Exploring patient participation in reducing health-care-related safety risks

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Exploring patient participation in reducing health-care-related safety risks 156 ANNEX 3. pATIENT INVOLVEMENT IN BLOOD TRANSFUSION IN ThE NEThERLANDS Willem Martinus Smid Organization of blood transfusion in the Netherlands The catalyst for the merger of all blood banks and the Central Laboratory of the Red Cross Blood Transfusion Service in the Netherlands was an evaluation report carried out by the Ombudsman. The evaluation was initiated following a series of complaints from patients receiving plasma products in the 1980s. The conclusion was that although no wrongdoing was found, the supervision system in place under the Ministry of Health, Welfare and Sports was complex, involving more than 20 independent organizations. As a result, Sanquin was formed and authorized by the Ministry of Health, Welfare and Sports in 1998 as the sole organization responsible for blood supply in the Netherlands. Development of blood transfusion in line with legislation EU legislation was transposed in the Netherlands legal texts, with provisions supporting the position of the patient. In the blood transfusion field, a good example is the case of Jehovah’s Witnesses refusing blood transfusion therapy. For legal procedures, the courts followed the reasoning of the individual patient’s right to choose for him or herself; more recently, however, there has been a tendency towards considering the duty of HCWs to deliver what is considered by professionals to be “standardized care”, particularly in situations in which a life is at risk. Most legislation had an effect on blood banks, given its focus on the quality and safety of blood and blood products. In hospital settings, the quality of patient care focused mainly on developing and implementing processes and procedures to prevent adverse transfusion reactions. The contribution of the patient to transfusion safety has been limited. Remaining risks of blood transfusion Haemovigilance in the Netherlands is organized quite differently from the way it is delivered in France. The Netherlands national haemovigilance office, Transfusion Reactions in Patients (TRIP), is an independent organization managed by representatives of professional societies involved in blood transfusion. Hospitals report transfusion reactions (Box A3.1 and Box A3.2) to TRIP and reports are subsequently compiled. In 2009, there were 30 reports involving administration of the wrong blood product, occurring as a result of identification errors (1). A study in 2010 involving automated registration of the transfusion process in an academic hospital found one case of incorrect blood product administration in 590 transfusions (1 in 790 for red cell concentrates and 1 in 365 for platelet concentrates). The study involved 33 000 transfusions of blood components and blood products (Huyhn et al., unpublished data, 2010).
Box A3 .1 . Reporting procedure Patient involvement in blood transfusion in the Netherlands Reports of transfusion reactions are sent to TRIP on a voluntary basis and are treated confidentially. Data analysis and reporting are anonymous. Reporting to TRIP is separate from the regular communication methods between hospitals and the supplying Sanquin blood banks about transfusion reactions or incidents. Who » The hospital submits a report if a reaction has been noted in the hospital. » The Sanquin blood bank submits a report if a problem has been detected by the blood bank after delivery of a blood component to a hospital. TRIP’s point of contact in each of the four supplying divisions is the manager of the clinical advisory service. » TRIP checks for double reporting by comparing product numbers. Responsible persons at hospital level » Haemovigilance officer, a staff member officially responsible for reporting to TRIP, nominated by the Blood Transfusion Committee and preferably officially appointed by the hospital board. » Haemovigilance assistant, who prepares the report to TRIP (visits ward, collects and collates information), assists the haemovigilance officer and provides education and training on blood transfusion. What Transfusion reaction (TRIP definition) » Any undesired medical event (symptom, sign or diagnosis) or worsening of a pre-existing medical condition during and/or after a blood transfusion. » Period: from the ordering of the transfusion until an unlimited time after administration of a blood component. » Imputability: rating the likelihood that the undesired event was due to the transfusion of the blood component. » More: categories of reactions that are to be reported to TRIP. 1 How How to report Department where reaction is detected » Treat/act according to hospital protocol; discuss with the consultant in charge. » Treating team sends report to blood transfusion laboratory. Blood transfusion laboratory » Further tests according to hospital procedures. » Report to supplying blood bank if appropriate. Report to TRIP (hospital haemovigilance officer) » Report to TRIP, generally after conclusion of investigation. » Send in completed reports at least every three months. » Please do not “save up” reports of grade II reactions (or higher), but instead submit when results of investigations are complete. Publication of results Communication with hospitals (currently 110 addresses) » TRIP confirms receipt of reports to the submitting party. » Each hospital receives a preliminary overview of (national) reports to date every six months and (if there has been no communication) a “nothing to report” card to confirm participation. » Personal contacts are maintained through regional meetings and visits to individual hospitals where possible. Annual report The submitted reaction reports are reviewed by an expert panel of board members. Any discrepancies in the assignment to a particular category of reaction, grading or classification of imputability are resolved by discussion with the reporting party. The annual report is sent (with analyses and recommendations) to the reporting haemovigilance officers, blood transfusion committees and governing boards of the hospitals, to the other participating organizations and to the Ministry of Health, Welfare and Sports. A summary in English is made available on request. Publication in relevant scientific journals is envisaged. 1 See Box A3.2 and the TRIP web site for more details (2). 157
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Exploring patient participation in
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ABSTRACT Patients’ rights have be
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iv Patient information: the link be
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vi LIST OF TABLES, FIGURES AND BOXE
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ACKNOWLEDGEMENTS The editors would
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LIST OF ABBREVIATIONS ABHR alcohol-
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FOREWORD Health is a social value a
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ChApTER 1. pATIENTS’ RIGhTS AND p
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Box 1 .1 . contd Reporting and Lear
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The causal mechanisms through which
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» be involved in routine monitorin
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elationships within the complex env
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ChApTER 2. pATIENTS’ RIGhTS AND p
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CoE Recommendation 2006/7 of the Co
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The 2005 United States act on patie
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The right to participate in policy-
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The right to participate in quality
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» engaging with patient representa
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hampered by the written and spoken
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prevents misunderstandings and shap
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Health care providers should nevert
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Recommendation 7 - Encourage the av
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20. Constitution of the World Healt
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ChApTER 3. pATIENT pARTICIpATION IN
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awareness of the sociomedical burde
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Patient participation in hand hygie
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Blood transfusion safety in France:
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Box 4 .1 . Definitions of adverse e
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Fig . 4 .4 . Distribution of advers
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The heterogeneity of situations and
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Fig . 4 .12 . Patients’ response
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Patient safety, rights and medicati
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Fig . 5 .3 . Frequency with which d
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ChApTER 6. pATIENT pARTICIpATION IN
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Patient participation in elective s
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e desirable to have a special statu
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inspections of surgical services to
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Page 135 and 136: Other studies on patient attitudes
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Page 141 and 142: Adverse events Respondents from the
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Page 147 and 148: care professionals’ and patients
Page 149 and 150: group recommends that patient invol
Page 151 and 152: 13. Hibbard JH et al. Can patients
Page 153 and 154: 52. Triemstra M et al. Measuring cl
Page 155 and 156: 2009 (http://www.bradfordresearch.n
Page 157 and 158: of a small-scale patient survey add
Page 159 and 160: Box 8 .2 . Curricula and CME Chapte
Page 161 and 162: is provided through interaction of
Page 163 and 164: Box 8 .4 . Patient education Chapte
Page 165 and 166: ANNEX 1. QUOTATIONS FROM INTERNATIO
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Page 173 and 174: Box A3 .2 . contd Haemosiderosis Ha
Page 175 and 176: ANNEX 4. pATIENT QUESTIONNAIRE ABOU
Page 177 and 178: ANNEX 6. WhO pATIENT SAFETY pROGRAM
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Page 181 and 182: ANNEX 7. hANDOVER pROjECT Paul Bara
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