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Periodically, hospitals hold a meeting to discuss results and effects d & # 39; learning. In addition, a meeting is held once a year with employees and hospital medical specialists who have been involved in a calamity. Here they present the most important learning experiences to each other.
Incident Report in 2017
In 2017, a total of 28,700 reports were made in mProve hospitals of incidents or things that are not going well. Of these, 105 have been reported to the Inspectorate in an emergency because the patient has died or has suffered serious damage due to an unintended or unplanned event. Of 64 of them, it was determined that the cause lies in a shortage of quality of care. Most of the cases were organizational in nature. This involved non-compliance with protocols, unclear communication by care providers, and incomplete file management. Human causes were lack of expertise, work pressure and inattention.
Calamities
Each calamity has led to at least one measure of improvement and sometimes to more. So, in total, the hospitals have taken at least 105 steps to improve. (For example, research on inflammation in the lungs, in which a tumor has also been detected in the abdomen), missed or incorrect diagnoses, in case of problems with anticoagulants and treatment Patient Vitally Threatened
Improvement Projects
Due to calamities, many improvement measures were taken, mainly by improving procedures and training. Improvements have also been made to the availability of information sources, communication flows and file management. The concrete measures mentioned by the hospitals are: Report of radiological images available within 24 hours, introduction of an awareness program to critical discoveries within the medical staff and establishment of a point of contact on the topic of anticoagulation at the hospital. MProve hospitals aim to interview the patient or family for each survey to determine the facts and describe the events. Of the 64 calamities, the patient or his family was interviewed in 33 studies. For the remaining 31 studies, the patient or his family indicated that they did not want to participate in the survey or that there was no direct involvement.
mProve
The hospitals that make up the mProve group are: Schweitzer Hospital in Dordrecht, Isala in Zwolle, Jeroen Bosch Hospital in Den Bosch, Máxima Medical Center in Veldhoven and Rijnstate in Arnhem
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