National and Institutional Patient Safety Resources
|1. Patient safety in law
|Health Care Act (2010)
Improve quality and patient safety
|The Government Response to the Health Select Committee Report ‘Patient Safety’ (2009)
Law on Specialist Health Services 2. Juli 1999 nr. 61 (the act for the hospitals) § 3-4 and § 3-4a on patient safety Law on the municipality’s health care service 24. juni 2011 nr. 30
(the act on municipality`s health care in Norway) § 4-2
Central to patient safety work in Norway is regulation of management and quality improvement in health and care services that are rooted in both laws
|Spanish Law 16/2003 on Cohesion and Quality in the National Health System paved the way for the Quality Plans. The Quality Plan for the National Health System (NHS) is designed to benefit citizens and promote high quality health care focused on patients and their needs. It supports health care personnel in the promotion of clinical excellence and in the adoption of best practices based on the best scientific knowledge available.
|2. Patient safety in national guidelines
|Promoting patient safety together. Strategy 2009-2013. The Ministry of Social Affairs and Health.
The National Institute for Health and Welfare: Finnish National programme on patient safety
|The National Patient Safety Agency: The site contained all national guidelines, reporting resources, educational resources from a national perspective
The site has now migrated to NHS Improvement: https://improvement.nhs.uk/improvement-hub/patient-safety/
|The Norwegian Patient Safety Programme: In Safe Hands
In Safe Hands was originally launched in 2011 as a patient safety campaign by the Norwegian Ministry of Health and Care Services. From 2014, the campaign continued as a five-year programme. The aim of the programme is to reduce patient harm.
|The Spanish Ministry of Health, Social Services and Equality (MSSSI) promotes the Patient Safety Strategy of the National Health System (NHS), developed since 2005 in collaboration with the Health Regions and different stakeholders interested in this issue.
The link to the main site where find reports, guidelines, training, projects, etc. is: [https://www.seguridaddelpaciente.es/en/]
The current report of the update of the “Patient Safety Strategy for the NHS 2015-2020” is also publish in English [https://www.seguridaddelpaciente.es/resources/documentos/2015/Spanish-Patient-Safety-Stratregy-2015-2020.pdf]
|3. Patient safety incidents reporting system
|National reporting system (Haipro)
|National reporting system. Each institution also logs its own incidents by ward, including things like infection/ MRSA and falls etc. Regional information will also be available to the Clinical Commissioning Boards. These have now come into operation following widespread changes in NHS legislation
|National reporting system
There is a national reporting system for hospitals. Law on Specialist Health Services Health Services Act § 3-3.
This applies to events that have led to death or significant injury to patients, also almost accidents.
The reports are mandatory, anonymous and goes to the State Knowledge Center for Health Services. The main emphasis of the system is to improving patient safety and learning from adverse events.
|The purpose of the Sistema de Notificación y Aprendizaje para la Seguridad del Paciente (SiNASP) (Notification and Registration of Incidents and Adverse Events System) is to improve patient safety through the analysis of situations, problems and incidents that occurred, or could have produced harm to patients. The main emphasis of the system is to improve learning. Although reporting is voluntary, it is strongly recommended to professionals encouraged to use the system, contributing to learning and improving patient safety. [https://www.sinasp.es]
|4. Information available about patient safety incidents
|The present system is only for professional use
|Yes, as above
|§ 3-3 messages are anonymous and available to the public. The Knowledge Center publishes reports with results from the scheme each year.
Some hospitals (like ours here in Østfold) publish the messages on their websites – anonymously.
|The information entered in the SiNASP is completely confidential and it is protected by the most advanced security systems.
The inform of reported safety incidents using SiNASP (2014-2015) has been published [https://www.seguridaddelpaciente.es/resources/documentos/2016/160523_FINAL-Informe_SiNASP.pdf]
|5. Patient safety education available
|The National Institute for Health and Welfare: Good practices and networking,
PS web-based programme
Patient safety coordinator in each Social and Health care District -> education and co-operation with SUAS
|Resources on NHS Improvement website. Each trust will also provide education and training for staff, as part of induction for new staff and mandatory training.
|There are resources on the The Norwegian Patient Safety Programme website and on the websites of national health authorities Statens helsetilsyn, (Norwegian board on health supervision) Helsedirektoratet (The Norwegian Directorate of Health) and Folkehelseinstitutet (The Norwegian Institute of Public Health)
In Norway, patient safety is taught at several universities and university colleges – especially at the University of Stavanger, which has several PhD students in the field
|Online Tutorial: Patient safety and prevention of adverse effects related with Healthcare National System; Risk management and patient safety enhancement: tutorial and support tools; Course on hand hygiene in health care.
|6. Patient safety included in the curriculum
● University/ UAS
|Patient safety module 3 ECTS points
|Not come under the ‘umbrella’ term of patient safety, it will be covered in relation to professional behavior, communication and confidentiality, managing falls, risk, health and safety, medications and their management, professional code of conduct for example. The related issues will be taught and also assessed in practice within NMC competencies
|7. Students can report patient safety incidents in the patient safety reporting system
|They can with their supervisors.
|They can, they are encouraged to do so, with their supervisors in practice and to take responsibility themselves for any issues. We would facilitate and support them through that process, but we would not report for them. We have a personal teacher system and link lecturers with every placement we use, so either of those would facilitate any issues in practice with reporting.
|Students can report incidents in the § 3-3 reporting system
All healthcare organizations in Norway have their own adverse event reporting systems for internal use – students can use these to report internally.
|Not at the moment. Only healthcare professionals (hospitals and healthcare centres).
|8. University/ UAS gets information about the patient safety incident reports
|9. University/ UAS lecturers have had patient safety education
|Some have had
|Some has had education
|10. The biggest patient safety needs/
|Systematical reporting of errors; Being more confident to report from errors; Learning from errors; Promoting patient safety culture:
Everyone’s input is important;
Promoting non-blaming culture; Improving communication and team work
Systematical improving: Enhancing medication safety, preventing hospital acquired infections, preventing falls
|Staff knowledge and confidence to report – much adverse publicity in the UK about whistleblowing and impact for whistle blowers, adverse publicity post Francis Report (2013). Clarity of process and support through the process, for staff, students, carers and others. Challenges include – evidence base around the staff skill mix and complement in a changing NHS environment, increased patient dependency levels, increased and complex care needs; safety during discharge planning from hospital to home and onwards; interruptions during medication rounds is well documented (staff now wear a tabard saying do not disturb me!); increased patient throughput and infection control, falls.
|From the last report on patient safety to the Norwegian Parliament – National level
Status and Challenges
This message summarizes challenges that require efforts at all levels: Information flow and communication, safe transition within the services and between service levels and compliance with procedures, guidelines and regulations.
It is important to use knowledge about quality and patient safety in planning, implementation, evaluation and correction of the business. In this report, the patient and user representatives, the Norwegian Board of Health and Welfare, Norwegian Patient Injury Compensation and the Registration Scheme provide insight into risk areas that require attention and follow-up. The sources provide different types of data. When we summarize the reports from the same sources in a single document each year, it provides insight into some ongoing challenges. This will make it easier to grab them.
|According with a document prepared by the Executive Agency of Health and Consumers, an organism that depends on European Commission, doctors and nurses have a poor or not formation about this subject in their curriculum.
Human patient simulation: teaching students to provide safe care
|The biggest need or challenge in my opinion is getting from reaction to pro-activity. In the ladder of culture (Hudson and Parker, (……) this is the next step
|11. Multi-disciplinary/-professional courses/
modules in the curriculum
Client centered practice, Social and Health Care service systems, Promoting of Health and Wellbeing
|One module – research methods
|12. International courses/
modules in the curriculum
|Client centered practice 3 ECTS points
|No (patient safety)