Adverse event reporting.pdf

Denmark
Type of reporting system: The Act on Patient Safety in the Danish Health Care
System came into force January 1, 2004. The objective of the Act is to improve
patient safety within the Danish health care system. The law obligates health care
professionals to report specified adverse events to a national database. To support
learning, this national mandatory system is sharply separated from the system of
sanctions.
What is reported: Reportable adverse events are “events resulting from treatment by
or stay in a hospital and not from the illness of a patient, if such event is at the same
time either harmful, or could have been harmful had it not been avoided beforehand,
or if the event did not occur for other reasons. Adverse events shall comprise events
and errors known and unknown” Surgical events and medication errors, including
close calls, must be reported.
Who reports: Healthcare professionals who become aware of an adverse event
in connection with a patient’s treatment or hospital stay are required to report the
event.
How they report: Health care professionals report to the national database. Reports
are automatically forwarded to the county where the event occurred and county
councils record, analyse, and de-identify the reports. Lastly, reports are forwarded
to the National Board of Health, which maintains a national register of adverse
events.
Analysis: Although there are no national requirements for analysis, there is general
use of the Safety Assessment Code (SAC) score. Adverse events with less serious
SAC scores are acted upon locally, whereas serious adverse events (SAC score of
three) prompt a root cause analysis.
Response, dissemination and application of results: Hospital owners are obligated
by the Act on Patient Safety to act on reports, while the National Board of Health is
charged with dissemination of lessons learnt. The National Board of Health issues
alerts in the form of regular newsletters, in addition to an annual report.
Further information: www.patientsikkerhed.dk
England and Wales
Type of reporting system: The National Reporting and Learning System (NRLS) has
been developed by the National Patient Safety Agency (NPSA) to promote an open
reporting culture and a process for learning from adverse events. The purpose of
the NRLS is to elicit reports of patient safety incidents, identify themes and patterns
in the types of incidents being reported including major systems failures, and to
develop and promote implementation of solutions.
The NRLS was launched in February 2004. As of July 2005, 548 NHS organizations
have successfully connected to NRLS (90% of the total number).