The Danish Experiences with Medication errors

1. The Danish Experiences with Medication errors Dr. Annemarie Hellebek, phd Patient safety officer/risk manager Danish Society for Patient Safety and Copenhagen Hospital Corporation H:S Unit for Patient Safety

2. H:S Unit for Patient Safety

3. Danish Health Care – Main Characteristics • Health care is a public task • 83% is financed through taxes • Hospital care and visits to general practioners and practicing specialists are free of charge • Total public and private expenditure is 8,1% of GNP H:S Unit for Patient Safety

4. Danish Society for Patient Safety: • Established December, 2001 • Board represents hospital owners, professions, industry, research, patient and consumer organizations • Goal is to ensure that Patient Safety aspects are considered in all decisions made in health care • Grant from the Danish Counties – rediscussed with intervals • Research grants from private foundations in particular from the doctors´- and community pharmacists´ organisations H:S Unit for Patient Safety

5. H:S Unit for Patient Safety

6. Clinical pharmacologist • Made medication errors since 1989 • Phd on insulin induced hypoglycemia • Worked with safe medication practices since 2001 with Danish Society for Patient Safety • Consultant in medication safety for DSPS in spare time H:S Unit for Patient Safety

7. My role • Networking • Document errors, consequences and evidence in solutions • Share/steal solutions H:S Unit for Patient Safety

8. Epidemiology • Blame free mandatory reporting system for hospitals since 2004 • www.patientsikkerhed.dk/about • Reporting system run by National Board of Health • Mediation errors with drugs transferred to the medicines agency • The medicines agency finally set up a working group to find out how to work with medication errors • In the talks to the agency and the press we used david Bates data- Frequency of errors equals frequency of side effects – and the former is preventable – how can you be against it. • 2005-2006: Projects to establish epidemiology and methods for analysis and learning in primary care and between primary and secondary care • Campaign for patient safety in community pharmacies 2004-2005 • ”Værløse- projektet” – commmunity based root cause analysis • 2006: 3 primary care patient safety officers – all physicians H:S Unit for Patient Safety

9. Solutions 1 • International campaigns- we steal with pride • NPSA solutions Methotrexate • 100K lives (”operation life”) • Transformed medicine reconcilliation campaign small scale Jan 2007 • Whole campaign April 2007 • Development of patient safety centered medication accredidation standards and indicators • Indicator: hospital must demonstrate learning from reported dispensing errors H:S Unit for Patient Safety

10. Solutions 2 • Medication order process • Electronic prescribing and transfer highly used in Denmark • Decision support • Analyzed 800 medicine order errors to facilitate which decision support elements may save most lives • Few drugs • Few situations • Together with drug information company H:S Unit for Patient Safety

11. Solutions 3 • Mix ups • Package • 11 packages have been changed in 2005 as a result of reported errors • Competition for designers to improve design of state owned pharmaceutical company • Manual stolen from NPSA • Brand Name • Assciated with EMEA NRG group • Report on knowledge on name mix ups for NRG • Challenge patient safety aspects into contracts when buying large quantities of medicines • Potassium 1 and 2 mmol/L • Challenge Use of INN names • Campaign in pharmacies H:S Unit for Patient Safety

12. Solutions 4 • Patient impowerment • Diaries • Ten tips for patients • Speak up campaigns H:S Unit for Patient Safety

13. Solutions 5 • Culture change • Surveys • Web site with M&M stories • Talks to anyone • HEXAGON – industry develpoing labels and glass for ampullas etc • Communication system setting standards for electronic transfer • Conferences for pharmacoepidemiology and clinical pharmacology • Medical students • Challenge get into the books and into the exams H:S Unit for Patient Safety

14. Expectations • Get the nice feeling of not being alone • More steal with pride • Develop some sort of international powerful organisation • Purpose to influence politicians and regulatory business to ensure safety first • WHO associated? • Discuss prioritisation of medication errors for solution • Discuss compliance issues • Discuss independance • Discuss implementation in regulatory documents H:S Unit for Patient Safety

15. Mix ups • Packages • Designers´ manual from NPSA for tablets • Challenge: designers´manual for ampullas and bottles H:S Unit for Patient Safety

16. Names • NRG group • European challenge: 25 countries/languages • Document problems (used ISMP and USP lists) • Report • Post marketing • Papers on analyses • Premarketing • US, Canada – papers by Lambert and Kondrak • Develop check list H:S Unit for Patient Safety