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Marta Vázquez Vázquez
Risk Management and Patient Safety
Strategy in Andalusia
Best Practices for Patient Safety and Quality Improvement
Bucharest, March 27th 2014
www.juntadeandalucia.es/agenciadecalidadsanitaria
What’s the Andalusian Patient Safety Observatory?
“The global burden of unsafe medical care: analytic modeling of observational studies” Ashish K Jha, Itziar Larizgoitia, Carmen
Audera-Lopez, et al. BMJ Qual Saf 2013 22: 809-815 originally published online September 18, 2013
There are 421 million hospitalisations in the world
annually, and approximately 42,7 millions of
adverse events , according to the World Health
Organization
1 out of 10 inpatients suffers from adverse events.
23 millions of disability-adjusted life years are
lost annually as a consequence of adverse events.
The global burden of unsafe medical care
Some figures…
418.500 AE (9,3 %)
2,511,000 aditional stays
Hospitalisations
4,500,000/year
904,744 avoidable stays
6 hospitals of 500 beds/year
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Burillo J, Gea-Velázquez de Castro MT, Requena-Puche J, Terol-García E and grupo de trabajo ENEAS. Impact
and preventability of adverse events in Spanish public hospitals. Results of the Spanish Nacional Study of adverse events (ENEAS). International Journal
for Quality in Health Care 2009;21(6):408-14.
http://intqhc.oxfordjournals.org/content/21/6/408.full.pdf+html
Impact on hospitalization
International Framework
2004: World Alliance for Patient Safety
“First do no harm”
2006: Council of Europe Recommendations
“Patient Safety as the center of every healthcare policies”
2009: Council of the European Union
Recommendations on Patient Safety, including surveillance
and prevention of hospital acquired infections
-To promote national strategies on patient safety
- To prevent and work against HAI
Patient Safety Strategy in Spain
Patient Safety Strategy in Spain
Reporting and
Learning
Systems
Safe practices
Training
Culture
Patients
Patient
Safety
Strategy
Research
Patient Safety Strategy in Andalusia
Dissemination
Implementation
Evaluation of NHS indicators
Experts Review
NHS Indicators
0 10 20 30 40 50 60 70 80 90 100
Hosp - ISMP [Ind.15]
Hosp - Conciliación[Ind.14]
Hosp - Mdto alto riesgo[Ind.13]
Pac - LVSQ [Ind.12]
Hosp - LVSQ [Ind.11]
Hosp - IncidenciaIRAS [Ind.10]
Hosp - PrevalenciaIRAS [Ind.9]
PrevalenciaUPP [Ind.8]
Pac - Valoración UPP [Ind.7]
Hosp - UPP [Ind.6]
Hosp - Identificación[Ind.5]
DAP - UFGR/Com SP [Ind.4]
Hosp - UFGR/Com. SP [Ind.3]
DAP - SNISP [Ind.2]
Hosp - SNISP [Ind.1]
Porcentaje(%)
Indicadores despliegue de la ESP
SNS
SSPA
Patient Safety Strategy in Andalusia 2011-2014
1
2
3
4
Safety and citizenship
Safety and healthcare professionals
A safe shared space
Strategic projects
42 actions
Macromanagement
(Regional Health
Ministry)
24 actions
Middle management
(Centres)
55 actions
Micromanagement
(Units)
3 blocks, 7 aims, 22 objectives, 121 actions
Patient Safety Strategy in Andalusia 2011-2014
979 units
(85% of total)
Criteria with the highest percentage of compliance
20%
20%
26%
8%
7%
67%
71%
64%
87%
88%
0% 20% 40% 60% 80% 100%
E_012. High risk procedures (n=701)
E_031. Reporting and Learning Systems (n=681)
E_037. AE management (n=662)
E_061a. Patient identification (n=652)
E_075. Hand Hygiene (n=644)
Not met Parcially met Met N/A
Criteria with the highest percentage of non-compliance
40%
41%
46%
51%
52%
26%
23%
17%
16%
20%
29%
30%
31%
24%
22%
0% 20% 40% 60% 80% 100%
E_014. Information about the Strategy (n=684)
E_063. Critical points monitoring (n=630)
E_060. PS information to citizens (n=644)
E_064b. PS information in clinical pathways (n=617)
E_045. Research groups (n=641)
Not met Parcially met Met N/A
#Safe Use of Drugs
#Hand Hygiene
#Safe Surgery
#Pain Control
Safe Practices in the Observatory
#Prevention of central venous
catheter-related infection
Online tools
Recommendation
Examples
Evidences
and improvement areas
Resources
Assessment criteria
Sharing
Resource bank and Badge
Aditional tools
International Network
1132 centres
39 Colombia
26 Argentina
25 Mexico
3 Panama
7 Peru
6 Cuba
5 Uruguay
5 Chile
2 Brazil
- Almost 1,500 reported
incidents
- 159 shared
improvement actions
Sharing solutions
2013
Patient Empowerment
Patient Empowerment
Pregunta por tu
salud
CompruebaRecuerdaMed
Following the PaSQ Sustainability Guidelines
- Sharing patient safety practices
-Exchange mechanism of patient safety
incidents and solutions
- Patient Empowerment
Agencia de Calidad Sanitaria de Andalucía
www.juntadeandalucia.es/agenciadecalidadsanitaria
Entidad gestionada por la Fundación Pública Andaluza Progreso y Salud
www.observatorioseguridaddelpaciente.es
marta.vazquez.vazquez@juntadeandalucia.es
Mulțumesc!

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Risk Management and Patient Safety Strategy in Andalusia

  • 1. Marta Vázquez Vázquez Risk Management and Patient Safety Strategy in Andalusia Best Practices for Patient Safety and Quality Improvement Bucharest, March 27th 2014
  • 3. “The global burden of unsafe medical care: analytic modeling of observational studies” Ashish K Jha, Itziar Larizgoitia, Carmen Audera-Lopez, et al. BMJ Qual Saf 2013 22: 809-815 originally published online September 18, 2013 There are 421 million hospitalisations in the world annually, and approximately 42,7 millions of adverse events , according to the World Health Organization 1 out of 10 inpatients suffers from adverse events. 23 millions of disability-adjusted life years are lost annually as a consequence of adverse events. The global burden of unsafe medical care Some figures…
  • 4. 418.500 AE (9,3 %) 2,511,000 aditional stays Hospitalisations 4,500,000/year 904,744 avoidable stays 6 hospitals of 500 beds/year Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Burillo J, Gea-Velázquez de Castro MT, Requena-Puche J, Terol-García E and grupo de trabajo ENEAS. Impact and preventability of adverse events in Spanish public hospitals. Results of the Spanish Nacional Study of adverse events (ENEAS). International Journal for Quality in Health Care 2009;21(6):408-14. http://intqhc.oxfordjournals.org/content/21/6/408.full.pdf+html Impact on hospitalization
  • 5.
  • 6. International Framework 2004: World Alliance for Patient Safety “First do no harm” 2006: Council of Europe Recommendations “Patient Safety as the center of every healthcare policies” 2009: Council of the European Union Recommendations on Patient Safety, including surveillance and prevention of hospital acquired infections -To promote national strategies on patient safety - To prevent and work against HAI Patient Safety Strategy in Spain
  • 7. Patient Safety Strategy in Spain Reporting and Learning Systems Safe practices Training Culture Patients Patient Safety Strategy Research
  • 8. Patient Safety Strategy in Andalusia Dissemination Implementation Evaluation of NHS indicators Experts Review
  • 9. NHS Indicators 0 10 20 30 40 50 60 70 80 90 100 Hosp - ISMP [Ind.15] Hosp - Conciliación[Ind.14] Hosp - Mdto alto riesgo[Ind.13] Pac - LVSQ [Ind.12] Hosp - LVSQ [Ind.11] Hosp - IncidenciaIRAS [Ind.10] Hosp - PrevalenciaIRAS [Ind.9] PrevalenciaUPP [Ind.8] Pac - Valoración UPP [Ind.7] Hosp - UPP [Ind.6] Hosp - Identificación[Ind.5] DAP - UFGR/Com SP [Ind.4] Hosp - UFGR/Com. SP [Ind.3] DAP - SNISP [Ind.2] Hosp - SNISP [Ind.1] Porcentaje(%) Indicadores despliegue de la ESP SNS SSPA
  • 10. Patient Safety Strategy in Andalusia 2011-2014
  • 11. 1 2 3 4 Safety and citizenship Safety and healthcare professionals A safe shared space Strategic projects 42 actions Macromanagement (Regional Health Ministry) 24 actions Middle management (Centres) 55 actions Micromanagement (Units) 3 blocks, 7 aims, 22 objectives, 121 actions Patient Safety Strategy in Andalusia 2011-2014
  • 13. Criteria with the highest percentage of compliance 20% 20% 26% 8% 7% 67% 71% 64% 87% 88% 0% 20% 40% 60% 80% 100% E_012. High risk procedures (n=701) E_031. Reporting and Learning Systems (n=681) E_037. AE management (n=662) E_061a. Patient identification (n=652) E_075. Hand Hygiene (n=644) Not met Parcially met Met N/A
  • 14. Criteria with the highest percentage of non-compliance 40% 41% 46% 51% 52% 26% 23% 17% 16% 20% 29% 30% 31% 24% 22% 0% 20% 40% 60% 80% 100% E_014. Information about the Strategy (n=684) E_063. Critical points monitoring (n=630) E_060. PS information to citizens (n=644) E_064b. PS information in clinical pathways (n=617) E_045. Research groups (n=641) Not met Parcially met Met N/A
  • 15. #Safe Use of Drugs #Hand Hygiene #Safe Surgery #Pain Control Safe Practices in the Observatory #Prevention of central venous catheter-related infection
  • 20.
  • 21. International Network 1132 centres 39 Colombia 26 Argentina 25 Mexico 3 Panama 7 Peru 6 Cuba 5 Uruguay 5 Chile 2 Brazil
  • 22. - Almost 1,500 reported incidents - 159 shared improvement actions Sharing solutions 2013
  • 24. Patient Empowerment Pregunta por tu salud CompruebaRecuerdaMed
  • 25. Following the PaSQ Sustainability Guidelines - Sharing patient safety practices -Exchange mechanism of patient safety incidents and solutions - Patient Empowerment
  • 26. Agencia de Calidad Sanitaria de Andalucía www.juntadeandalucia.es/agenciadecalidadsanitaria Entidad gestionada por la Fundación Pública Andaluza Progreso y Salud www.observatorioseguridaddelpaciente.es marta.vazquez.vazquez@juntadeandalucia.es Mulțumesc!