News from our PFPS Champions
A halfyearly round-up of news - August 2009
AUSTRALIAN PFPS WORKSHOP
The first Australian Patients for Patient Safety workshop took place in Perth, Western Australia on 7-9 July. 40 health consumers, many of whom had experienced harm in health care, health-care providers and policy makers came together to share their experiences, build partnerships, and develop strategies and action plans for taking patient safety forward in Australia. The workshop was a collaboration between WHO Patient Safety–Patients for Patient Safety, Health Consumers Council WA, Western Australian Department of Health–Office of Safety and Quality in Health Care and Curtin University of Technology, Partnerships for Patient Safety and Patients for Patient Safety global champion Stephanie Newell, from Australia.
One of the key outcomes from the workshop was the development of the Perth Declaration for Patient Safety, the participants collective call to action and vision for the future of patient safety in Australia. The Perth Declaration for Patient Safety was officially launched on August 5, 2009 at Parliament House in Perth. The Declaration is a collective call and commitment to make Patient Safety a priority within all areas of health care, to prevent health care harm, to ensure our experience informs positive change and to advance patient safety in partnership for co-creating safer care.
Stephanie Newell, Australian PFPS Champion said: "The last four weeks have been a most amazing and inspirational time for me. My long held aspiration and dream of holding the first Patients for Patient Safety workshop here in Australia became a reality. Over the three days of the workshop I was continually humbled by the participant’s courage and generosity of spirit in sharing their experience of health care harm and I was motivated by their energy, drive and powerful commitment to partnership in patient safety for lasting change. It was a privilege to witness the participants consider one another’s perspectives, build partnerships and work together on solutions, considering the principles of patient safety, to make a lasting impact for safer care."
CHECKLIST IMPLEMENTATION IN AN EGYPTIAN HOSPITAL
Reported by Mahmoud el Damaty, PFPS Champion, Egypt
The Sharq Al-Madina Hospital faced many events that drew the attention for the great need to implement the Surgical Safety Checklist, such as adverse events and near misses. The following indicates the steps that were taken in implementing the Surgical Safety Checklist at the Sharq Al-Madina Hospital in Alexandria.
First a ‘critical mass’ group was created, which consisted of staff with the right mix of skills and motivation to take on this task. WHO had recommended that one person be responsible for implementing the checklist, but we found in our hospital this lead to antagonistic relationships with other members of the operating room. Therefore, we formed a team of anaesthesiologists and / or nurses. We selected individuals that had good relationships with everyone, and good communication and negotiation skills.
The checklist was then modified in the following ways in order to be best suited to implementation at the Sharq Al-Madina Hospital;
- Within the sign-in stage, a section was added to include the patients name and date of birth as two identification tools.
- It was decided sign-out should be made before the closure of the patients wound, rather than before the patient leaves the Operating Room.
- Another section was added to allow for signatures of individual members of the operating team (ie, anaesthesiologist, surgeons, scrub nurse etc).
- The open-cardio thoracic surgical team designed their own checklist.
- It was agreed that sign-in should occur in the Open Heart ICU which is close to operation theatres.
There was some opposition to the implementation of checklist, some feeling it was a waste of time, an added frustration to the workload. The main causes of the opposition was a lack of knowledge, and a natural instinct to resist change. We decided the way to overcome this resistance, was by ensuring top management involvement and commitment, creating awareness by sharing knowledge, the setting of goals and priorities, convincing people on an individual basis and getting the individuals opposed to the checklist, involved in its implementation.
First the checklist was only implemented in one operating room (general surgery) and was then extended to three further theatres (to include general surgery, special surgery and open heart surgery) plus an emergency operating room. Posters of the checklist have been displayed in all theatres and after surgery a hard copy of the completed checklist is attached to each surgical case medical record. The benefits of implementing the checklist include increased safety of patients, ethical considerations, efficiency, effectiveness, efficacy, continuity, appropriateness and legitimacy and this therefore results in the improvement of the hospital image and reputation.
REGIONAL HEALTH FORUM, POLAND
Reported by Jolanta Bilinska, PFPS Champion, Poland
A regional health forum held in Poland on 8 July for over 70 members of the health care system, resulted in the signing of a ‘Safe Hospital, Safe Patient’ Declaration. The Declaration emphasizes the importance of involving patients in the decision making process around diagnosis and treatment, the necessity to run a hospital and its medical staff efficiently, and the need to educate patients in health problems and for better communication between doctors and patients. The theme of the conference was ‘Patient Safety in the health care system in Poland – challenges and achievements’, and participants included medical and legal representatives, NGOs and patients.
The honorary lecturer was Vice Minister of Health, Mr Adam Fronczak, who presented the assumptions of the Act of 21 May 09, on individual and collective patients’ rights which places the Commissioner for Patients Rights as the central authority protecting patients rights.
During the forum, many issues were discussed such as patients claims and compensation for damages to patients in Scandinavian countries and in France. Attendees were also interested in the role of communication between a patient and medical staff, and in medical information as the basis for the commencement of treatment. Doctor's duty is to convey a message clearly and reliably so that the patient can make an informed decision.