that the results of Aiken were adjusted for other resources, such as doctor / beds or others.

In this sense, the project is underway Forecasting Registered Nurse (RN4CAST) that aims to collect data from 15,000 nurses and 10,000 patients in 330 hospitals in 11 countries participating in the study. Data are being collected from the environment and human resource nurses through the hospital and the nurses themselves.

These data will be associated with patient outcomes, which will be drawn from the records afterthe high standard of patients.

Data collection will take place in acute general hospitals and in them the majority of working nurses are responsible for the greatest number of medical errors and the biggest share of health spending.

The project is coordinated by the Center for Health Services and Nursing Research of the Katholieke Universiteit Leuven, Belgium, together with the Center for Health Outcomes and Policy Research at the University of Pennsylvania (USA) as vice-coordinator.

Participating countries are Belgium, Finland, Germany, Greece, Ireland, Poland, Spain, Sweden, Switzerland,Netherlands, UK, U.S. and three international cooperation partners (Botswana, China, and South Africa).

In Spain, the project is coordinated by the Instituto de Salud Carlos III, through INVESTEN.

With the results of the project will support the creation of standards for human resource planning in nursing.

It would be interesting that studies be undertaken similar to this one focusing on the area of primary care,which allow us to explore in an objective manner, what is the influence of staffing ratios on patient safety.


Aiken, LH, Clarke SP, Sloane DM, (2002) Hospital staffing, organization, and quality of care: cross-national Findings Nurs. Outlook, 50.187-194
Aiken, LH, Clarke SP, Cheung RB, Sloane, DM, Silber JH (2003) Educational Levels of hospital nurses and surgical patient mortality. JAMA, 290.1617-1623


Posted by Juan José Jurado
English version by Jesús Moreno

1st Congress of the Health Blogosphere: Madrid, June 14, 2010

The next June 14, 2010, the Instituto Carlos III, Madrid, will take place the 1st Congress of the Health Blogosphere, in wich veteran and expert bloggers are participating.

I quote below the reason for the call, in organizers words.

See you there.

"Why?

Knowledge has gone from the conferences and books to computer screens. Internet is the natural way of searching for professionals and users of the National Health System. To analyze the status of the health blogosphere and the initiatives in information exchange is getting more and more important. The Hispanic health blogosphere is very active and dynamic. The blogs, magazines and digital forums, live together with initiatives with high impact in the training of professionals and patients. This Congress aims to value the health blogosphere as a source of organized knowledge and as a key in a modern health system. The First Congress of the Health Blogosphere in Spain also intends to build an active discussion group integrated by the major health bloggers, soy they can work synergistically. This conference intends to be the first of a couple of meetings and actions to provide an integrative field for all users and players of the health blogosphere. The Congress will also serve to share ideas, tools and initiatives through a market of blogs and web initiatives with free acces. "


Posted by Jesús Palacio
English version by Erika Céspedes

5th May, World Hand Hygiene Day

As we reported in this blog, today, 5 May 2010, the World Health Organization (WHO) announces the second global annual day of hand hygiene in health-care facilities and our blog joins this iniciative also for the second consecutive year (see post of 5 May 2009).

This year the World Alliance for Patient Safety´s new proposals include the participation in a global survey on or around 5 May by observing the adherence to this good practice in the Moment 1 (before touching a patient) and performing a structural self-assessment to analyze the promotion and practice of hand hygiene in each health institution.

Webinars will also take place.

The Ministerio de Sanidad y Política Social of Spain has developed an outreach letter to health professionals through the Coordination Group of the Hand Hygiene Program. All information is also on their website.

Our group adapted the recommendations of the WHO for Primary Health Care (see here) and we have discussed this subject in the blog (all posts can be found inserting “manos” in the web searcher engine on the right column).

This year we offer a new resource for professionals: a video that shows in a nice way that even a child can wash his hands properly. In the film two children wash their hands with the technique proposed by the WHO, quickly and effectively. This technique is similar for alcohol-based handrubs, even faster because you don´t need to rinse or dry your hands.

The video can be used both for activities directed at professionals and for health education and activities for children or general population. This video can be used without permission, but we would appreciate if the reference is cited. If used for health professionals, we suggest combining it with this video fragment from the WHO recorded in a health center, showing the proper technique for that setting. The one we presents here can be shown entirely, so you can see that the rubbing technique proposed by the WHO is very easy to learn and to practice: it´s child's play.

SAVE LIVES: Clean your hands


Posted by Marisa Torijano, Jesús Palacio and Lola Martín
English version by Erika Céspedes