The Danish Experiences with
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The Danish Experiences with Medication errors Dr. Annemarie Hellebek, phd Patient safety officer/risk manager Danish Society for Patient Safety and Copenhagen Hospital Corporation Danish Health Care – Main Characteristics Health care is a public task 83% is financed through taxes

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Presentation Transcript
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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



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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


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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



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  • 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


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My role

  • Networking

  • Document errors, consequences and evidence in solutions

  • Share/steal solutions

H:S Unit for Patient Safety


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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


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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


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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


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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


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Solutions 4

  • Patient impowerment

    • Diaries

    • Ten tips for patients

    • Speak up campaigns

H:S Unit for Patient Safety


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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


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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


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Mix ups

  • Packages

    • Designers´ manual from NPSA for tablets

    • Challenge: designers´manual for ampullas and bottles

H:S Unit for Patient Safety


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  • 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


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