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Safety does not happen by accident - Improving patient safety using risk management systems and formulating measures for improvement

Schraa, M.A. (2014) Safety does not happen by accident - Improving patient safety using risk management systems and formulating measures for improvement.

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Abstract:A national white decision in 2008 in the Netherland was the starting point of new measurements in the field of patient safety. The target contains a 50% decrease in medical errors.. This national decision was accompanied by several improvement measurements. One of these measurements is the introduction of a mandatory incident reporting system in every hospital. This reporting system may lead to more insight in the number and origin of medical errors. The University Medical Center in Groningen (UMCG) introduced a hospital wide incident reporting system in 2008. This system helped learning from incidents and increased patient safety. The system was based on experience, common sense and national requirements. De safety culture ladder of Parker & Hudson was used as inspiration. The UMCG is striving to increase on higher levels of the ladder aimed to improve patient safety. The questions are 1) whether all the measurements during the past years lead to a improved patient safety, 2) whether the model of Parker&Hudson was the right inspiration model and 3) what further improvement measurements for the UMCG may be. An extensive literature review shows safety principles from aviation industry which are also used in healthcare. Comparing literature with daily practice in the UMCG, shows an important gap. In literature no practical or specific instrument is described for assessing current state of patient safety or improving patient safety in hospitals; only end terms are described. The most important similarity between literature and practice is the need of a constructive model for improving patient safety. The five different levels of the safety culture ladder are described by Parker&Hudson as pathological – reactive –calculative – proactive – generative. The steps between the levels of this safety culture ladder not specific enough , therefore extra steps are introduced. For each level five extra steps are added: acknowledgement – no blaming and shaming – incident reporting – incident analysis – improvement measurements. Results following literature review and the case description of UMCG are combined in order to make the safety culture ladder useful in daily practice in the the UMCG. Three departments within the UMCG are interviewed, as well as 5 other, Dutch, UMCs. These interviews are based on the theoretical framework following the literature review and are checked by an expert panel. Different stakeholders are interviewed in the departments surgery, pediatrics and internal medicine covering the following functions: doctors, nurses, managers and DIM (Decentralized Incident reporting Commission)-members. Also the organizational structure of the UMCG is compared to other Dutch UMCs. Not only at department level patient safety is reviewed, also on organizational level. Surgery, Pediatrics and Internal Medicine are located between reactive moving up to calculative at the patient safety ladder. Collaboration within the department and with other departments should be improved. Important aspects are decentralizing of incident analysis at larger departments and introducing a new hospital wide incident reporting system. This new reporting system should support easy sharing of incidents and comparing with other departments. Also trend analysis should be one of the features. Improvement measurements are proposed, but not carried out well enough. This means that responsibility should be divided to nurses or doctors. The head of the department should monitor the general progress of the implementation. Near-incidents are hardly reported. Because of the learning aspect of near-incidents, this should be explained, promoted and more stimulated at the departments.
Item Type:Essay (Master)
Faculty:BMS: Behavioural, Management and Social Sciences
Subject:44 medicine, 85 business administration, organizational science
Programme:Industrial Engineering and Management MSc (60029)
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