Increasing patient safety in healthcare
23 May 2012
Jon Ahlberg, of the Swedish Medical Association, provides an overview of the improvements that have been made to the country’s health system in order to enhance patient safety
In Sweden, as in many other countries, the publication of the American report ‘To Err is human – building a safer health system’ in 2000 came as a wake-up call. Prior to the report, medical mistakes that caused injuries were considered to be the result of failures on an individual level. However, Swedish healthcare had been influenced by the quality movement during the late 1980s and 90s, which led to a fairly widespread knowledge of quality methods, such as the plan, do, act, study (PDSA) cycle; flow charts; and to a lesser extent, statistical process control methods.
As early as 1975, a national quality register for knee replacement surgery was initiated in Sweden, which was followed by a register for hip replacement in 1985 and one for vascular surgery in 1987. Since then, in addition to a large number of local and regional registers, almost 90 national quality registers have been started, containing individualised data concerning patient problems, medical interventions and outcomes after treatment. The registers are based almost entirely on single or related diagnoses or procedures. Whilst most of them do not record patient safety data, they have influenced staff, especially doctors, to think about systems regarding positive as well as negative outcomes.
The first patient safety conference was held in 2001 by the Swedish Medical Society, Swedish Patient Insurance and SALAR. This was followed by the first national conference in 2003, which was arranged by the same organisations, together with the National Board of Health and Welfare, the Swedish Medical Association and the Swedish Association of Health Professionals, as well as several others. Since then, a national patient safety conference has been held every 18 months, attracting an increased number of delegates, with 2,100 attending in 2011.
Reducing patient risk
Organisations and agencies have contributed on a national level by developing patient safety tools. The first of these was a Swedish version of root cause analysis (RCA) and risk analysis in 2005, which sold over 14,000 printed copies and has been followed by a second revised edition. The RCA has been used to a great extent as far as serious healthcare related injuries are concerned, but the risk analysis does not seem to have had the same impact. In 2008, meanwhile, the Institute for Healthcare Improvement (IHI) Global Trigger Tool was translated and adapted for Swedish conditions, and is now used in 11 out of 21 regions. In addition to this, the US’s Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture was translated into Swedish and validated in 2009. In the first couple of years, approximately 10,000 staff members took part in the survey, and by 2011 there was a tenfold increase in this number due to a governmental incentive. Results of the survey are much in line with those in other European countries, as well as in the USA, except that hospital staff give lower values on top management support for patient safety.
Moreover, a national project aimed at reducing healthcare related infections was launched in 2004, which used the Breakthrough Series method that was originally designed by the IHI. The project was repeated in 2007, and has since been continued on local and regional levels. Single day prevalence measurements of healthcare related infections in hospitalised patients have been conducted twice annually in all hospitals since 2008. For the first two years, the prevalence was gradually decreasing from 11% to approximately 9%, but this now has frozen at that level. A novel model of continuous real-time measurement is being tested in two regions, and is expected to give reliable data on prevalence as well as incidence. The registration occurs when antibiotics are entered into the electronic prescription record, adding information as to whether it is a social or healthcare acquired infection.
The WHO Safe Surgery Checklist, meanwhile, was launched in 2008, and a Swedish adaptation and translation was performed and launched in March 2009 with remarkable success. Virtually all hospitals with operating facilities currently have this in use, and it has been accepted by surgeons, anaesthetists and theatre nurses. An important factor that contributes to this success was that all professional societies involved in surgery gave their support.
Professional societies have an enormous impact on their members and also have a far better insight into patient safety risk factors in their specific fields than other organisations. Thus, professional societies have played a major role in three projects concerning brain damage in new-borns caused by asphyxia, deep infections in knee and hip replacement surgery, and complications in abdominal surgery. Major changes in structure and process have taken place as a result – and although outcome measures are not available as yet, there have been some promising preliminary results.
Achieving increased patient safety
The Swedish Association of Local Authorities and Regions (SALAR) has launched a national campaign on patient safety in eight healthcare related categories concerning urinary tract infections, central venous catheter infections, postoperative wound infections, falls, pressure ulcers, medication errors in handovers, medication and malnutrition.
Until recently, Swedish laws and regulations have focused on individuals concerning adverse events, healthcare related injuries and malpractice. This was considered counterproductive and, after considerable pressure from healthcare professionals and others involved in this area, a new patient safety act was introduced on 1st January 2011. This defines an adverse event as suffering, physical or mental harm, or illness and death that could have been avoided if adequate measures had been taken in the patient’s contact with healthcare services. A serious adverse event is long-lasting and not minor, or something that has led to either a significant increase in requirement for healthcare or to death.
The act includes an increased responsibility in the duties of healthcare providers in risk management, open disclosure and leadership for patient safety. Healthcare professionals are required to report risks and adverse events. Disciplinary actions are no longer taken against staff, but at the same time, registrations can be withdrawn without delay if someone is considered inadequate for healthcare professional responsibility.
In order to promote the ideas behind the new patient safety act, the Swedish government has created a model for economic incentives in order to encourage healthcare providers in their attempts to achieve an increased level of patient safety. To be eligible for these incentives, the healthcare provider must deliver an annual account of its patient safety commitments, establish a regional strategy group for rational use of antibiotics, participate in the AHRQ’s Hospital Survey on Patient Safety Culture and take significant steps in order to make electronic medical records available throughout the whole country in co-operation with the Swedish Strategy for eHealth. If eligible, the healthcare provider will only be rewarded with the incentive if at least 25% of employees take part in the safety culture survey, if adherence to basic hygiene rules and dress code is measured in at least 75% of hospital wards, if prevalence of pressure ulcers is measured in at least 50% of hospital wards and if the prescribing of antibiotics in outpatients is decreased according to certain criteria.
Moreover, the requirements for the incentive have increased further to include the introduction of continuous real-time measurement of hospital acquired infections and the use of the adapted IHI Global Trigger Tool on a regular monthly basis in all hospitals. It also includes results from a national patient survey and registration of bed occupancy rate (overcrowded wards). It is anticipated that in 2013 an indicator for medication will be introduced. The total sum for the incentives is SEK675m (€76m) per annum, which is to be divided between the 21 Swedish regions.
During the past 10 years, Swedish patient safety has gone through a period of rapid development due to awareness to commitment from healthcare professionals, leaders and management, all the way up to government. Much work has been, and is being, done. So far, we have yet to wait for evidence of positive results. Moreover, there is undoubtedly insufficient coordination between local, regional and national initiatives. The National Board of Health and Welfare has been mandated by the government to form a national strategy for patient safety to be delivered by November 2012.
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