The progress in science and technology, combined with advanced specialisation in health care are leading to increasingly complex care situations for increasingly frail patients. We should realise that health care is becoming less safe, partly because of this enormous progress in hospital care. Making errors is a normal, but with regard to outcome often undesired, deviation in human behaviour. The risk of errors increases in complex situations with hierarchical relationships. To be able to reduce the risk of errors and incidents in hospitals, many different actions could be undertaken. These will be discussed further.
Increasing attention to and action on safety problems is urgently needed. Unfortunately, up to now there is limited scientific evidence on the effectiveness of specific interventions. We are forced to use whatever evidence or expe-
rience is available, combined with the analysis and understanding of the problem and the local situation, when selecting actions that should be undertaken in a given organization. The project has developed an overview of these actions / instruments, that is being presented for discussion. However, even as we are discussing them new knowledge is being generated about the ones listed here and new innovative approaches are being initiated.
Therefore the key issue being presented here for discussion is:
What would be the ways and means of further cooperation in Europe in order to increase learning, knowledge and exchange related to different approaches to improve patient safety and facilitate their implementation in health care organizations?
For the purpose of discussion we have classified instruments, evaluated within the scope of the project,
in
three groups. Some of the instruments include aspects from more than one group:
1. Instruments for registration of information (data) relevant for safety
These include both specific registration of safety incidents as well as possible data sources for safety information derived from other, more general, registration systems. Important feature here is the possibility to develop or define indicators and benchmarks that can be used for comparison on different level (within organization, between organizations on regional, national and European level)
2. Tools for analysis of safety incidents and risks
The group includes two types of instruments:
for retroactive analysis: Root Cause Analysis (Systematic Incident Reconstruction and Evaluation, Prisma) and Trigger tool status study.
for proactive analysis: Health Failure Mode Effect Analysis and Bow tie model.
3. Intervention approaches
Two levels of intervention can be roughly distinguished here, although experience indicates that best results of these interventions can be achieved when action is taken simultaneously on both levels.
Interventions directed towards the system, namely organizational leadership, culture, communication, management and relations. This includes attention to safety culture, involvement of patients, a safety management system, crew resource management and multidisciplinary team training.
Interventions directed to specific processes of professional health care delivery. Many of them are specifically developed to improve communication within one or more care processes and teams, inclu-
ding walk rounds, briefings, time out or SBAR. Others have been designed with a specific group of patients at safety risk in mind, like bundles or rapid response teams. Some combine both aspects and include system components, like a package of interventions developed to decrease hospital mortality (move your dot or campaign approach).
