The German experience in education on Patient Safety

IV. International Conference on Patient Safety

Finding the Best Practices for Safer Care

Madrid, 25.-26.11.2008

Matthias Schrappewww.schrappe.com

The German Experiencein Education on Patient Safety

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Prof. Dr. M. Schrappe

German Coalition for Patient Safety

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www.aktionsbuendnis-patientensicherheit.de

Personal Experience (Teaching)00qm\lehre\PersExp.cdr

Since 1997: lecture of QM as part of the studyof Health Economics at the University of Cologne

since 2005, as part of the MA study of Health Economics at the University of Cologne

Lecture in EBM and Clinical Epidemiology

Postgraduate training of QM 1997-2001 LÄK Nordrhein

Lectures in Governance and LeadershipProf. Dr. M. Schrappe

Quality Management

Patient Safety and Risk Management

Others

German Situation00qm\lehre\d-Situat.cdr

Curriculum on patient safetyCurriculum on QM

Skill-based training coursesPatient safety curriculum

University of Cologne: study of Health Economy

Curriculum governance and leadership

Bonn: University Institute for Patient Safety (from 1.1.09)Prof. Dr. M. Schrappe

National Physicians Organization

Regional Physicians Organizations

University Education

Presentation

Knowledge

Skills

Attitude

Perspectives and Summary

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IV. InternationalConference onPatient Safety

The GermanExperience in Educationon Patient Safety

Prof. Dr. med. Matthias SchrappeGeneralbevollmächtigter des ARKlinikum der Goethe-Univ. Frankfurt

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Presentation

Knowledge

Skills

Attitude





Knowledge

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Modern understanding of incidents (error chain)


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Swiss Cheese - the error chain


aus: Reason BMJ 320, 2000, 768

Knowledge



Nomenclature


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Systematology

+

=Adverse event

Error

Preventable Adverse Event


Knowledge



Nomenclature

Incidence


0

10

20

30

40

50

60

70

80

90

100

10 100 1000 10000 100000 1000000 10000000Stichprobe (n)

AE

(%)

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Review:Incidence AE*

*AE = adverse event

147/184 trials

Agenda Patientensicherheit 2006

0

10

20

30

40

50

60

70

80

90

100

10 100 1000 10000 100000 1000000 10000000

Stichprobe (n)

Patie

nten

mit

AD

E(%

)



Review:Incidence ADE*

68/184 trials

Agenda Patientensicherheit 2006

*ADE = adverse drug event

Knowledge



Nomenclature

Incidence

Kind of events


Falls:

Autopsy-Studies:

Decubitus (w/o. Stad. 1):

Nosocomial Infections:

Adv. Drug Events:

Adv. Med. Device Events:

Prevalence: 2,4%

Metaanalysis: 10,1%

Prevalence: 4,2%

Prevalence D: 3,6%

Metaanalysis: 2,1%

Incidence: 8,4 %

Dassen 2004

AHRQ 2002

Dassen 2004

Rüden 1996

Lazarou 1998

Samore 2004


Frequency of in Hospitalsadverse events


Knowledge



Nomenclature

Incidence

Kind of events

Prevention


Prevention Wrong Site Surgery

Bild: aus Presseservice Gesundheit AOK 28.4.05

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Prevention: ErgonomyOrganizetechnicalprocessessafely

from: T.M. Nolan: System changes to improve patient safety. BMJ 320,2000,771

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IT and Error-Prevention

- Improvement of communication- Access to knowledge- Coming to information- Support of calculations- Support of timeliness- Monitoring- Give decision aids

Bates, DW, Gawende AA: Improving Safetywith Information Technology.NEJM 348, 2003, 2526

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Knowledge



Nomenclature

Incidence

Kind of events

Prevention

Informed consent and litigation


Knowledge



Nomenclature

Incidence

Kind of events

Prevention

Informed consent and litigation


gliedrg.cdr

Presentation

Knowledge

Skills

Attitude





Skills

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Processanalysis after critical incidents


Events: to understand the process

Act CausingPreventable

Adverse Event

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Unsafe Acts

Unsafe Care Process


Act CausingPreventable

Adverse Event

Unsafe Care ProcessIndividualTask

TechnicalEnvironmentOrganization

Events: to understand the process

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Unsafe Acts


Skills



How to measure: random bias, small numbers


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Cholera-Epidemie London 1854


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Measurement and Counting

events / 100 patients ?

events / 100 admissions ?

events / 1000 patient-days ?

events / 100 patients at risk ?

events / 1000 patient-days at risk ?


Skills




Human factors


Skills




Human factors

Why not doing what we are knowing?


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Effectiveness Gap: DeterminantsPatient-related factors

Health Care Professionals

Organisations

System factors

AgeGenderEthnic group ComorbidityPreferences

Skills and knowledgeWillingness to learnAttitudes

FlexibilityAbility to integrate innovationsIntegration of heterogeneityFinancingSectoral organisation (Germany!)


Skills




Human factors


Concepts of organizational learning


Skills




Human factors


Concepts of organizational learning


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Presentation

Knowledge

Skills

Attitude





Aktion Saubere Hände

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Learning by feedback

Volume of hand desinfectants

Publicity: TV, mass media

National agenda


German Clean Your Hands Campaigne

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Presentation

Knowledge

Skills

Attitude





Institute for Patient SafetyMedical Faculty of the Friedrich-Wilhelms-University of Bonn

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Federal Ministry of Health, donations, 28 sponsors

1.1.2009, official opening 8.5.2009

Integration in education of health professions

Patient safety indicators, epidemiology and measurement,implementation research, safety culture


Financing

Start

Teaching

Research topics

Summaryzusfassg.cdr

Don’t underestimate knowledge (e.g., systematology,epidemiology)

Skills: establishing new training facilities - process analysis after catastrophic events, human factorsAttitude: integrate safety in university and basiceducation, understand organizational learning

Perspective: making regional experiencestrengthening skill-orientationhelp physicians to trust in the benefit of change in organizational culturedevelop targeted programms for professionsintegrate patient safety in university education and outcome research


Schluß

Vielen Dank für Ihre Aufmerksamkeit !


Health & Medicine

The German experience in education on Patient Safety