Patient Safety in Practice

Transcription

1 Patient Safety in Practice Ambassadors from Sweden, France and Spain and countries I forgot to mention Came from all over Europe to this international convention. A very long day, the weather grey, we simply had to cope But the stairway led to heaven, at the first floor there was Hope! And there was coffee, there were cookies, and I noticed right away: Everyone was looking forward to an interesting day. Patient Safety in Practice: important subject to us all We hoped to get some tools, to bring back to our hospital. Nice, intelligent people quickly filled the whole first floor An audience of doctors, I never felt so safe before. Our host, mr. de Boer, seemed in control here, I must say He gently led the way, our mr. Fifty Shades of Grey. He started five minutes late, with a good morning to us all But in a country with waiting lists, five minutes are neglectable. This was gonna be an intellectual challenge, well, we couldn t wait Our chairman hoped we had our coffee, so we could all participate. There is no happy ending without a great start, learned the class And it was up to Ferry Breedveld to provide all that for us. In God we trust, he said, and we agreed, between these walls But we also needed data, because we were intellectuals. A Framework Patient Safety Competencies, Ferry showed on screen And then mr. van Halden happily entered the scene. Welcome to The Hague, a Rembrandt painting, beautiful Visit the Beach, visit the city, he recommended to us all. Leon talked about the costs of healthcare, they rose tremendously They grew harder and bigger than our economy. Because of many incidents, healthcare became priority Prevent harm, work safely, what else could we than agree? Ten teams that formed the pillars of a program for preventing harm I only speak of hospitals, said Leon, full of charm. He mentioned a technical agreement, things took time, and they went slow There was a Certified Safety Management System, and also a long way to go. Safety was a subject that was never finished, said Leon It had to stay on the agenda, he recommended, and was gone. His own agenda was quite full, so Leon couldn t stay No questions for Leon, he smelled the beach and ran away.

2 We listened to the interesting keynote speech from Niek He also started his lecture with Rembrandt, whose paintings were unique. There was an error in the painting, and the message, crystal clear: Errors are everywhere, even with Rembrandt they appear. In God we trust, he also said, with mr. de Boer he agreed But we can t trust our famous painters, it s the data that we need. Quality strategies, research questions, different countries were being compared The outcome of the investigation was generously shared. A complete framework was shown to us, without errors I must say I preferred the Rembrandt painting, but we went another way. Hand hygiene procedures are important, I admit But I really am quite certain, Rembrandt never heard of it. We all tried very hard to follow the interesting speech from Niek He did his very best and he used all his tongue in cheek. He talked about transparency, external pressure, then on screen A sheet that was the least transparent I have ever seen! A management board involved lead to better results, Niek said But the doctors and the nurses were needed for the road ahead. A higher level of involvement was needed, Niek believed profound Washing your hands was not enough to keep the patient safe and sound. Patients identified with bracelets, hip fracture patients, Niek went on How many people died in Denmark? How many problems there, were gone? He told us about stroke and he concluded finally: Each country had its own danger, and needed its own strategy. Some questions and a coffee break, and then we listened to Wim I thought, if he also starts to talk about Rembrandt, I am gonna yell at him. But, mr. van Harten didn t turn his back on us The Dutch Patient Safety Program, well informed he was. You work here safely, or you don t work here at all, he said He cited a Shell guy who severely said, that. Safety is a permanent issue, because of increasing complexity Technical and organizational, we needed transparency. Dutch steps in patient safety, there were two steps, we learned from Wim He mentioned goals that were achieved, and we were glad for him. The Dutch technical agreement, Wim guided us through it, like a coach The requirements for patient safety, the collaborative approach. Medical training and education were implemented, promised Wim And the program was rather ambitious, according to him. And so is this poem, but I figured I should try And if Rembrandt is allowed to make mistakes, then so am I.

3 And then we looked at half a man, his words, and not from me The half of an identical twin, and like his brother, a busy bee. He showed some shocking pictures and then spoke with great esteem About the responsibilities and achievements of a team. Teams in healthcare are dynamic and complex, the half man said About the systems in healthcare, he continued straight ahead. To be banned to Australia, what do you have to do? And everybody could take pictures, the half man invited us to. Does clinical governance work?, Heineman said: Well Because we have to cope with living systems, sometimes it is hell. Hospitals were on the edge of chaos, never quiet and peace And health care organizations were tribal societies. The half man needed interaction, on screen appeared a grid We had to put the nurses in and tell him were the doctors sit. Pieter Degelings picture made some things here crystal clear Different tribes, they hate each other and they live in fear. But that was only in the western world, the communists, you see Live peacefully together because of lack of individuality. In China there is no word for me, they all just say there: we But in the western world, the first word we learn is: me! Thank you very much, we heard from mr. Heineman Although he was only half a man, to he was a fine man. I was glad to have him on the stage, not his identical twin brother I was sure he was the better half and more man than the other. And then finally a lady, after a parade of middle aged men A professor in a red skirt, and her first name was Diane. She talked about patient participation, the most serious question of them all: Did doctors wash their hands? Or was it chaos in the hospital? Or do patients feel embarrassed, if they ask questions about hygiene? Some examples of surveys, Diane showed on screen. So many mistakes were made, with medication, treatment, dose Rembrandt, with his paintings, he didn t even come close. Patients are dependent, so we all can understand That they are afraid to ask their doctor to even wash one hand. Diana had some Polish people who investigated things for her They might be cheaper, but she gave them all the credits, that was nice and fair. Then all doctors appeared on stage, after the chairmans call We could take their pictures and pop some questions to them all. There were interesting questions, everybody grabbed their chance But the one question nobody dared to ask: did the doctors wash their hands?

4 Yvonne had five pages, but she promised to be brief We were all very hungry, so that was a great relief. Trust comes on foot and not on horseback, an old Dutch saying, Yvonne said We heard food, instead of foot, because we were craving for some bread. Lunch was served, and we grabbed food, and we enjoyed it all Nobody washed their hands, but this was not a hospital. A French lady took her shoes off, planted her feet in an empty chair Hygiene didn t seem to be a real big deal to her. Our next keynote speaker, determined to hold his grip Flip, started the competition with your after dinner dip. Our chairman brought some bad news: the weather improved outside But the beach was not an option, we were captured here inside. Next to me stands Eelco, serious about his task I think he washed his hands, but I am too afraid to ask. Unlike Rembrandt, he never makes mistakes, he s never wrong But I know why that is: he only plays this single song I saw some foreigners debating: Is this guy real? Is he a fraud? When someone from Austria won the screen, there wasn t any doubt. A man from Yugoslavia looked dizzy at the screen Was he a doctor or a patient? He said: I am something in between! A little lesson about our country, to the audience it was thrilling In the meantime, somewhere in the building, they started drilling. In order to announce the breakout sessions? In a very special way? Or were they going to destroy this building after the conference of today? Reporting incidents, the first session where I took a seat Someone from Denmark and from Scotland gave us a very special treat. Jeanette was a nurse from Scotland, she looked safe, but we were wrong Because she hasn t seen any patients now, for ten years long. The Scots knew they had a problem, how did they discover that? I started with some heavy claims, the Scottish Jeanette said About support in Scotland, Jeannette started to inform the crowd Some people, including myself, decided to break out. Communication gaps, a man was communicating like hell Was he from Sweden or from Spain? By his accent I couldn t tell. He asked if there were any nurses or doctors on the floor The majority worked in the office, we only counted four. Two Spanish examples, if you don t know what s left, what s right They can operate you easily on the wrong side. And an image proved to us a solution can be find But after an operation, scissors are sometimes left behind.

5 The man from Spain, he did his best, but walked in his own trap Because of his accent he was his own communication gap. My pronunciation is also terrible sometimes But I do that on purpose, to make sure everything rhymes. The second round of breakout sessions, the room where I began Was the session: workshop air medic sky one. The room was filled with laptops and there wasn t any light I left there in a jiffy, because it was to dark to write. Infection prevention, it was an interactive class About skills and about tools, three lovely ladies talked to us. How to prevent infections, is something every nurse must know There were sixty five guidelines, where to start? And where to go? There were different phases, and I left after phase two Because there were other breakout sessions I wanted to do. Working in teams, a Frenchman who sounded like Hercule Poirot Talked about data sharing and had lots of sheets to show. What is a team? Well, in a team it s never about me It s about accepting rules, working together, sharing responsibility. How to improve a team? Because if that became reality Eighteen percent decrease could be reached in mortality. Teamwork seemed to be the solution, oh, we ve known that for so long If I would perform alone, I m sure you would detest this song. After Poirot was finished, I felt positive energy Although I was convinced that almost nobody listened but me. Because everybody was tired, but we had more things to do We had to listen to an interview with mr. Jean Bacou. And we had to listen to Marc Haerkens, who said: I really think I am the only thing standing between you and a cold drink! Marc was a pilot, talked about working in a cockpit crew What was successful in the air, might also work for you. Houston, do we have a problem? Marc had a tremendous drive He was always willing and prepared to save a life. He didn t like window dressing, lots of medals on the wall And effective communication wasn t a talent of us all. Examples of human failure and they really went very far They can remove your prostate by accident, if they don t know who you are! The only thing left at five, was a little interview The ten minutes of fame of the handsome mr. Jean Bacou Lots of people left the building, but you stayed and that was fair Because you, unlike these gentlemen, didn t have a lazy chair.

6 Bacou explained what PaSQ was, then our chairman asked Bascou: How to make this day more successful? What would you recommend to do? The exchange program was vivid, it was one tool, we were told And there was no best practice to take home, Bacou said a little bold. Changes, they take lots of time, the chairman had to say And local barriers, how can they be taken away? Implementation in each country happened in a different way Flexibility was the key word, and then I read my resumé The lyrics of this poem, I don t think at home you ll need them But I will put them on the website, so to all: feel free to read them. Like Yvonne, I have five pages, but I ll read four of them, I think Because I can tell that everyone is dying for a drink. If you still have questions for Heineman? No need to bother During lunch break I saw him trading places with his brother. And Ferry Breedveld already left for the beach at half past ten And the French lady is dying to get out of her shoes again. I m almost providing your happy ending, after that we part I could never have achieved this without Ferry Breedveld s start. What did we learn today? Between the lunch and coffee breaks? In God we trust, but we must act, and even Rembrandt made mistakes! I could go on for ever, but this poem has to end Although it was my first time, I loved the experiment All women my age are trying Fifty Shades of Grey But I explored the borders of the English Resumé. I know you must be thirsty, so I want to thank you all I don t know about you, but I myself, I had a ball And he still has his prostate! This is where the story ends In God we trust, but for god s sake, dear doctors, wash your hands! Dominique Engers, The Hague, June 11 th