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Speer T, Mühlbradt T, Fastner C, Schröder S. [Safety‑II: a systemic approach for an effective clinical risk management]. DIE ANAESTHESIOLOGIE 2023; 72:48-56. [PMID: 36434272 DOI: 10.1007/s00101-022-01215-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/26/2022]
Abstract
The healthcare system is an example of a complex sociotechnical system where the goal is the best possible individual treatment together with the cost-effective use of modern technology. Working in anesthesia requires medical knowledge as well as manual skills and the use of specialized technical equipment in an interdisciplinary and interprofessional setting. The susceptibility to errors and adverse events, especially in the care of critically ill patients, is high.In order to avoid unintentional hospital-induced patient harm, the healthcare system has recently taken the path of prescribing the best possible care for a large number of patients with the help of evidence-based guidelines and specific algorithms or instructions for action. Patient safety is defined accordingly as a state in which adverse events occur as rarely as possible (Safety‑I).Following this approach clinical risk management is defined as the purposeful planning, coordination, execution and control of all measures that serve to avoid unintended hospital-induced patient harm or to limit its effects. For this purpose, the focus has recently been placed on instruments such as Critical Incident Reporting Systems (CIRS) or Morbidity and Mortality Conferences (M&MC); however, it is increasingly recognized that adverse events in complex sociotechnical systems such as the healthcare system arise situationally from the interaction of numerous components of the system. The effectiveness of CIRS and M&MC is limited because they do not comprehensively take situational effects into account. Thus, only selective changes are possible which, however, do not imply a sustainable improvement of the system. Newer approaches to strengthening safety in complex sociotechnical systems understand positive as well as negative events as being equally caused by the variable adaptation of behavior to daily practice. They therefore focus on the majority of positive courses of treatment and the necessary adaptations of the health professionals involved in daily practice (Safety‑II). In this way, the adaptability of the system under unexpected conditions should be increased (Resilience Engineering). Taking this systemic approach into account, the Functional Resonance Analysis Method (FRAM) offers a variety of possibilities for the prospective analysis of a complex sociotechnical system or for retrospective incident analysis through modelling of actual everyday actions (work as done). Through interviews with the health professionals involved, document analyses and work inspections, processes and their functions as well as the associated variability are assessed and graphically presented. The FRAM models the collected information of the process as complexes of interconnected functions represented by hexagonal symbols. Each corner of the hexagon represents a given aspect, which together form the properties of the function (input, output, precondition, resource, time, control). Through this visualization and evaluation of the interview results, the actual everyday actions (work as done) can be compared with the predefined ones (work as imagined). The evaluation of the variability found in this way enables the strengths and weaknesses of processes to be uncovered. As a result, specific measures can be derived to strengthen the system. Increased consideration of the Safety‑II approach within clinical risk management can be a valuable addition to existing clinical risk management methods.
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Affiliation(s)
- Tillmann Speer
- Klinik für Anästhesiologie, Klinikum Itzehoe, Robert-Koch-Str. 2, 25524, Itzehoe, Deutschland.
| | | | - Christian Fastner
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland.,IV. Medizinische Klinik, Geriatrisches Zentrum, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Stefan Schröder
- Klinik für Anästhesiologie, Intensivmedizin, Schmerztherapie und Notfallmedizin, Krankenhaus Düren gem. GmbH, Düren, Deutschland
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[Development of clinical risk management in German hospitals]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022; 65:293-301. [PMID: 35133463 PMCID: PMC8888368 DOI: 10.1007/s00103-022-03491-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/17/2022] [Indexed: 11/02/2022]
Abstract
Clinical risk management supports healthcare workers in recognizing, reducing, and managing risks in patient care. It is mandatory for all outpatient and inpatient facilities in the German healthcare system. The contents of the clinical risk management are regulated in the Social Code (Title 5), the guidelines of the Federal Joint Committee, the Patients' Rights Act, and the norms and recommendations of the Patient Safety Alliance. The Federal Joint Committee explicitly points out that minimum standards of risk management, error management, error reporting systems, complaint management in hospitals, and the use of checklists for surgical interventions must be implemented.The legislator requires that the effectiveness of the clinical risk management be checked regularly. Questionnaire surveys on clinical risk management in Germany show an overall positive development. However, the data are not sufficient for a comprehensive assessment. Methodologically reliable procedures should therefore be developed that check the status of the clinical risk management much more frequently and regularly. The data measuring structure, process, and outcome should be collected systematically and presented in a comparative manner in relation to the facilities.Opportunities for clinical risk management arise from the World Health Organization's Global Action Safety Plan, advances in digitization, the integration of clinical risk management into organizational risk management, and the improvement of structural quality. Clinical risk management must be given even more space in the daily routine of doctors and nurses. This requires competence and human resources in this area. These are not sufficiently available in German hospitals.
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Tuca AC, Münch J, Schwappach DLB, Borenich A, Banfi C, Mautner S, Hoffmann M, Schwarz C, Kamolz LP, Brunner G, Sendlhofer G. Implementation status of morbidity and mortality conferences in Austrian hospitals-A cross-sectional national survey study. PLoS One 2021; 16:e0248692. [PMID: 33730067 PMCID: PMC7968694 DOI: 10.1371/journal.pone.0248692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Morbidity and mortality conferences (M&MCs) are an instrument for learning from past complications, unexpected follow-ups and deaths in hospitals and are important for improving patient safety. However, there are currently no quantitative data on the implementation of M&MCs in Austria. The aim of the study was to determine the status quo of the M&MCs in Austria. MATERIALS AND METHODS A national cross-sectional study was conducted by means of a survey of 982 chief physicians of surgical disciplines, internal medicine, anesthesiology, intensive care, gynecology/obstetrics and pediatrics. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. RESULTS Of the 982 contacted chief physicians, 314 (32.0%) completed the survey. Almost two thirds of the respondents, i.e. 203 (64.7%), had already implemented M&MCs. Of the 111 chief physicians who had not yet introduced M&MCs, 62 (55.9%) were interested in introducing such conferences in the future. Of the 203 respondents that had implemented M&MCs, 100 stated that their M&MC could be improved. They reported issues with "shame and blame" culture, hierarchical structures, too little knowledge about the capability of M&MC and, in particular, time constraints. Overall, the participating chief physicians showed that they are striving to improve their existing M&MCs. DISCUSSION/CONCLUSION While we found a relatively high number of already implemented M&MCs we also identified a large heterogeneity in the format of the M&MCs. A highly structured M&MC including guidelines, checklists or templates does not only considerably improve its outcome but can also alleviate the main limiting factor which is the lack of time.
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Affiliation(s)
- Alexandru-Cristian Tuca
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Johanna Münch
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - David L. B. Schwappach
- Swiss Patient Safety Foundation Zurich, Zürich, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Chiara Banfi
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Selma Mautner
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Magdalena Hoffmann
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Christine Schwarz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Lars-Peter Kamolz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Executive Department for Quality and Risk Management, University Hospital Graz, Graz, Austria
- Austrian Society for Quality and Safety in Healthcare (ASQS), Graz, Austria
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