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Adapting Solutions for Wrong Site Surgery: The Danish Experience

Adapting Solutions for Wrong Site Surgery: The Danish Experience. “Something is rotten in the state of Denmark”. Act on Patient Safety. Frontline Personnel obligated to report Hospital Owners are obligated to act Board of Health is obligated to communicate. §6 in Act on Patient Safety.

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Adapting Solutions for Wrong Site Surgery: The Danish Experience

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  1. Adapting Solutions for Wrong Site Surgery: The Danish Experience

  2. “Something is rotten in the state of Denmark”

  3. Act on Patient Safety • Frontline Personnel obligated to report • Hospital Owners are obligated to act • Board of Health is obligated to communicate

  4. §6 in Act on Patient Safety • A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice

  5. National Board of Health Regional Patient Safety Units Hospitals The organization of the Danish Reporting System The regional level

  6. Reported adverse events Regional level Example from Copenhagen Hospital Corporation (H:S)

  7. NCPS’ 5 steps for ensuring correct surgeryJCAHO’s Universal Protocol Known Solution Regional level

  8. Wrong site event # 1 Patient operated on the wrong side of the head Regional level

  9. Wrong site event # 2 Patient operated on the wrong finger Regional level

  10. Wrong site event # 3 Patient operated on the wrong side of the head Regional level

  11. Departments without reported wrong site events 410 procedures More than 90% of the surgeons made positive comments Participating departments Gynecology Urology Orthopedic surgery Surgical gastroenterology Head Office calls for Action: Pilot test of a Danish version of NCPS’5 steps Regional level

  12. During this time 12 wrong site surgical events 5 was prevented before incision 7 RCA (all with incision) 1:32.500 surgical procedures Regional level

  13. www.de5trin.dk • Procedure to be used by all hospitals in the Copenhagen Hospital Corporation • News Letters • Power Point Presentations • Literature Review • FAQA • Posters Regional level

  14. Regional level

  15. Regional level

  16. Baseline – April 2005 Questionnaire survey to 65 head of departments • 66% response rate, 40 out of 65 questionnaires fully completed (29 doctors, 11 nurses) • Full knowledge of guideline • Two more wrong site events identified Regional level

  17. National Board of Health Regional Patient Safety Units Hospitals The organization of the Danish Reporting System In 2004 additional 9 wrong site events reported to the national reporting system. The national level

  18. Epidemiology of wrong site surgery • 57 wrong site surgical procedures reported to The Patient Insurance in 6 years • 1:12.292 knee operations • 1:8017 Neurosurgical procedures National level

  19. Lessons learned • Ownership to the problem requires ownership to the solution • It makes good sense to share solutions tested and proved effect full elsewhere

  20. Reporting

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