PowerPointprsentation

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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
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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

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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

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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

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

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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

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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

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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

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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

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Solutions 4

• Patient impowerment
• Diaries
• Ten tips for patients
• Speak up campaigns

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Solutions 5

• Culture change
• Surveys
• Web site with MM 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

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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

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Mix ups

• Packages
• Designers manual from NPSA for tablets
• Challenge designersmanual for ampullas and
  bottles

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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