GP.17.Concerning the development of Patient Safety Tools (DSFP)

Patient Safety Tools (Denmark)

Inspired by the dissemination of the first results of SIMPATIE's Working Packages (Luxembourg Conference, 18–19 September 2006), the Danish Society for Patient Safety would like to give an input for the "next wave" in the European Patient Safety work.

It especially concerns the development of tools and instruments to improve patient safety at institutional level. At the conference a catalogue was presented rpoviding a good overview of instruments to be used at institutional level. What we need now in order to facilitate real action is to turn this description into usable tools that can be used in the daily patient safety work at the institutions.

The Danish Society for Patient Safety has until now developed the following Toolkits that has been used in all Danish hospitals the last couple of years:

• Root Cause Analysis


• Health Failure Mode Effect Analysis


• Human Factor


• Legal aspects of patient safety work

We have received positive feedback from both patient safety managers and clinical staff using the toolkits. Therefore this autumn we are publishing toolkits, on:

• Medication Reconciliation


• Aggregated Root Cause Analysis


• How Patient Organizations can reduce harm


• Patient Safety Walk rounds

The toolkits typically consist of:

• A Compendium that gives a detailed description and explains the method step by step, including how it can be implemented



• A Power point presentation (including explaining notes) so that the patient safety manager easily can educate others to use the method



• Relevant forms, charts, checklists and diagrams



• A handbook



• A CD with all the material

Development of toolkits for European level will of course have to be done in collaboration with representatives from different health cultures so that we make sure that it is adequate to most systems.

The Danish toolkits can be a valuable starting point and The Danish Society for Patient Safety can deliver patient safety expert knowledge and the experience in developing toolkits. See, e.g: toolkits available on www.trygpatient.dk where there is general information on patient safety and toolkits (for free) on Root Cause Analysis, Health Failure Mode Effect Analysis, Human Factor, Legal aspects of patient safety work, Medication Reconciliation, Aggregated Root Cause Analysis, How Patient Organizations can reduce harm and soon on Patient Safety Walk rounds.

Translation of the root cause analysis toolkit into English is in its final stage as of 31st December 2006. For update contact DSFP via www.patientsikkerhed.dk)

Author: Beth Lilja Pedersen, Director Danish Society for Patient Safety (e-mail: Beth.Lilja@hh.hosp.dk ).