Marta Vázquez Vázquez

Risk Management and Patient Safety Strategy in Andalusia

Best Practices for Patient Safety and Quality ImprovementBucharest, 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

Hospitalisations4,500,000/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 Framework2004: 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 UnionRecommendations 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

DisseminationImplementation Evaluation of NHS indicatorsExperts 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 - Incidencia IRAS [Ind.10]

Hosp - Prevalencia IRAS [Ind.9]

Prevalencia UPP [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 actionsMacromanagement

(Regional Health Ministry)

24 actionsMiddle

management(Centres)

55 actionsMicromanagement

(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 identif ication (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 centres39 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 Andalucíawww.juntadeandalucia.es/agenciadecalidadsanitaria

Entidad gestionada por la Fundación Pública Andaluza Progreso y Salud

www.observatorioseguridaddelpaciente.esmarta.vazquez.vazquez@juntadeandalucia.es

Mulțumesc!