PATIENT SAFETY LESSONS FROM OTHER COUNTRIES

1. PATIENT SAFETY LESSONS FROM OTHER COUNTRIES Alberto R. Ferreres

5. PATIENT SAFETY IN ARGENTINA Landmarks 1960_ E. Debenetti The paths of clinical error 1991_ LF Fiscella et al: Prospective study of anesthetic errors in 20840 surgical procedures 1997_ A Ferreres: Wrong side surgery 2006_ 52 publications in Argentina

6. PATIENT SAFETY IN ARGENTINA Malpractice litigation Criminal and Civil Law

7. LA RESPONSABILIDAD MEDICA Y LA PRACTICA COTIDIANA

8. PATIENT SAFETY IN ARGENTINA Epidemiology of Errors • Most data from claims • Lack of prospective studies • Analysis of 1500 malpractice claims 84% system errors 38% technical errors 26% judgement errors 21% medication errors Ferreres (2007)

9. PATIENT SAFETY IN ARGENTINA Epidemiology of Errors Cross-sectional study revealed: • Antibiotic misuse in 75% of admissions • Medication errors in 22% of prescriptions • Judgement errors in 26% of postoperative controls • Technical errors in 15% of surgeries • Error notification rate: 2% Ferreres (2007, unpublished data)

10. PATIENT SAFETY IN ARGENTINA Dr. Alberto Agrest

11. PATIENT SAFETY IN ARGENTINA Prof. Vicente P. Gutiérrez

12. Resolution 517/01 (july 30, 2001) Committee of Medical Error A.Agrest F. Benaim A. Sonis

13. PATIENT SAFETY IN ARGENTINA • National Data Bank of Errors • Create a leadership in the topic • Support of the most important academic institution • Lack of support • Mostly theoretical knowledge • Apart from everyday troubles

14. PATIENT SAFETY IN ARGENTINA PS Conferences 2004: 1st. 2005: 2nd. 2006: 3rd. Guest: Susan Sheridan 2007: 4th. JCI: Dennis O´Leary Karen Timmons David Jaimovich ACS: Thomas Russell 2008: 5th. Guest: Robert Wachter

15. PATIENT SAFETY IN ARGENTINA Patient Safety Hospital Committees University of Buenos Aires Hospital Pediatric Hospitals Now: 27 institutions

16. PATIENT SAFETY IN ARGENTINA Resolution 1616/2007 Advisory Commission for Patient Safety National Ministry of Health

17. PATIENT SAFETY IN ARGENTINA Recent Initiatives • University of Buenos Aires Institute for Patient Safety • Joint Commission International Local Representative • PAHO & WHO Local and Ministerial Support

18. PATIENT SAFETY IN ARGENTINA Present Challenges • Law and Tort system • Fear of error notification • High rates of malpractice litigation • Lack of awareness • Health literacy • Patients´ associations

19. PATIENT SAFETY IN ARGENTINA The future • Implementation of the 9 Safety Solutions • Implementation of the “Safe Surgery saves lifes” Challenge • Better awareness by public, physicians and institutions • PS Committees • Shift from Risk Management to PS + Quality

20. Thanks for your attention!