Safe Patient, Safe HospitalA Prelude to Culture of Safety

in Polish Hospitals

B.Kutryba, H.Wąsikowska, A.BanaszewskaAmsterdam, ISQua 2004

PolandNumber of clinical errors: unknown

What do we know?

- lack of separate legislative measures for malpractice claims

- hospitals are underinsured- number of malpractice claims: unknown- no data on the amount of claims

What Do We Know?• Lack of adequate patient care on

weekends and/or holidays• Incidents of sudden, unexpected death

after a simple surgery• Heavy complications, not anticipated by a

patient nor patient’s family• Lack of effective doctor-patient

communication

Prof. B.Świątek

The deduced rate of participationin adverse events

78,5%

Keep It To Myself ...

3,4%

94,7%

1,9%

0%10%20%30%40%50%60%70%80%90%

100%

Yes No Don't know

Health Professionals’ Attitude

Doctors (89%) are more willing than nurses (55%) to talk about adverse

events with their peers

Nurses (43%) more than doctors (25%)are afraid of reprimand from the

superior

Inform the Patient About the Incident

25,6%

34,6%

19,1%20,7%

0%

5%

10%

15%

20%

25%

30%

35%

Yes No Don't know No answer

What Is the Cause of Adverse Events?

• Overwork (83%)

• Lack of nurses’ (55%) and doctors’ (41%) motivation

• Obsolete or incomplete procedures (53%)

• No tradition for correcting each other (40%)

• Lack of support from more experienced peers (40%)

• Insufficient education and learning (39%)

Preferred Models of Reporting

4,3%

31,6%

64,1%

0%

10%

20%

30%

40%

50%

60%

70%

Anonymous Confidential Conditionallyconfidential

Patient Safety Will Be ImprovedIf a Reporting System Is Introduced

36,6%

43,2%

4,5%1,6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Agree strongly Agree Disagree Disagree strongly

„ ...reporting the incident will allow others to avoid

the similar event from happening again”