Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience.

Danish Society for Patient Safety

Adapting Solutions for Wrong Site Surgery: The Danish Experience


“Something is rotten in the state of Denmark”


Act on Patient Safety

• Frontline Personnel obligated to report

• Hospital Owners are obligated to act

• Board of Health is obligated to communicate


§6 in Act on Patient Safety

• A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice


The organization of the Danish Reporting System

National Board of Health

Regional Patient Safety Units

Hospitals

The regional level


Reported adverse events

Example from Copenhagen Hospital Corporation (H:S)

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2002 2003 2004 2005


NCPS’ 5 steps for ensuring correct surgery

JCAHO’s Universal Protocol

Known Solution

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Wrong site event # 1

Patient operated on the wrong side of the head

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Patient operated on the wrong finger

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Patient operated on the wrong side of the head

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Head Office calls for Action: Pilot test of a Danish version of NCPS’ 5 steps• Departments

without reported wrong site events

• 410 procedures• More than 90% of

the surgeons made positive comments

Participating departments

• Gynecology• Urology• Orthopedic surgery• Surgical

gastroenterology

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Danish Society for Patient SafetyDuring this time

12 wrong site surgical events

5 was prevented before incision

7 RCA (all with incision)

1:32.500 surgical procedures

Root causes: Wrong site surgery is more likely to happen when:

Number of occurrence in the 7 RCA’s

The surgeon doesn’t participate in the preoperative identification of the patient

7

Scanty/obscure communication between OR personnel

4

Due to work pressure interruptions in the preoperative procedures

3

Significant differences between the operation schedule and the anaesthesia schedule

2

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• Procedure to be used by all hospitals in the Copenhagen Hospital Corporation

• News Letters• Power Point Presentations• Literature Review• FAQA• Posters

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Baseline – April 2005

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Always/often

Now and then

Rarely/never

• 66% response rate, 40 out of 65 questionnaires fully completed (29 doctors, 11 nurses)

• Full knowledge of guideline

• Two more wrong site events identified

Questionnaire survey to 65 head of departments

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The organization of the Danish Reporting System

National Board of Health

Regional Patient Safety Units

Hospitals

The national level

In 2004 additional 9 wrong site events reported to the national reporting system.


Epidemiology of wrong site surgery• 57 wrong site

surgical procedures reported to The Patient Insurance in 6 years

• 1:12.292 knee operations

• 1:8017 Neurosurgical procedures

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Extremities Trunk andunpaired organs

Head and neck Paired organs Not stated

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Lessons learned

• Ownership to the problem requires ownership to the solution

• It makes good sense to share solutions tested and proved effect full elsewhere


Reporting

Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience.

Documents

Transcript of Danish Society for Patient Safety Adapting Solutions for Wrong Site Surgery: The Danish Experience.