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Patient Safety- do it yourself!
How to learn about safer healthcare
21. September 2011
Workshop on Good Practices in Patient Safety
Zagreb
Günther Jonitz, M.D.
President of the Berlin Chamber of Physicians
Member of the Board of the German Medical Association
Chairman of the German Coalition for Patient Safety
Î „The Professional Approach“
Quality and safety is the primary concern of medicine.
„Value based health care“
21. September 2011
Dr. med. Günther Jonitz
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Patient care has become
a challenging and risky issue:
Î Quality and safety on the agenda
21. September 2011
Dr. med. Günther Jonitz
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Prepositions
¾ Comprehensive competencies for health
care workers
„Patient safety can be learned as a part
of professionalism“
21. September 2011
Dr. med. Günther Jonitz
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Education and training for Patient Safety
¾ Knowledge
¾ Skills
¾ Behaviour/ attitude!!
Î “Getting to the heart of the
doctors.”
Colin Feek, MinHealthNZ, 2006
21. September 2011
Dr. med. Günther Jonitz
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Human
Factors
System
failure
Inadequate
Training
21. September
2011 Rall
Source:
Marcus
¾ 70% of causes of accidents
¾ Not covered enough in
medical training or education
¾
¾
¾
¾
It´s not the bad doctor
Complex, coupled, kybernetic
Latent errors
„predictably unpredictable“
¾ Current training does not reflect
the real-world problems of the
ill-structured patient care reality
Dr. med. Günther Jonitz
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Solutions/ Organisational level
Knowledge about dealing with incidents
increases
Inefficent organisational structures and lack of
proper communication instead of „individual
blame“
„WHY“ not „WHO“
New procedures for incident prevention are
available
Critical Incident Reporting and Learning
Systems
Professional Training, Education, Certification,
Procedures…
21. September 2011
Dr. med. Günther Jonitz
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…a holistic approach is needed!
Î broad range of contents!
Î all professions!
21. September 2011
Dr. med. Günther Jonitz
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CPD/
Continous Professional Development
¾ Cooperation and teamwork
¾ Communication
¾ Leadership
¾ Management (of health care organisations)
¾ Knowledge-management
¾ Human Factor
¾ Empathy
¾ …
21. September 2011
Dr. med. Günther Jonitz
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http://www.forum-patientensicherheit.de/
service/literatur/pdf/
fbkonzept_patientensicherheit_english.pdf
21. September 2011
German Curricula/ National level:
•Quality Management
•Evidence Based Medicine
•Patient Safety
•Leadership
•Peer Review
•Managed Care
Dr. med. Günther Jonitz
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Implementation/ Regional level:
Examples from Berlin
21. September 2011
Dr. med. Günther Jonitz
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One Example:
Patient Safety Training
Training course of 3,5 days duration, interactive seminar:
Case studies, lectures, group discussion, group work, group
assignments
Target group
• All medical professions, in particular those people
concerned with accident analysis, incident analysis, incident
reporting and quality assurance
Learning outcomes
• Ability to analyse complex incidents on several levels;
knowledge about human behaviour and human
strengths/weaknesses (psychology of Human Factors)
•
•
21. September 2011
Aim: To give participants a systematic understanding of how
incidents come about in complex organisations and how these
incidents and potential damage might be analysed in order to
develop preventive measures.
Special attention is given to methods of root cause analysis,
observation and analysis of organisational factors including
teamwork and communication as well as factors conducive
to a safety culture.
Dr.www.german-coalition-for-patient-safety.org
med. Günther Jonitz
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Content: Root Cause Analysis
21. September 2011
¾
Patient safety and concepts on safety
¾
Mistake development: models and analysis methods
¾
Human Factors:
- Team and leadership
- Organisation environment and safety culture
- Incident management and prevention
- Conditions for incident analysis
¾
Applied process analysis
¾
Models and methods
¾
Communicating analytic results
¾
Communicating with patients and their families about
incidents and analytic results
¾
Implementation of analytic results
Dr. med. Günther Jonitz
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21. September 2011
EUNETPAS
-REPORT: www.eunetpas.eu
Dr. med. Günther Jonitz
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CIRS-NETWORK GERMANY, www.cirsmedical.de
21. September 2011
Dr. med. Günther Jonitz
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www.cirsmedical.de
Round about 2450 reports
(in all groups, without excluding double reports)
Report groups:
¾ CIRSmedical.de
¾ CIRS-AINS/ Anaesthesiology: 60 hospitals
¾ Report Network Berlin: 20 hospitals
¾ Report Network Munich: 5 hospitals
¾ Other report groups: 11 hospitals
¾ 9 further groups for different health care institutions
21. September 2011
Dr. med. Günther Jonitz
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German Coalition of Patient Safety
Î Working Group „Education and Training“
present activity:
Draft version of a „Curriculum Patient Safety“
Î all health care professions
Î practical orientation!
…work in progress…
21. September 2011
Dr. med. Günther Jonitz
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Simulation Training to enhance
patient safety
http://www.tupass.de/
21. September 2011
Marcus Rall
TüPASS
Centre for Patient Safety and
Simulation Tubingen
since 10 years
Department of Anaesthesiology
andGünther
Intensive
Dr. med.
JonitzCare Medicine
University of Tubingen, Germany
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http://www.europatientsafety.eu/epsc/
21. September 2011
Dr. med. Günther Jonitz
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„Aviation meets Medicine“
Steps:
¾Briefing
¾Checklist
¾Feedback
¾Debriefing
Airport Hannover
Picture:
Dr. sc. mil. Goepfert,
Dr. med. Rall
21. September 2011
Dr. med. Günther Jonitz
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Key factors
Safety and Learning Culture:
Reflective practice at
the system and at the individual level
¾ „Learning“ system
¾ Responsibility
¾ Cooperation
¾ Value based leadership
21. September 2011
Dr. med. Günther Jonitz
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No more management by
„mechanisation“
but
„humanisation“ !!
„Patient safety is not about constructing a machine, but growing
a garden!“
Günther Jonitz
21. September 2011
Dr. med. Günther Jonitz
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Quality Assurance
and
Patient Safety
is the re-discovery
of primary medical virtues
on systematic ground.
21. September 2011
Dr. med. Günther Jonitz
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“Not enough money is being spent on safety, so be careful.”
THANK YOU!
21. September 2011
Dr. med. Günther Jonitz
[email protected]
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