Day :
- Patient Safety
Chair
Special Session
Session Introduction
Martin Egerth
Lufthansa Flight Training, Germany
Title: Why do we need more than technical and procedural competencies in the medical industry to improve patient safety?
Time : 11:20-12:20
Biography:
Martin Egerth is a Product Manager of human factors training at Lufthansa Flight Training. As a Psychologist and Human Factors Expert, he manages Lufthansa’s entire
portfolio of human factors and security trainings for the aviation industry and also for external industries. During his ten years at Lufthansa, he has developed, overseen and
conducted trainings that have developed the skill sets of pilots, flights attendants and non-flying staff. From basic trainings, to recurrent trainings to management trainings
for Lufthansa and external airlines, he has trained over 8,000 flying staff. He has also founded human factors working group comprised of 26 European and international
airlines that meets annually to exchange CRM best practices, discuss how to avoid incidents and accidents, identify the influence that culture and safety culture has on
CRM and develop CRM for the future. He holds Master’s degree in Psychology at University of Innsbruck and is currently pursuing his Doctorate degree.
Abstract:
Between 500 and 1,000 people die every year in plane crashes worldwide. Despite this seemingly high number, the number of
preventable deaths annually as a result of medical errors is far greater. Patients die daily due to human errors committed by
doctors, nurses and hospital staff. Why then is there such a great emphasis on rules, regulations and standardized simulations
and trainings in the aviation industry, but not in the medical sector? How do we define safety and how can we continuously
improve this notion? What similarities and differences exist between the aviation and medical industries and what can medical
professionals learn from the established human factors and safety trainings already in place for pilots, flights attendants and
non-flying staff. And what can aviation learn from medicine? A clear distinction is that trainings in aviation industry focus
not only on technical and procedural competencies, but also interpersonal and personal skills. Interpersonal and personal
skills must be strengthened for those working with or on patients and a safety culture needs to be introduced. This will result
in proper error management, a positive working environment and ultimately less patients dying due to staff fatigue, a lack of
assertiveness and hierarchy. Lufthansa Flight Training and the German Society of Orthopedic and Trauma Surgery (DGOU)
have implemented a new trainings philosophy to strengthen interpersonal and personal competencies. From basic trainings
to leadership trainings to assessments in the surgery room, this philosophy encompasses a broad implementation of human
factors. The overarching goal is to make hospitals safer and to improve overall patient safety. During these training, strategies to
combat complacency and fatigue are introduced, incidents are openly discussed and risk assessment is fine-tuned. Additionally,
the trainings focus on improving communication within the team, providing decision making tools and making individuals
aware of their own strength and weaknesses. This speech will emphasize the importance of human factors trainings for the
medical sector. It will stress that human factor trainings must not only continue to develop in terms of subject matter and
training methods, but continue to be an integral part of a hospital’s strategy regardless of how safe current operations are. It
will critically examine the current methods used in human factors trainings to see what needs to be done preemptively to adapt
to the requirements of future generations of trainees and of the medical industry in general. It will highlight the importance
of thinking creatively and outside of the box to push human factors trainings of the future and patient safety standards. New
research results of these trainings and the effects will be presented.
Pia Knudsen
Danish Safety Authority, Denmark
Title: The Danish patient safety database and identification of high-risk medicines
Biography:
Pia Knudsen has her expertise in Medicine Errors and Patient Safety. At Danish Safety Authority, she is responsible for the administration of the system for reporting
inadvertent incidents within the health service, and helps to make sure that the knowledge gained from these incidents reports are used preventatively.
Abstract:
Since 1 January 2004, reports about patient safety incidents in Denmark have been reported to a national patient safety reporting
system – The Danish Patient Safety Database (DPSD). Frontline personnel in hospitals and in the primary care sector are
obligated to report adverse events to a national reporting system. Patients and relatives may report adverse events. Hospital owners
are obligated to act on the reports and the Danish safety authority is obligated to communicate the learning nationally. In 2011, it
was decided to develop a national list of high-risk medicines based on the medicine incidents reported to DPSD. The purpose was to
identify medicines that posed a particular risk for patients. The inclusion criteria were preventable medicine incidents that had led
to: hospitalization, prolonged hospitalization, the need for urgent life-saving treatment, permanent injuries or death. The inclusion is
based on an assessment of several steps based on the patient situation as well as drug and learning potential (fig 1). The list is an overall
list, and is prepared in a spreadsheet. This makes it possible for the users themselves to refine the list to local demands and needs, in
tune with the site's recommendation list and medication guides. Based on the list the Danish Safety Authority has identified seven
groups of medicines that require special attention: Anti-diabetic medicines; anticoagulants; low-dose methotrexate; concentrated
potassium; opioids; gentamicin and; digoxin. The Danish safety authority has published a table of risk situation and medicine groups,
and a booklet on the seven groups of medicines that require special attention. The booklet on the seven groups of medicines that
require special attention, includes suggestions for precautionary. The advisory committee consists of 21 individuals with a technical
knowledge of medicines and knowledge on patient safety. The representatives have different professional backgrounds. Pro.medicin.
dk is a website
Saraswati Aryasomayajula
Luton and Dunstable University Hospital, UK
Title: A quality improvement project addressing VTE prophylaxis: factors contributing to compliance
Biography:
Saraswati Aryasomayajula recently completed MBcHB degree from University of Birmingham, UK. She is currently working as a Junior Doctor at the Luton and
Dunstable University Hospital. Her interest and passion to deliver effective patient care has allowed her to find an area of clinical need, carry out an audit and place
recommendations within 4 months of starting work in the General Surgery department
Abstract:
Statement of the Problem: The House of Commons Health Committee reported in 2005 that approximately 25,000 people in the UK
die from preventable hospital-acquired venous thromboembolism (VTE) annually. It is a simple intervention to reduce risk of fatal
complications. It is important to address the factors that prevent achievement of 100% compliance.
Method: In September 2016, all trainees in the general surgical department completed a questionnaire addressing whether they
received induction and how confident they felt about prescribing based on the VTE proforma. They reported how frequently they
assessed patient’s VTE risk. A spot audit on 25 patients who stayed for more than 48 hours was done in September.
Findings: 67% of trainees had received induction in VTE prophylaxis and 79% claimed that they always knew what to prescribe after
using the current proforma. 42% of trainees reported that they never re-assess patients’ VTE risk 24 hours after admission and 45%
never reassess on discharge. These trends were similar in the spot audit. Although 87% of patients had VTE assessment on admission,
75% of proforma were completed incorrectly and 62% of patients had an incorrect prescription. Some reasons for not adhering to the
proforma were; it is too complicated, difficult to find and there isn’t enough time. Targets for VTE prophylaxis are consistently below
100% and re-assessment rates are very low using the current VTE proforma.
Conclusion & Significance: Findings were presented at the Clinical Governance meeting. Emphasis was made for senior clinicians
to check VTE assessment and make time on ward rounds. Specific VTE Training was provided to the new FY1 cohorts which will
continue on a 4-monthly basis. A new, simplified proforma was designed and trialed in the unit. Having liaised with pharmacy, a
compulsory VTE assessment on the electronic prescribing software is being trialed.
Biography:
Laura Porro has completed her PhD in Philosophy at University of St Andrews. After completing NHS Graduate Training Scheme, she joined PPL, where she works
as an Analyst, supporting a range of NHS organizations with the implementation of ambitious change programmes.
Abstract:
Statement of the Problem: North West London (NWL) has seen its demand on local services outstrip funding the past few years.
This led to variations in the accessibility and quality of care, duplication and inefficiencies in a fragmented commissioning landscape.
The project aimed at delivering a programme of systemic change, joint-funded by the local CCGs.
Methodology: We rolled out a single hospital discharge function across NWL, focused on improving patients’ outcomes and
experience, and reducing capacity pressures on local acute services. We mapped existing discharge processes, co-designed new
shared policies and protocols and co-located discharge teams at key hospital sites, implementing the ‘early identification’ model. We
supported the development of a shared IT process, to allow quick and accurate transfer of patient information. We co-designed a new
model of hospital discharge, tailored to suit each locality, which includes the new role of the key discharge worker. Social workers
are allocated to specific wards and attend their multi-disciplinary teams, which mean patients’ assessment is holistic from admission
through to discharge. We supported staff through the change with a bespoke training programme, focusing on the soft skills needed
to work collaboratively and effectively across professional and organizational boundaries, as well as across seniority levels. We made
these programme sustainable thanks to an effective handover to a cohort of internal facilitators, who can deliver the training again
in the future.
Conclusion & Significance: We engaged with over 200 staff and managers across eight organizations throughout design and
implementation process. We standardized over 100 existing and varying processes into four clearly defined pathways and one set
of principles for the choice policy. The evaluation shows that delayed transfers of care figures have almost halved since the launch
in Match 2016. Other outcomes include a 5-10% decrease in referrals into higher levels of care; improved patients’ experience of
discharge; and reduced length of stay.
Biography:
Danielle Cunningham is a Medical student at University of Dundee. She has taken a year out of her medical studies to undertake a BMSc in Clinical Research. She
has spent the year observing doctors on both sides of the healthcare boundary in to identify factors which may affect medicines reconciliation
Abstract:
Statement of the Problem: Medicines reconciliation is a top priority both nationally and internationally. The consequences of an
inaccurate medications list can lead to adverse drug events and compromise patient safety. This is an even greater risk between
healthcare boundaries. While most of the time medicine reconciliation is carried out effectively, unfortunately, adverse drug events
still occur despite best efforts and the introduction of multiple policies and technologies. This study aims to identify both good
practice and potential barriers to the accurate and timely communication of changes to medication from secondary to primary care.
Methodology & Theoretical Orientation: This project uses a qualitative mixed methods approach to gather a complete picture
of the process of medicines reconciliation at discharge. Non-participant observation allowed the researcher to gather information
on the process and systems in place to carry out a discharge. The researcher then conducted semi structured interviews with renal
physicians, nurses, pharmacists and GP’s. A deductive thematic analysis was conducted.
Findings: Within such a complex system there were multiple factors found to affect the quality of discharge letters. These areas
included: layout of technology, environment, and availability of information, workload and inter-professional relationships. However,
while there were many day to day barriers which could occur when filling out EDD’s there was many areas of good practice identified,
such as the introduction of checks by different healthcare professionals at various points of the process.
Conclusion: The complex nature of healthcare and medicines reconciliation acts as both a barrier and safety net for patients. However,
more research should be done to further understand how this network affects other areas of healthcare. Recommendations for this
research would be to collect data from more healthcare settings possibly more rural areas or a community pharmacy setting.
- Infection Prevention & Control
Chair
Special Session
Session Introduction
Sari Himanen
University in Tampere, Finland
Title: Why do we need more than technical and procedural competencies in the medical industry to improve patient safety?
Time : 12:10-13:10
Biography:
The presentation describes the development of a virtual hospital game in nursing education. Development process started
in 2009. The present-day version can be found in the internet at mediansa.tamk.fi. In the infectious diseases ward of the
virtual hospital students can practise aseptic work and nursing procedures used with infectious and contagious disease patients.
The virtual hospital patient 1 is suspected to have MRSA, the patient 2 has clostridium difficile, and the patient 3 tuberculosis.
Aseptic guidelines have to be followed carefully in nursing the patients to avoid the infections from spreading to the staff or
other patients. The learning environment consists of authentic hospital panorama photographs and a game-like interactive
user interface. The gamer ”virtual nurse” receives points if (s)he follows the right protective clothing, hand hygiene and aseptic
procedures when nursing the virtual patient. The game includes a variety of learning assignments, information texts, and
videos. Development of teaching methods in nursing of infectious diseases patients is quite a topical theme. It is difficult to
practise nursing of isolated patients and the related aseptic procedures in real life due to shortage of such facilities. The gamelike
online environment is quite innovative in nursing education and also a suitable tool for nursing staff’s extension studies.
A lot of attention has been paid on infection control and hand hygiene in the past years but hand hygiene has faced passive
and subconscious resistance among both nursing staff and doctors. Improvement of hand hygiene requires multiform work
and further development of hand hygiene promotion methods because spreading of for example MRSA is not under control.
Virtual games seem to make possible to create authentic nursing situations and contexts, and strengthen the development of
mental models for nursing.
Abstract:
Sari Himanen works as a Senior Lecturer and Head of Degree Programme at Tampere University of Applied Sciences. She is working on her Doctoral thesis, which
focuses on information and communication technology applications in nursing education. She has developed diverse ICT-based teaching methods in nursing education
and studied their effects on learning.
Martin Egerth
Lufthansa Flight Training, Germany
Title: Why do we need more than technical and procedural competencies in the medical industry to improve patient safety?
Biography:
Martin Egerth is a Product Manager of human factors training at Lufthansa Flight Training. As a Psychologist and Human Factors Expert, he manages Lufthansa’s entire
portfolio of human factors and security trainings for the aviation industry and also for external industries. During his ten years at Lufthansa, he has developed, overseen and
conducted trainings that have developed the skill sets of pilots, flights attendants and non-flying staff. From basic trainings, to recurrent trainings to management trainings
for Lufthansa and external airlines, he has trained over 8,000 flying staff. He has also founded human factors working group comprised of 26 European and international
airlines that meets annually to exchange CRM best practices, discuss how to avoid incidents and accidents, identify the influence that culture and safety culture has on
CRM and develop CRM for the future. He holds Master’s degree in Psychology at University of Innsbruck and is currently pursuing his Doctorate degree.
Abstract:
Martin Egerth is a Product Manager of human factors training at Lufthansa Flight Training. As a Psychologist and Human Factors Expert, he manages Lufthansa’s entire
portfolio of human factors and security trainings for the aviation industry and also for external industries. During his ten years at Lufthansa, he has developed, overseen and
conducted trainings that have developed the skill sets of pilots, flights attendants and non-flying staff. From basic trainings, to recurrent trainings to management trainings
for Lufthansa and external airlines, he has trained over 8,000 flying staff. He has also founded human factors working group comprised of 26 European and international
airlines that meets annually to exchange CRM best practices, discuss how to avoid incidents and accidents, identify the influence that culture and safety culture has on
CRM and develop CRM for the future. He holds Master’s degree in Psychology at University of Innsbruck and is currently pursuing his Doctorate degree.
- Medication Safety
- Nursing Education & Practice
Session Introduction
Rohini A Mehta
American College of Nursing, USA
Title: Cultural is important in healthcare
Biography:
Rohini A. Mehta I am a quality and performance director for Castle family health clinics. Nurse educator for American college of Nursing have worked in the health
care field for a little over thirty years. Licensed vocational nurse with a Bachelor of Science in Nursing Information Systems. Certified lactation educator, Certified
in Six Sigma green Belt. Board member for Charitable Care Foundation. NCQA and ASQ Graduate (BS) University of Phoenix
Abstract:
The United States of America has been a kaleidoscope of cultures for hundreds of years. This has never been truer than it is
today, as people from every corner of the globe continue to seek out a life in the U.S., whether permanently or temporarily. The
multicultural makeup of the U.S.-especially in metropolitan areas-presents special challenges for medical professionals, whose job
requires relating to patients on a very personal level. In urban areas it is not unusual for a doctor to have a diverse patient lineupseeing
a patient in the morning who recently emigrated from the Philippines, a multi-generational family of Indian descent later in
the afternoon, and a tourist from China in the evening might be a typical day for some in the healthcare profession. Even doctors
and nurses who work in rural areas will inevitably encounter people of various ethnicities and cultural backgrounds in their careers,
especially as the U.S. countryside continues to become more ethnically and racially diverse. Sensitivity, compassion, understanding,
and acceptance of patients with different values, beliefs, and behaviors are essential qualities for those who work in the medical
arena. The increasing diversity of the nation brings opportunities and challenges for health care providers, health care systems, and
policy makers to create and deliver culturally competent services. Cultural competence is defined as the ability of providers and
organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients. A culturally
competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial
and ethnic health disparities. Examples of strategies to move the health care system towards these goals include providing relevant
training on cultural competence and cross-cultural issues to health professionals and creating policies that reduce administrative and
linguistic barriers to patient care.
- Patient Safety & Nursing Education
Session Introduction
Theeb M Almotairi
Royal Commission Medical Center, Saudi Arabia
Title: The relationship between structural empowerment and the patient safety culture in the Saudi public hospitals
Biography:
Theeb M Almotairi has 12 years of experience in the field of Quality, Patient Safety and Health Care Management and Accreditation. He worked as Quality
Management and Planning department for more than two years. He participated in hospital accreditation as Chapter Leader and Counterpart in Joint Commission
International (JCI) and Saudi Center for Health Institute Accreditation (CBAHI) for chapter of quality and patient safety and chapter of leadership. He is an expert in
implementing quality concept and improvement tools for improving healthcare and patient safety. He completed his PhD in Health Management.
Abstract:
This study is focused on examining the direct relationship between structural empowerment and the patient safety culture in
Saudi public hospitals. The primary research design employed in the present study is a quantitative method of survey. A sample
of 127 out of 251 healthcare organizations were selected in Saudi Arabia divided as follows - 70 from the central and 57 from the
western region. These are all public hospitals operating under the Kingdom’s Ministry of Health. 30 questionnaires were distributed
in each of the 127 public hospitals of Saudi Arabia in the two regions. The staff workers in the nursing units are respondents for
the data collection through these questionnaires. The numbers of questionnaires returned and usable are 1793 and therefore the
response rate is calculated by dividing the number of questionnaires returned or completed with the number of participants of the
survey. This study used correlation analyses to examine the relationship between structural empowerment and patient safety culture.
Specifically, the findings showed significant between structural empowerment and patent safety culture. Finally, this study offers
recommendations for future researchers at the end.
- Medication Safety
Session Introduction
Sachin Raval
Apollo Hospitals International Limited, India
Title: High alert medications
Biography:
Sachin Raval is working as Deputy Manager at Apollo Hospitals International limited, Ahmedabad, India. He participated in many international conferences. He is
also part of JCI Audit and accredited successfully. He is constantly working on improving quality work and patient safety with recent ideas on high alert medications.
Abstract:
High alert medications are medicines that are most likely to cause significant harm to the patient, even when used as intended.
The Institute for Safe Medication Practices (ISMP) reports that the incident rates of this group of medicines may not necessarily
be higher than the other medicines but when incidents occur the impact on the patients would be serious (significant). In seeking to
improve patient safety, the primary focus should be on preventing errors with the greatest potential for harm. Many of the highest risk
medications – e.g., concentrated electrolyte, chemotherapy drugs, narcotics, insulin, heparin and LASA are delivered by IV infusion.
The most serious and life threatening potential adverse drug events (ADEs) are IV drug related. Preventing the harm from high alert
medications: Awareness, readiness, education: Training arranged for nursing, pharmacists and doctors for high alert medication;
develop list for high alert medications and show cash in every wards/ICUs. Develop museum for high alert medications. Standardize
care process: Double sign and double check at the time of dispensing and administration. PAT (Prescription Audit) verified by
clinical pharmacist before indenting; specific label design for each high alert medicine. Decision support: include pharmacist on ward
round and monitor overlapping medications prescribe for patients. Prevent failure: Identify LASA medicines and create mechanism
to reduce errors (different location and double checking/labeling) and; Involve the patient & family: Patient counseling in case of
insulin. Provide patient education at literacy level understandable by all.