IN SEARCH OF CONTINUOUS HEALTHCARE IMPROVEMENT Over the last 10 years, more attention has been paid to embedding safety throughout the health system. The digitalisation of reporting, registering and analysing incidents has positively contributed to the way in which safety is organized. Regrettably, however, healthcare institutions seem to ignore important opportunities in the field of cyclical analysis that would promote continuous improvement in healthcare systems, despite the available options to do so. This presentation shows you: - How to make the switch from the registration of incidents to optimizing healthcare processes; - Different tools to do so; - The importance of analysis to realize this; - Practical solutions to start analyzing (large amounts of) incidents; - How to prevent silo solutions and share lessons learned.

1. INCIDENT MANAGEMENT
In search of continuous quality improvement

2. Incident Management
More attention has been paid to embedding safety
throughout the health system.
Important contributions:
2000 USA Research on unintended damage and
death in hospitals.
2000 Shell Report ‘To err is human: building a safer
health system’.
2005 WHO Guidelines on safe incident reporting.
2005 EU Luxembourg Declaration on Patient
Safety.

4. Unused opportunities
Over 10-year period of increasing attention for
healthcare safety, we have gained considerable
experience in the reporting and registration of incidents.
Analysis is necessary to understand what went wrong,
so lessons can be learned and healthcare can be
enhanced.

5. Challenges
Analysis of incidents is still regarded as a challenge:
- # of notifications has increased substantially
Not only incidents but also near misses are reported
- Incidents are not addressed and dealt with quickly
No longer top of mind
- Vast majority of incidents are classified as low risk
No sense of urgency

7. Analysis methodologies
Even low risk-incidents provide important information
about the healthcare safety.
Fundamental causes need to be revealed.
Different methods available:
• RCA ROOT Cause Analysis
• PRISMA Prevention and Recovery System for
Monitoring and Analysis

8. Benefits PRISMA
- A quick way to analyze incidents
- Classification root causes
- Enables identification of trends
- Opportunity to compare departments, clinics, etc.
- Create a database with root causes

10. Registration > optimization
Where to start when dealing with a large number of
reported incidents?
Simply BEGIN!
Each and every analysis reveals protentional
areas for improvement!

11. Practical solutions
- Cluster comparable incidents, analyze them collectively
- Begin with a recurring type of incidents or with a high-risk
incident
- Random check so that incidents are analyzed structurally
- Use trend analysis
- Make a choice!
Focus on a specific theme, period or care process.

13. Prevent silo solutions
Share the lessons learned from incident analysis within
the team, department and organization!
- Make the organization aware of risks
- Prevent that somebody else makes the same mistake

14. Share lessons learned
- Use team meetings to discuss the number and kind of
incidents.
- Publish incident descriptions on the intranet.
- Publish analysis outcomes and improvement actions
on the intranet.

15. Want to know more?
Download the Incident
Management Ebook!
Click the link below:
http://info.patientsafety.co
m/incident-management-
ebook-en

16. Contents 1/3
Introduction
Transparency with regard to medical incidents
A learning network of hospitals and researchers
Incident disclosure
Incident Management: is that solely incident registration?
Unused opportunities for improvement
Learned lessons in stead of silo solutions
Timely incident registration
Role of departmental supervisor and quality manager
Analysis with the help of the PRISMA method
DOWNLOAD

17. Contents 2/3
Database with root causes
From registration to optimization
Practical solutions
Trend analysis
Random Check
Making a Choice
Monitoring and transparency
Incident reporting offers insight into risks of care processes
Case study: Endoscopy department
Incident analysis
Insight into root causes of the incident
Lessons learned
DOWNLOAD

18. Contents 3/3
Success factors
How can The Patient Safety Company help?
Incident reporting
Reporting process
Analysis
Process improvement
Benefits in a nutshell
Sources
DOWNLOAD

19. www.patientsafety.com