Ministero della Salute 1 Sentinel Event System The Italian Experience Giuseppe Murolo, MD Ministry...
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1 Ministero della Salute Sentinel Event System The Italian Experience Giuseppe Murolo, MD Ministry of Health, Department of Quality General Directorate for Health Planning and Policy [email protected]1° OECD Healthcare Quality Indicators Seminar on improving Patient Safety Data Systems June 29-30, 2006
Ministero della Salute 1 Sentinel Event System The Italian Experience Giuseppe Murolo, MD Ministry of Health, Department of Quality General Directorate
Ministero della Salute 1 Sentinel Event System The Italian
Experience Giuseppe Murolo, MD Ministry of Health, Department of
Quality General Directorate for Health Planning and Policy
[email protected] 1 OECD Healthcare Quality Indicators Seminar on
improving Patient Safety Data Systems June 29-30, 2006
Slide 2
Ministero della Salute 2 Outline 1.Background 2.Sentinel Event
System 3.The Sicilian case 4.Strategies
Slide 3
Ministero della Salute National Health Services Parliament
Government Central Agencies Regions Camera Senato Commissioni
parlamentari Conferenza Stato - RegioniMinistero della Salute
Consiglio Superiore di Sanit Istituto Superiore di Sanit Agenzia
Nazionale per i Servizi Sanitari Istituto Nazionale per la
Prevenzione e Sicurezza sul lavoro Conferenza dei Presidenti
Regioni ordinarie Aziende Unit Sanitarie Locali, Aziende
Ospedaliere Province Autonome Ospedali Universitari, IRCCS
Slide 4
Ministero della Salute National Health Service Essential levels
of health care 2001 National Health Plan 2006 2008 Promotion of
Clinical Governance and quality in the NHS: Clinical Risk
Management and Patient Safety Reporting systems Cooperation among
institutional level national regional local First step sentinel
event system
Slide 5
Ministero della Salute Patient safety and Risk Management
Activities 1.National Commission (2003) 2.Working group, 2004
3.Working Group on Patient safety, 2006
Slide 6
Ministero della Salute www.ministerosalute.it National
Commission (2003) 2002 Survey on patients safety within the NHS
Hospitals Clinical Risk Management Unit 17% Manual on clinical
risk
Slide 7
Ministero della Salute Methods and tools for reporting Sentinel
Events Advers events Near Misses Education and training General
framework on national training Basic course for all Health
professional Recommendation: to provide health professionals and
administrators with information on high risk medications that have
the potential to cause serious or catastrophic harm to patients.
The aim is to raise awareness of the potential harm and provide a
strategy for local level response (KCl). Working group, 2004
Slide 8
Ministero della Salute 8 Working Group on Patient safety, 2006
SG.1. Sentinel Event System and Recommendations SG.2. Methodologies
to Analyze adverse events and education packages and tools for
Health professionals SG.3. Patients involvement SG.4. Methods to
investigate Insurance costs and medico legal aspects 2005 Survey
Insurance costs in the NHS Hospitals Clinical Risk Management Unit
28%
Slide 9
Ministero della Salute Sentinel Event Reporting System Sentinel
events are rare and preventable events that lead to catastrophic
patient outcomes*. Australian Council for Patient Safety and
Quality and the JCAHO OECD
Slide 10
Ministero della Salute 10 Sentinel Event List 1.Procedures
involving the wrong patient 2.Procedures involving the wrong body
part 3.Suicide of patients in inpatient units 4.Retained
instruments or other material after surgery requiring re- operation
or further surgical procedure 5.Haemolytic blood transfusion
reaction resulting from ABO compatibility 6.Medication error
leading to the death of a patient 7.Maternal death or serious
morbidity associated with labour or delivery 8.Mortality in newborn
with => 2,500 grams 9.Violence on patients 10.Any other adverse
event in which death or serious harm to a patient has
occurred.
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Ministero della Salute Contributing Factors and Root Causes
1.patient assessment 2.staff training or competency 3.equipment
4.lack or misinterpretation of information 5.communication
6.appropriateness or lack policies/procedures or guidelines
7.safety mechanism 8.specific patient issues Risk Reduction Action
Plan Recommendation addressing contributing factor(s) Personnel
accountable for implementing recommendation Outcome measure
Slide 12
Ministero della Salute Preliminary Results (September 2005 -
April 2006) Sentinel eventN% 1. Wrong Patient0- 2. Wrong site
surgery0- 3. Inpatient Suicide711 4. Foreign body retention58 5.
Transfusion error35 6. Medication error0- 7. Maternal death or
serious morbidity46 8. Violence12 9. Perinatal death
(weight>2.500 gr)610 10. Other catastrophic event3759 Total
number of sentinel event63100
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Ministero della Salute Source of Sentinel Event N% Media3962
Self-reported2438 Total63100 Patient OutcomeN% Death4978 Loss of
function58 Other914 Total6310 0 Other catastrophic eventN% Surgery
complications1027 Emergency management719 Fetal Complications of
delivery411 Anesthesia Complications38 Patient falls (death or
serious injury)38 Embolism25 Other822 Total37100 Preliminary
Results (September 2005 - April 2006)
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Ministero della Salute Analysis of contributing and causing
factor
Slide 15
Ministero della Salute Characteristics of Successful Reporting
Systems *Leape, L.L. Reporting adverse event. NEJM, 2002, 347 (20):
1633-8 ConfidentialYes Expert analysisYes TimelyYes
Systems-orientedYes ResponsiveYes IndependentPartially
Non-punitivePartially
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Ministero della Salute Recommendations Working group Open
Consultation Regions/Hospita ls/Professionals Medication error
Wrong patient, site, procedure Retained instruments Suicide
Maternal death Disclosure of adverse event Violence Transfusion
reaction Neonatal death( >2500 gr) Work in Progress
Slide 17
Ministero della Salute Short term effect The Sicilian case
Slide 18
Ministero della Salute Percentage of postoperative Pulmonary
Embolism or Deep Vein Thrombosis (surgical discharges) 200120022003
Sicilia0,120,10 Italia0,14 0,13 Administrative data
Slide 19
Ministero della Salute Sentinel event comparison between Sicily
and Italy RegioneN% Sicilia2946 Italia63100 RegioneN% Sicilia
1.286.751 10 Italia 12.942.935 100 Total hospital discharges
Sentinel events Regional Authorities document (2005) recommends to
report sentinel events to Ministry of Health
Slide 20
Ministero della Salute Patient Safety Board Program
developement Chair (Clinical leader) Stakeholder involvement
Mainstream Actions
Slide 21
Ministero della Salute Agreement Ministry of Health - Sicilian
Region Regional Coordination Center on Patient safety Task force
against Adverse event Context Analysis Professional Training
Implementation of clinical guidelines, pathways and recommendations
Improvement of Emergency management Investment on facilities
(buildings, operating theaters and medical equipments) Inspection
Taskforce (40 professionals)
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Ministero della Salute Development of a methodology for
clinical risk management Pilot project on 6 hospitals Training
program on audit and tutorship Implementation of a Software for
hospital self- assessment Risk management project Program on
quality improvement
Slide 23
Ministero della Salute Strategies Education and training on
clinical risk management and patient safety at regional and
hospital level Analysis on contributing factors in all settings
Implementation of recommendations and preventive actions
Slide 24
Ministero della Salute Right to citizen defense Jurisdictional
framework Quality improvement Patient safety How to remove the main
barrier to patient safety ? Long term: Law to ensure protection of
reporting
Slide 25
Ministero della Salute Partnership for Patient Safety Ministry
of Health Regions Hospitals Scientific Societies Professionals
Patients
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Ministero della Salute Reporting system and Feedback Ministry
of Health Regions Hospitals Health professionals
Slide 27
Ministero della Salute Thank you for your attention Your
experience and suggestions are welcome