Transcript Patient safety challenges in a case study hospital – Of

Patient safety challenges
in a case study hospital
– Of relevance for transfusion processes?
Transfusion and Apheresis Science 39 (2008) 167–172
Karina Aase, Sindre Hoyland, Espen Olsen, Siri Wiig, Stein Tore Nilsen
Speaker: Jenny
2008/12/17
Outline
• Objective
• Introduction
• Methods
• Results
• Discussion
Objective
• patient safety
• transfusion medicine
• In-depth knowledge of the
status and influencing factors
concerning patient safety
• Case study
Introduction
• Undesired events related to
hospitalization: 2.9-16.6%
(Brennan TA, 1991; Thomas EJ, 2000)
• The growing complexity of
health care services points to a
multi-perspective approach to
studying patient study.
Introduction
• Transfusion services
– Assurance of blood recipients and
donors blood
– Integration and coordination
among multiple hospital services
– Organizational interfaces: handoffs
and transitions, and collaboration
across hospital units
– US: 12-13 deaths /year
Methods
• Regional Norwegian hospital
– State funded hospital
• Data collection
– interview & document analysis
– questionnaire and error reports
Methods
• 91 interviews
• Regulatory inspectors, top
managers, Doctors, nurses
• Risk perception, human and
organizational factors, error
report, learning
• Document analysis: inspection
reports, annual reports, policy
documents, procedures and
guidelines
Methods
• Hospital survey on patient safety
(Sorra J,
2004)
• 11 dimensions
– Supervisor expectations and actions
promoting safety
– Organizational learning and improvement
– Teamwork within/across units
– Communication and openness
– Feedback and communication about error
– Non-punitive response to error
– Staffing
– Hospital management support
– Hospital handoffs and transitions
– Incidents report
Methods
• Return: 1919 questionnaires
• Response: 55%
Results
• Positive attitude
• Prioritization of safety and quality
• Health care reforms changed the
framework conditions
• Focus: economy, production , and
competition
• Production V.S Safety
Results
• Poor: Management support
– Perceived pressure: production and safety
– Finance change: reduce waiting lists
– Management encourages divisions to report
errors and prioritize patient safety
– Cost down and budget balance
– Worry: understaffing & corridor patients
– Limited resource slack
Results
• Poor: incidents report
–
–
–
–
Accidents belong to procedures & routines
45% (no report) & 20% (1 or 2)
Underreport: restrict learning & designing ability
Reason: time pressure, low feedback, low
perceived utility values, fear of reputation
– nurse(65%) & bioengineers(9.5%)
– Different risk perception, threshold to report,
reporting cultures
– Patient falls(65%): harmless error and
preventing difficults
Results
• Poor: Collaboration across units
– Collaboration, intersection, learning from
errors
– Accident report, analysis and
development of preventive measures
– “We write good reports, but we don’t get
the hospitals to read.”
– Learning loops at satisfactory level
Results
• Poor: Hospital handoffs and transitions
– Interfaces between shits, wards, and
divisions
– Experience, communication skills, time
pressure, and patients number
– The quality of shift handover influenced
patient safety.
– Suggestion: enough time, minimum of
external interruptions, experience, match
between patient No. and capacity,
individual communication skills