Reluctance to implement patient safety tools: it is time to improve our practice
Safety, Safety,equipment
M. Van Haperen, L. Koers, F. M. Eveleens, W. S. Schlack, B. Preckel
Department of Anaesthesiology AMC - Amsterdam (Netherlands)

Background and Goal of Study: After publishing the Helsinki Declaration on patient safety, numerous tools have been published in order to improve patient safety during the perioperative period. Emergency manuals are care-bundles of cognitive aids (CA) that help care providers to perform and speed up all the critical steps to be taken in an emergency situation. In 2014 we developed and published (1) the AMC Emergency manual, which is based on the Stanford Emergency manual (2). The bundle was presented on the national congress of the Dutch Society of Anaesthesiologists. We made an editable version of our CA-bundle freely available to all hospitals in the Netherlands. Three years later, we now surveyed the implementation of this CA-bundle amongst the hospitals that received an editable version.

Materials and Methods: We registered hospitals asking for an editable version of our CA-bundle from October 2014 to November 2017. At 1st of December 2017, we requested information about the implementation process for CA-bundle in the respective hospitals.

Results: From 97 hospitals in the Netherlands with Anesthesia Departments, 27 requested an editable version of our CA-bundle (3 University Hospitals, 24 community hospitals). Even 3 years after presenting the CA-bundle in the Netherlands, only 5 departments adopted and implemented the CA-bundle in their own hospital. Two departments answered that they started, but not yet finished adoption and implementation, while 20 departments not yet started to adopt the manual. One university hospital used the content of our manual but adopted the lay-out according to crisis cards of the Dutch Air Force.
Of the remaining 70 hospitals who didn’t requested an editable version, so far 9 hospitals have responded. One hospital had adopted and implemented a digital version of our CA-bundle and eight hospitals weren’t familiar with our, CA-bundle. Most of these hospitals were unfamiliar with cognitive aids as a safety tool in general and the need for it. 

Discussion: Although a Dutch version of a Cognitive Aid Bundle was freely available to all Dutch anesthesia departments, only 6 departments produced and implemented a local CA-bundle in their hospital. 

Conclusion: Like with other patient safety tools, production, implementation and use of cognitive aids is very limited in hospitals in the Netherlands. Not only do we have to investigate the effectiveness of different patient safety tools, we also need to significantly improve strategies to implement these tools into our hospitals in the future.

References: 
1. Koers et al. Cognitive aid for emergencies in the OR--AMC bundle helps ensure that no steps are left out, Ned Tijdschr Geneeskd. 2015;159: A8325 

2. Goldhaber-Fiebert et al. Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture from the Perspective of Anesthesia Residents: A Pilot Study, Anesth Analg 2016;123:641–9


05 / Reluctance to implement patient safety tools: it is time to improve our practice