Moving forth in the healthcare sector - Östergötland County Council

”We still have a lot of work to do”, she claims. “Too many patients are subject to disease or injury while the healthcare system is taking care of them. The sector is not safe, and will not be as long as we don’t succeed in changing attitudes like 'it is impossible to avoid damage anyway'. If we can avoid making errors, it is not acceptable that they happen,” Öhrn states honestly

The Patient Safety Coordinator at Östergötland County Council in South-Eastern Sweden knows what she is talking about.  She deals with 12,000 employees working at three hospitals and 41 health centres. They all report in Synergi, which is their only risk management system, and 500 of them are extensive users.

In 2000, they realised that something had to be done about the repetitive occurrences of deviance. Acquiring Synergi as a tool to begin analysing this was the first step, according to Öhrn.

“At the time, the term 'patient safety' did not exist in Sweden, there was only talk of 'risk management'. We had to start eliminating the unfruitful scapegoat mindset which had been dominating the sector for too long. We have managed to show that this is not about the individuals not doing their job well enough, but rather organisational breaches and bad communication.”

Through root cause analysis and risk analysis they started to understand the relations between risk management and data they received from other kinds of analysis. Instead of assuming why things happened, they could now document it. This sparked real action.

“Whereas before we were working reactively, we are now doing pretty well on the proactive side. We have built-in mechanisms that make it harder to commit mistakes,” says Öhrn. “But we also work a lot to ensure that employees maintain their focus. We have to brainwash them into thinking about safety and reporting as two sides of the same coin. We continually ask the managers to provide us with risk analysis reports, for instance.”

The people responsible for HSE in Östergötland go the extra mile. Instead of just being content with their reported data, they are active in finding out how the registered cases actually happened. Another valuable measure taken is a pilot project where Synergi is used in nursing homes and old people’s homes. The solution allows knowledge to be shared with a larger part of the healthcare system. Öhrn insists this is the only right path to follow, and that all regions in the country must join in and work with patient safety using the same tools and methods.

But there are other more general measures that should be taken as well, according to the Patient Safety Coordinator.

“We need to get more attention directed towards safety consultants in the healthcare sector. A lot of effort is put into cutting costs and recruiting personnel, but little is done for the patient safety issue. We have to set a price on a human life by promoting the cost impact for society when a person has to be hospitalised for an extra week due to hospital malpractice. People working with HSE must be aware of which expressions to employ when discussing the subject; we must apply the same kind of rhetoric for example the road constructing business and other sectors that are good at making budgeting powers listen.”

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