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The Danish Experiences with Medication errors

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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
slide1
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

danish health care main characteristics
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

slide4
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

slide6
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

slide7
My role
  • Networking
  • Document errors, consequences and evidence in solutions
  • Share/steal solutions

H:S Unit for Patient Safety

epidemiology
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

solutions 1
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

solutions 2
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

solutions 3
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

solutions 4
Solutions 4
  • Patient impowerment
    • Diaries
    • Ten tips for patients
    • Speak up campaigns

H:S Unit for Patient Safety

solutions 5
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

expectations
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

mix ups
Mix ups
  • Packages
    • Designers´ manual from NPSA for tablets
    • Challenge: designers´manual for ampullas and bottles

H:S Unit for Patient Safety

slide16
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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