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Titel: Framgång kräver ledningens stöd och resurser [summary] (serie: Tema patientsäkerhet) 2007 nr 4 sid 224-8
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Summary:
A systematic effort to improve patient safety in the County Council of Östergötland was started in the year 2000. The process involved six stages as described in this article. We began by improving the management of adverse events (from registration to follow-up of measures taken). Thereafter major adverse event (root cause analysis) and prospective risk analyses were performed, dialogue maintained with each department (including reports on how work with patient safety was proceeding) and finally patient involvement was introduced.
To date 103 root cause analysis of major adverse events have been performed and our experience has been favourable. Considerably more event root causes have been discovered using this systematic approach compared to previous ways of working. This in turn has led to an improvement in measures being taken.
Even better is to analyse a procedure before an adverse event occurs, and today risk analyses are performed prior to major changes in healthcare structure, procedures and technology. Some examples are described.
Patient safety has become a priority for the leaders of healthcare in Östergötland, and they have access to a specially designated Patient Safety Unit for assistance. The existence of this unit as well as the efforts of its members has been of major importance for the success of the patient safety project.
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