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Council of Europe Recommendation (2006)7

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Please, see Appendix G (Blank copy of the survey tool), or as a pdf-file here

Question 1. Standard definition

As to there being a recognised definition of patient safety, there are positive responses from 10 countries, Austria, England and Wales, Finland, Greece, Italy, Lithuania, Netherlands, Slovak Republic, Slovenia and Sweden. In four countries, Czech Republic, Denmark, Portugal and Spain different respondents could not agree (suggesting that there was certainly a current definition but not one totally accepted). The remaining eight countries did not have a recognized definition.

Of those that had a definition, five (plus obviously England & Wales) had it translated in English. These were Austria, Denmark, Netherlands, Slovenia and Sweden. Of the fourteen that had acknowledged a definition, only two countries, Netherlands and Sweden, argued that theirs differed in certain respects from that of the Council of Europe study.

Question 2. National Agencies/Bodies and/or Institutions

Given the answers from some countries, e.g. Austria, Czech republic, Germany, Ireland and Netherlands, where seven or more national agencies were cited, one might well conclude with the advantage of hindsight that the original question was not specific enough.

To make a rough summary across the 22 respondent countries, in only five countries were agencies identified which had a role exclusively in patient safety, namely: the German Coalition for patient safety (APeV), the Danish Society for Patient Safety (DSFP), the National Patient Safety Agency (NPSA) in England and Wales, the National Platform for Patient Safety (PPV) in the Netherlands and the SMHCA in Spain (a specialist agency within the Ministry). Certainly, the Ministry of Health (or equivalent) was quoted as a principal agent in promoting patient safety in eight countries, Belgium, Cyprus, Czech Republic, Estonia, France, Hungary, Italy and Slovenia.

Sometimes e.g. with the Joint Accreditation Committee of the Czech Republic or the Finnish National Authority for Medico-Legal affairs, or the Irish Clinical Indemnity Scheme and finally, the Polish Centre for Monitoring Healthcare Quality (CMJ) a significant role was perceived for an agency not apparently directly part of the Health Ministry.

Equally there are inevitably statutory bodies dealing with safety of medicines, medical devices, infection control and so forth that are cited by at least half of the respondents.

Patient organizations are mentioned by respondents from Czech Republic, Hungary, Ireland and Netherlands. Medical associations are quoted for Austria, Czech Republic, Germany and Netherlands.

Two final observations:

* responses from both Spain and Sweden suggest some tension between activities at a national and at a regional level,
and

* proliferation of agencies perceived as playing some role in patient safety in Austria and the Netherlands (10+) is difficult to understand or interpret.

Question 3. Taxonomy

Nine countries report the availability of a nationally agreed taxonomy for incidents or adverse events, Czech Republic, Denmark, Finland, Germany, Italy, Netherlands, Slovak Republic, Slovenia and Spain. Austria reports a taxonomy related to pharmacovigilance. Others report ongoing work to develop agreement. The response from Estonia is equivocal.

In the three cases, Slovak Republic, Slovenia and Spain where there is an English version available this is because these countries are in fact using the taxonomy developed by the Council of Europe.

Question 4. Standards/guidelines

Only two countries answered ‘no’ to this question, others giving a wide range of examples, between one (in fact a weblink to a pdf containing dozens of examples from the Danish Patient Safety Office) to ‘numerous’. With the advantage of hindsight, the question, despite appearing to probe a number of areas, is still ambiguous.

The two ‘no’ answers are quoted below and explain the difficulty …

Estonia

- “Comments re: Question 4: There are no official guidelines of patient safety”
- “Validation response: I would disagree. Because there are guidelines on medications, on blood (transfusion), on infection, on medical devices and even clinical guidelines. Some of them are even laws. And all of them are done because of patient safety.”

Finland

- “Comments re: Question 4: Finland does not have specific patient safety guidelines, but of course patient safety is the aim in e.g. national legislation regarding medication, blood transfusions and medical devices as well as health care personnel. Finnish legislation can be found at www.finlex.fi.
- The Finnish Medical Society Duodecim has produced a large variety of clinical guidelines to improve the quality of care and reduce variations in care practices. They are available through an internet portal and actively used in the whole country.”

Nevertheless, although it is time-consuming, detailed scrutiny of this data does reveal some interesting guidelines e.g:

on safe transfer of patients (in Hungarian only),

on effective hand hygiene ( in Danish only)

on protecting patients who are neck breathers (a safety notice issued by the NPSA for the care of patients with long term tracheostomy).

In addition, as one would expect, most countries give examples of guidelines or standards related to blood products, infection control, medical devices and medication safety.

Question 5. National experts

There are variable reports, from only one nominated expert to 10>. For the purposes of the call for good practice examples a maximum of six were identified per country, but the list for all 23 respondent countries still exceeded 100. The details by country can be obtained from the mapping database. In addition, where experts nominated others who had initiated good practices, the contact details of the latter are available on the good practice database.

Question 6. National Reporting Systems

Seven countries claim to have a national reporting system. These are Czech Republic, Denmark, England & Wales, Germany, Ireland, Slovak Republic and Sweden. Some detail is given about potential differences in systems, e.g. the English NHS system is fairly comprehensive (see 'national reporting and learning system' and Appendix B), the Swedish system collects data from healthcare organizations, but does not include patient complaints, and the Slovak Republic, on the other hand, collects patient complaints and ‘reports based on non-compliance between clinical diagnosis and necropsy’.

In relation to sub-sections c. - i. of Question 6:

besides the Slovak Republic all respondent countries, answer:

‘yes’ to - 'near misses' (subquestion c.);
'yes' to - 'data protection' (subquestion d.);
'yes' to - 'analysing reported events' (subquestion g.); and

'no' to - 'connection to litigation' (subquestion e.).

In Sweden apparently in exceptional cases, the National board for Health and Welfare (NBHW) will refer information to a disciplinary board for assessment. Most respondents answered subquestion f. ('how is the data collected used', along similar lines to the Danish response, namely:

‘1. For learning purposes; news letters, thematic risk reviews and case studies, based on RCA, are issued.
2. To elaborate regulations that aim to reduce risks and to avoid adverse events in health care services.
3. To prioritise supervisory actions'.

The Irish response refers in addition to early identification of possible claims.

In relation to the 'systematic approaches' used (subsection h. of Q6) four countries, Denmark, Germany, Ireland and Sweden refer specifically to Root Cause Analysis (RCA). The Czech Republic and the Slovak Republic don’t answer this question. The English response is very detailed and is given in Appendix B.

Finally, in four countries, Czech Republic, England and Wales, Germany and the Slovak Republic, patients can 'report incidents directly to the system' (subsection i. of Q6). In Denmark this facility is being prepared.

Six countries reported an unequivocal ‘no’: Estonia, Finland, Greece, Hungary, Lithuania and Poland. Although other responders from Spain report ‘no’ (also), the Health Ministry reports that their Quality department has designed a national reporting system which they are currently piloting (as does Hungary in the Good Practice compendium).

The following countries; Austria, Belgium, Cyprus, France, Italy, Netherlands, Portugal and Slovenia report partial systems. These responses are pasted in Appendix C.

Question 7. Local Incident Reporting Systems

Here fewer countries report affirmatively i.e. England and Wales, Ireland and Sweden. These responses are quoted in full in Appendix D, as they reflect how local legislation, policy direction and health system culture all influence the approach taken in a particular country.

Eight countries report ’no’: Cyprus, Denmark, Estonia, Finland, Germany, Greece, Italy and the Slovak Republic.

The other 11 countries; Austria, Belgium, Czech Republic, France, Hungary, Lithuania, the Netherlands, Poland, Portugal, Slovenia and Spain report very patchy activity at the local level. However, the Netherlands report a system due to come into force in 2008, which will be more comprehensive and no longer voluntary, Portugal identifies inci-
dent reporting as part of a national accreditation project involving 23 hospitals and similarly Lithuania and Hungary see incidents as evidence of non-compliance within their ISO based approach to health quality systems.

Question 8. No-Fault/No Blame Compensation Systems

A helpful editorial from the BMJ on no-fault compensation systems is available here. The principle is that claimants must show that a medical error was a causative factor in the resultant injury, irrespective of who is to blame. This allows more rapid investigation of claims without the restriction of communication typical of the adversarial process. Such a system is deemed by many, more equitable and more efficient.

Five countries report the existence of such a system: Austria, Denmark, Finland, France and Sweden. Spain's response is equivocal. There appears to be no national system but the Spanish Medical Association and Spanish Association of Health Risk Managers report that such a system operates in ‘Autonomous Communities’, supported by legislation, presumably an example where local government has taken a step in advance of national policy. The response from Estonia is also difficult to interpret. It does seem that more work is needed on researching which alternatives to litigation in clinical negligence cases exist and what constitutes good practice.

There is no such system reported to be in place in the other 15 countries.

Question 9. Legal disclosure of adverse incident information

This is a very difficult question to summarize. Logically, responses could be Yes/Yes, Yes/No, No/Yes or No/No
(for respective subsections 'clinical information protected from disclosure' (subsection a.) and 'legal requirement to inform affected patients (subsection b.). In part this relates to legislation or good practice guides on confidentiality which vary from country to country and the degree of anonymising of data which is routinely employed locally or nationally. One might conclude that Yes/No implies maximum exclusion of patients from knowledge, for whatever reason and No/Yes the opposite. Both No/No and Yes/Yes appear somewhat ambiguous and therefore explanatory information is provided, if available, from the responses.

Answers provided (to subsections a. respective b.):

‘No/Yes: -Cyprus, Estonia, France, Hungary, Slovenia and Sweden. Finland and Greece both qualify the ’Yes’ to 9b. by stating that '... there is a legal requirement to give patients information about their treatment. but not specifically about adverse events if they occur ...'.

Yes/No: - Belgium only.

No/No: - Austria, England and Wales, Germany, Netherlands and Spain. These countries all indicate that although there is no legal protection, data generally is available in an anonymised form. Usually individual data can be required by a court if there are claim proceedings. As to informing patients, in these countries it is seen as part of the ethical code under which professionals practice. In Germany their solution to the lack of protection of incident data is to house their voluntary Critical Incident Reporting System (CIRS) in Switzerland (what they call a ‘workaround solu-
tion’!). Ireland, Italy, Lithuania, Poland, Portugal and Slovak Republic all respond similarly but with no explanation.

Yes/Yes: - Czech Republic offers no explanation. For Denmark it appears that professionals are protected by having their data legally secured but patients are also safeguarded by there being a legal requirement under the Safety Law to inform patients both of incidents and of the existence of the No-Fault Compensation scheme.

Question 10. Public availability of patient safety incident data

For your convenience, please see the rows and columns of the following matrix

Analysis so far done on this complex data set indicates that, as far as the responses to the survey are concerned (given a degree of uncertainty about validity) there is little available public data on the performance of individual clinicians. One respondent in Belgium claims that such data is available publicly, but this might be checked e.g. via the Belgian National Mortality Databank and the public health data at www.iph.fgov.be.

Certainly if one looks at the column ‘Department’ a handful of countries report data and this is similar for the column ‘Healthcare Organisation’. There is least data in the categories 'falls'; 'deaths in restraint'; 'deaths following trauma'; 'suicide in care settings'; and 'suicide within one month of seeking advice'. In all cases there are three countries or less per cell in the matrix except that Austria claims comprehensive data based on both autonomous data from the nine Austrian provinces and from the operation of an IQIP (International Quality Indicator project).

Mortality data by 'Department' is available in addition from Denmark, Germany (some), Portugal and Slovak Republic and by 'Healthcare Organisation' from Denmark, Greece, Slovak Republic and Spain. Data on the categories 'deaths in accident and emergency' and 'deaths on intensive care units' are available by 'Department' apparently from Belgium, Cyprus, Czech Republic, Portugal and Spain (some). For the column 'Healthcare Organisation' data is also available for A and E (ER) for a similar number of countries (i.e. four or five).

Data on 'healthcare acquired infection'and on 'peri-operative deaths' is available in about six countries per cell in the ‘Department’ and ‘Healthcare organisation’ columns, the exception being 'healthcare acquired infection' which has 11 entries (Belgium, Czech Republic, Denmark, England and Wales, France, Greece, Ireland, Slovak Republic and Spain, with Germany and Finland reporting ‘some’ data).

Data on 'obstetric' in these columns has about six entries per cell.

Turning to the column 'National', there are five entries or less in the categories 'falls', 'deaths in restraint', 'deaths in A and E' and for the two 'suicide' categories each.

The remaining eight categories will be listed by country:

Question 11. Liability arrangements

There are affirmative answers on the subsection 'existence of medical defence organisation' (a) of Q11 from seven countries: Belgium, Czech Republic, England and Wales, Germany, Ireland, Slovak Republic and Spain. A helpful definition of the term ‘medical defence organisation’ is given by the General Medical Council. A point of interest is whether there is a pattern in the liability arrangements associated with the existence or otherwise of 'no-fault com-
pensation schemes'. This appears not to be the case. Although it is true that none of the five countries in Q. 8 has a large medical defence organisation, essentially private practitioners in Austria, Denmark, France and Finland use indemnity insurance. In Sweden claims tend to be made against the healthcare organization (as in Denmark).

Only three countries respond affirmatively to subsection 'clinicians' use of medical defence organisations' (b) of this Q. In France a limited number of physicians engaged in high risk activities use such medical defence organisations based in other countries. Their 'Clinical Indemnity Scheme' in Ireland does not cover private practice in private hospitals and clinicians obtain indemnity for this work from the Medical Defence Union or the Medical Protection Society in the UK. In Belgium it seems that clinicians use private insurance schemes, either in Belgium or else-
where in the EU. Subsection 'other malpractice protection schemes' (c) of Q11 provided no significant data. There is a slightly ambiguous response from Poland, where the Chamber of Physicians is apparently asked to investigate certain cases.

Finally, in relation to who pays premiums, in countries where there is a large medical defence organisation, there tends to be nevertheless a situation that although clinicians pay premiums, there is also a state indemnity scheme or the equivalent. This is the case in England, Ireland and Spain and to some extent in Belgium. In the Czech Republic, the employer pays and to some extent this is also the case in Slovenia and the Slovak Republic.

In Greece, Hungary, Italy, Lithuania, Netherlands and Poland, employers cover the cost of indemnity insurance. In Portugal it is paid by the clinician.

There are four countries, Austria, Cyprus, Estonia and France where arrangements are slightly more complex (see Appendix E). In Cyprus examination of the response suggests that neither patients nor clinicians may be well served. In Estonia clinicians are automatically insured by paying their union dues but there are also some voluntary malpractice insurance schemes for employers but it is not made clear for how much these are subscribed to. France is mentioned because it appears to be the only country where doctors in private practice are given an incentive to join accreditation schemes by having part of their liability insurance paid for by the State.

Question 12. Whistle-blowing

Although six countries report that such a system exists, only two, England and Wales and Greece appear to have understood the question. Their replies are pasted in Appendix F. This appears to be an issue of vocabulary (see also peer review, Q.19, another source of misunderstanding). Interestingly, the term whistle-blowing is not among the 24 items selected by the expert group in Work package 4 of this project. Neither does the term feature in the glossary prepared by the expert sub-group on medication safety within the Council of Europe recommendations.

Whistle-blowing, the ability of an employee to report to higher management an example of malpractice, without fear of reprisals, was a major concern in the National Health Service of England and Wales, following the public enquiry at the Bristol Royal Infirmary (see also here). It is seen as one of the important elements that contribute to a ‘safety culture’. A committee, headed by Lord Nolan, provided a now widely accepted description of the components of a whistle-blowing policy and this is also pasted in Appendix F.

Of the four other ‘yes’ responses, those of Belgium and Sweden in fact refer to alerts, that of one of the Hungarian respondents to a proposed National programme on patient safety generally and the response from one of the Czechs is ambiguous.

Although all other countries report ‘no’, Austria and Ireland qualify this by reporting that such a scheme is currently under consideration. From telephone conversations with a few other respondents, one could reasonably conclude that some of those who answered ‘no’ also misunderstood the question. The term should probably have been defined in the questionnaire. However, it seems unlikely that whistle-blowing policies under another name would exist in those countries where the English label was not understood.

Question 13. Professional patient safety membership organisations

Eight countries report professional organisations, but only four appear to meet the criteria implied in the question. France reports two small, relatively new risk manager associations, AFGRIS and SOGFRES. Ireland has an esta-
blished Healthcare Risk managers Forum.

In Spain there are four organisations reported which exemplify the complexity of inter-relationships. The first is FAD, the prestigious Foundation Avedis Donabedian. This is a health quality research institute, but since 2002 has run CISP, a patient safety department. Although contributing to education and research, it is not a membership organisation like those quoted above. Similarly, both AEGRIS and SECA (the latter, part of the Spanish Society for Quality in healthcare) are multi-professional organisations supporting patient safety activity but are certainly not exclusively for patient safety specialists. Finally, ISMP (Spain) is dedicated to safe medication practices, but not to a comprehensive approach to risk or safety.

The German examples reflect this also. The German Coalition for Patient Safety (Aktionsbundnis Patientsicher-
heit.e.V) was in fact initiated by GQMG, the Society for Quality Management in Healthcare and is a multi-profes-
sional platform, of which Patient Safety specialists are but part.

Four countries who answer ‘yes’ to this question, Czech Republic, Greece, Italy and Lithuania on closer exami-
nation cite member organizations interested in health quality, but not exclusively in patient safety.

Although no organisation is reported for England and Wales, the authors are aware of the association of litigation and risk management (ALARM). This simply confirms that the questionnaire data can only provide an approximation of what goes on in each country.

Three countries answer ‘no’, but give information about relevant activity. Finland reports a network and meetings set up by the Ministry of Social Affairs and Health for organisations involved in patient safety. Netherlands sees its National Platform for Patient Safety where various patient safety experts share experiences as ‘not official’ and therefore answers ‘no’. It, like the four countries mentioned previously, also cites their national health quality membership organisation (in Netherlands, NVKZ). Similarly Poland refers to its health quality society as actively involved in teaching and other activities related to patient safety.

Question 14. Risk management qualifications

Eleven countries give examples of various trainings, which more or less fit with the question asked. For example, one respondent from Austria describes quality assurance commissioners (verificators), but these quality trained doctors in fact have the task of auditing the performance of health staff, not clinical risk management per se. In Cyprus ‘some healthcare risk management initiatives are currently being developed by the National Quality Assurance and Risk Management Committee’. In France, Germany and Spain, courses are available as modules in University courses, although in France these are only non-medical risk qualifications.

It is therefore only in five countries that clinical risk management qualifications can be identified, in Czech Republic (at the postgraduate institute of education in Public Health, IPVZ), Denmark (at the Danish Society for Patient Safety), in England & Wales (run by the NHS and the London Deanery), in Italy (a Masters at the University of Padova), in Ireland (the HDipHRM at University College, Dublin) and in Portugal (as in Czech republic, at the National school for Public Health, ENSP).

Question 15. Risk or patient safety managers required

Five countries answer ‘yes’. Risk or safety managers are required in Czech Republic, England & Wales, Germany and Sweden. In Portugal it is the case for hospitals working with Joint Commission International or involved in the IQS accreditation scheme.

Although the question was answered ‘no’, in Hungary quality managers or quality specialists are required who then do risk or patient safety work within their overall remit. In Netherlands, there will be a requirement for risk assess-
ment as part of an overall safety system from January 2008. In five other countries, Finland, France, Ireland, Italy and Spain, risk managers are strongly recommended, but their employment by organisations is voluntary, not mandatory.

Question 16. Training in patient safety

Eleven countries answered ‘yes’ to this question. Scrutiny of the results for Questions 13, 14 and 15, shows a strong overlap between those identified as active in those areas. Here, Austria, Cyprus, the Czech Republic, Denmark, England and Wales, Estonia, Finland, Ireland, Netherlands, Portugal and Spain indicate training in two or more of the five categories (medical under- and post-graduate, nursing, other clinical staff and managers).

For Germany and Sweden there is an unequivocal ‘no’ to all categories. In France, it is indicated that training courses are on the way, but not so far required.

Question 17. Specialist patient organisations for patient safety

Eight countries answer ‘yes’. However, in most cases the names suggest that these are generic patients’ rights organisations. The exceptions are: England & Wales (Action against Medical Accidents, AvMA; although generics, the Patients Association and the Patients Forum are also quoted ), Spain (Asociacion El DEfensor del PAciente, ADEPA, plus two patients rights organisations, CECU and FEP), France (a small organization, LIEN, for patients acquiring nosocomial infections, within the Collectif Interassociatif Sur la Sante, CISS, another generic being Fede-
ration des Associations AVIAM) and Germany, where there is the German Coalition for Patient Safety (see Q. 13) and a number of generics, e.g. DPSB and NGM-Bayern.

There are four countries that answered ‘yes’ and four that answered ‘no’ that have patient organisations involved in patient safety activity: Cyprus (PRAG), Estonia (EPAA), Ireland (IPA & Patient Focus), Slovak Republic (ANOPP), Czech Republic (Paziendi), Denmark (part of DSFP) Poland (Polish Patients Association Primum Non Nocere) and Netherlands (National Platform for Patient Safety, see Q. 2 and Q.13. Note also, Ne Ve Me Dis, the Dutch Society of Medical Dissidents).

It has been pointed out by Peter Walsh (see: 'initiating the workpackage' section of Methodology) that there may be a difficulty in identifying patient organizations specifically concerned with patient safety, particularly those formed by the ‘victims’ of medical accidents. They may not be recognized by those in the patient safety ‘establishment’ because they are seen as too informal, too outspoken or their messages are simply too uncomfortable. This area needs further examination.

Question 18. National patient safety campaigns

Only six countries answered ‘no’: Austria, Estonia, Greece, Hungary, Lithuania and the Slovak Republic.

However, of the remaining countries, careful scrutiny suggests that only nine countries have genuinely had national patient safety campaigns aimed at two or more of the four categories, professionals, managers, purchasers or patients and the public. These are Belgium, the Czech Republic, Denmark, England and Wales, France, Ireland, Netherlands, Spain and Sweden. Cyprus and Portugal report narrowly focused campaigns, on blood safety and medication safety respectively. Italy reports activity on a regional level, but not on a national one.

There are four countries that answered ‘yes’, where in fact the ‘campaigns’ were one-off national conferences, usually for doctors or some other form of medical education (Finland, Germany, Poland and Slovenia). Some respondents confused general public health education campaigns (e.g. on AIDS or early detection of breast cancer) with patient safety campaigns.

Question 19. Peer review schemes with the aim of reducing medical error

Peer review is used in many industry sectors to delineate the use of people who are peers within an industry or an organisation who review and judge a person’s performance, work product or other behaviour. Unfortunately, in health, there are nuances to the term, related to ‘peer review’ as a verb (relating mainly to publications), internal versus external peer review etc.

As with Q.12, vocabulary problems arise in part because, with the advantage of hindsight, it appears that the question should have been articulated more clearly. The wording of the question, because it specifies peer review involving an aspect of patient safety, may result in some countries having answered ‘no’ because the classical internal clinical peer review using a ‘case conference’ or similar style was not seen as related directly enough to patient safety. So there may be false negatives. Cyprus, the Czech Republic, Denmark, Finland, Greece, Italy, Lithuania and Portugal constitute this group.

Equally, following the analysis of external audit methods in the introduction to Work package 5 of this project, accreditation does not equate with external peer review, despite the argument put by more than one respondent, that because trained assessors are in fact of the same peer group as those they are assessing, this is peer review (e.g. Ireland and Poland). Four countries among their responses offer external review for the purpose of re-certifi-
cation as a form of external peer review arguing that working knowledge of patient safety is part of the expertise audited. Estonia, Germany, Netherlands and Poland fall into this category. Slovenia cites involvement of the Slovenian medical chamber in peer review of patient complaints as a form of external peer review. Certainly the ‘visitatie’ carried out via the NIAZ in the Netherlands, according to the experts from Work package 5, does qualify as external peer review. The comprehensive external peer review carried out in France via HAS certainly meets that criterion.

This leaves only seven countries that offer internal peer review, as described in the second paragraph, above, as a basis for their ‘yes’ answer; Austria, Belgium, England and Wales, France (to some extent), Germany (to some extent), Hungary and Spain (patchy implementation).

Question 20. The role of European Bodies in patient safety

As this was a question seeking opinions rather than facts and because analysis of a matrix answer can be complex (see Q.10) it was decided to omit this question from the final analysis.

Question 21. Learning about patient safety

One country, Austria, gives an ambiguous answer. England and Wales and Ireland have English as a native tongue and interestingly Denmark and Finland, but not Sweden state that health professionals are assumed to be bi-lingual. Finland comments that the documents referred to are not widely disseminated. Netherlands also sees itself as more or less bilingual.

Only two countries claim to have translated versions of the documents, Italy and Spain (although not all documents are available in Spanish).

There are therefore fourteen remaining countries that confirm that native translations of key patient safety documents would be helpful.

By individual clinician By department By healthcare organisation Nationally Mortality data Falls in care settings Deaths while in restraint Deaths in accident and emergency department Deaths while on intensive care Deaths following trauma Healthcare acquired infections Suicide in care settings Suicide within one months of seeking professional advice Maternal deaths Peri-operative deaths Still births Infant deaths within hospitals