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HOSŤ MESIACA MUDr. Peter Bandura, PhD.


 | 12.3.2014 | komentárov: 323

Je nám potešením, že pozvanie portálu pravo-medicina.sk byť HOSŤOM MESIACA MAREC 2014 prijal MUDr. Peter Bandura, PhD., ktorý sa venuje problematike bezpečnosti pacientov, hlásení nežiaducich účinkov a poučení sa z nich. MUDr. Peter Bandura, PhD. zastupuje Ministerstvo zdravotníctva SR v Pracovnej skupine pre bezpečnosť pacientov a kvalitu zdravotnej starostlivosti(PSQWG) pri Európskej komisii v Bruseli a v podskupine pre systémy hlásení a poučení pri nežiaducich udalostiach. Aktuálne je leadrom projektu Bezpečnosti pacientov a kvality zdravotnej starostlivosti (PaSQ) Európskej komisie. Aj o tomto projekte sa viac dočítate v rozhovore.

Obrazok

MEDIUS: Pán doktor, môžete priblížiť čitateľom, čomu sa venujete, kde momentálne pôsobíte?

Venujem sa bezpečnosti pacientov a systému hlásení a poučení sa z nežiaducich udalostí pri poskytovaní zdravotnej starostlivosti. Pôsobím na Ministerstve zdravotníctva SR, ktoré zastupujem v Pracovnej skupine pre bezpečnosť pacientov a kvalitu zdravotnej starostlivosti(PSQWG) pri Európskej komisii v Bruseli a v podskupine pre systémy hlásení a poučení pri nežiaducich udalostiach. Zároveň zastupujem Ministerstvo zdravotníctva SR v medzinárodnom projekte PaSQ, ako národný kontaktný bod a vedúci pracovného balíka WP 7 projektu PaSQ,  kde Slovensko vedie skupinu zodpovednú za udržateľnosť siete vytvorenej počas projektu PaSQ. Okrem toho prednášam na Lekárskej fakulte UK v BA  v rámci špecializačného štúdia Manažment a financovanie zdravotníctva, kde po prvýkrát na Slovensku v zmysle Odporučení Rady Európy z r.2009 bol akreditovaný a zaradený do učebných osnov predmet Bezpečnosť pacientov a hlásenie nežiaducich udalostí.

MEDIUS: Na čom aktuálne pracujete?

Pracujem ako leader projektu Bezpečnosti pacientov a kvality zdravotnej starostlivosti (PaSQ) Európskej komisie s cieľom vytvorenia permanentnej siete Bezpečnosti pacientov a kvality zdravotnej starostlivosti, do ktorého je zapojených 27 členských krajín EÚ. Úlohou tohto projektu je umožniť členským štátom vzájomnú výmenu skúseností  a osvedčených postupov v oblasti bezpečnosti pacientov a kvality zdravotnej starostlivosti. Slovenská republika v rámci projektu, ktorý má 7 pracovných balíkov, je zodpovedná za Pracovný balík č. 7, ktorý ma za cieľ udržateľnosť permanentnej siete Bezpečnosti pacientov aj po skončení projektu. Ďalšou z úloh, na ktorých pracujem v rámci projektu Európskej komisie, je návrh vytvorenia Rýchleho výstražného systému hlásenia nežiaducich udalostí tzv. Rapid Alert System  medzi členskými štátmi EÚ.


MEDIUS: Aký je dnes postup pri ohlasovaní nežiaducich  udalostí pri poskytovaní zdravotnej starostlivosti?

V Slovenskej republike bolo vytvorených niekoľko systémov hlásení nežiaducich príhod, ktoré sú regulované príslušnými zákonmi, vyhláškami a metodickými usmerneniami s rôznym stupňom účinnosti a spätnej väzby. Neexistuje jednotný systém hlásení. Niektoré hlásenia sú povinné a niektoré dobrovoľné. Podľa oblasti výskytu  nežiaducej udalosti sú hlásené 3 rozličným inštitúciám.

Povinné hlásenia nežiaducich príhod pri podávaní krvi, krvných derivátov, liekov  zdravotníckych pomôcok. Inštitúcia, ktorej sa podávajú tieto hlásenia je Štátny ústav pre kontrolu liečiv (ŠUKL).  Zákon č.362/2011 Z.z.  o liekoch a zdravotníckych pomôckach, vyhláška  a metodické usmernenie Ministerstva zdravotníctva SR presne stanovuje, kto podáva hlásenie, čo hlási, kedy a akým spôsobom.

Sledovanie nozokomiálnych nákaz a povinnosť hlásenia infekcií spojených s hospitalizáciou Úradom verejného zdravotníctva je zakotvené v zákone č.355/2007 Z.Z.o ochrane, podpore a rozvoji verejného zdravia.  

Hlásenie nežiaducich udalostí pri poskytovaní zdravotnej starostlivosti upravuje Metodické usmernenie č.7/2006 ÚDZS o zavádzaní systémov hlásení v ústavnej zdravotnej starostlivosti v rámci stratégie bezpečnosti pacienta. Sú dva druhy hlásení:

1. dobrovoľné: zdravotnícki pracovníci sami evidujú, hlásia a analyzujú vlastné chyby a omyly počas poskytovania zdravotnej starostlivosti
2. povinné: zdravotnícki  pracovníci hlásia závažné nežiaduce udalosti, vzniknuté v súvislosti s poskytovanou zdravotnej starostlivosti – nečakané úmrtia, udalosti s následným trvalým postihnutím a iné závažné udalosti. Úradu podávajú aj hlásenia počtu sťažností a podnetov.

Poskytovatelia ústavnej zdravotnej starostlivosti zasielajú ÚDZS raz ročne k 31.januáru štatistické výsledky hlásení za predchádzajúci kalendárny rok.
Zatiaľ na Slovensku nemajú možnosť nahlásiť nežiaduce udalosti pacienti ani poskytovatelia ambulantnej zdravotnej starostlivosti.

MEDIUS: Sú tieto „čísla“ reprezentatívne?

V roku 2011 bolo zo všetkých ústavných zdravotníckych zariadení nahlásených RÚVZ spolu 5.557 nemocničných infekcií. Pri počte 1.118.068 hospitalizovaných pacientov to predstavuje výskyt 0,5%. Je to  ale len zlomok predpokladaného výskytu nemocničných infekcií. Pri tom zo 144 ústavných zdravotníckych zariadení až 45, čo je 31,25% hlásilo 0% výskyt, čiže žiadnu infekciu. Predpokladá sa, že skutočný výskyt infekcií je 5 až 8% hospitalizovaných pacientov.
V roku 2011 poslalo ÚDZS ročné povinné hlásenie zo 144 len 80 ústavných zdravotníckych zariadení, pričom 34% udáva 0% výskyt nežiaducich udalostí.  Odhaduje sa, že 8-12 % hospitalizovaných pacientov v členských štátoch EÚ počas poskytovania zdravotnej starostlivosti je vystavených nežiaducim udalostiam. Podľa štúdie výskytu nežiaducich udalostí, ktorú sme vykonali v roku 2011 podľa metodiky WHO, sme zistili 14 % výskyt nežiaducich udalostí u hospitalizovaných pacientov v skúmaných nemocniciach.

MEDIUS: Prečo sa  zdravotnícki pracovníci vyhýbajú odhaľovaniu chýb?

V našej spoločnosti je tendencia za každú cenu nájsť vinníka a potrestať ho, pričom väčšina nežiaducich udalostí je dôsledkom systémovej chyby. Zo strany zdravotníckych pracovníkov je to často obava z verejného odhalenia a potrestania, z diskriminácie a diskreditácie. Často je to  aj chýbajúca motivácia. Hlásenie a s tým spojenú administratívnu prácu pokladajú často za zbytočnú, keďže veľmi často chýba analýza, spätná väzba a poučenie sa. Veľmi často majú pocit osobného zlyhania a prevláda u nich pocit , že priznanie sa k chybe zvyšuje riziko sťažnosti a žalôb.

MEDIUS: Ako by mal byť, podľa Vášho názoru, nastavený systém ohlasovania nežiaducich udalostí? Čo by mal sledovať?

Prvotným cieľom systémov hlásenia nežiaducich udalostí je poučiť sa zo skúseností. Samotné hlásenie nevedie k zlepšeniu bezpečnosti. Je to schopnosť reagovať na hlásenia, ktorá vedie k zmene. Systém hlásenia musí vytvárať viditeľnú, užitočnú odpoveď hlásiteľom udalostí, aby dokázal oprávnenosť nákladov, ktoré si vyžaduje systém hlásenia a zároveň, aby stimuloval poskytovateľov aktívne hlásiť nežiaduce udalosti.
Hlásenie má byť bezpečné pre tých, ktorí hlásia a má viesť ku konštruktívnej odpovedi. Systém hlásenia musí byť schopný rozširovať informácie o rizikách a odporučeniach pre vykonanie potrebných zmien. Pre úspešné fungovanie  by mal byť systém nerepresívny, nezávislý, dobrovoľný, dôveryhodný a včasný. Hlásia sa udalosti, pri ktorých došlo k poškodeniu pacienta v súvislosti s diagnostikou a liečbou a nie následkom samotného ochorenia.

MEDIUS: Aký zmysel má odhaľovanie nežiaducich udalostí pre poskytovanie zdravotnej starostlivosti?

Hlavný zmysel zisťovania nežiaducich udalostí je zistiť ich výskyt, následne urobiť dôkladný analýzu ich hlavných príčin a prispievajúcich podmienok ich vzniku, následne na základe výsledkov analýzy realizovať úpravu chýb v systéme poskytovania zdravotnej starostlivosti a prechádzať výskytu podobných chýb a poučiť ostatných poskytovateľov  sa z chýb iných. Výskumy OECD ukazujú, že 50% nežiaducich udalostí sa dá predísť. V štúdii, ktorú sme realizovali podľa metodiky WHO v 5 nemocniciach v roku 2011,  sme zistili až 72% nežiaducich udalostí, ktorým sa dalo predísť.

MEDIUS: Na našej poslednej konferencii Aké princípy vládnu zdravotníctvu sa skloňoval pojem tzv. neobviňujúcej kultúry. Viete prosím vysvetliť, o čo ide?

Neobviňujúca kultúra bezpečnosti pacienta je vytvorenie takého prostredia v zdravotníckom zariadení, v ktorom správanie sa jednotlivca a kolektívu je založené na neustálom úsilí minimalizovať poškodenie pacienta, ku ktorému by mohlo prísť v súvislosti s poskytovaním zdravotnej starostlivosti. V takomto prostredí sú zdravotnícki pracovníci otvorení a poctiví vo vzťahu k nahlasovaniu chýb , omylov a nežiaducich udalostí, ktorých sú sami účastní a poučia sa z nich.

MEDIUS: Aké sú jej základné princípy?

Základný princíp neobviňujúcej kultúry je systémové hľadisko, to znamená, hľadanie príčiny nežiaducej udalosti, na rozdiel od individuálneho hľadiska, kde sa hľadá vinník. Väčšina problémov nie je len sériou náhodných, nesúvisiacich  jednorazových  udalostí.
Chyby pri poskytovaní zdravotnej starostlivosti sú spôsobené slabými systémami a  často majú spoločné príčiny, ktoré možno zovšeobecniť a napraviť. Hoci  každá udalosť je jedinečná, je pravdepodobné, že mnohé majú podobné príčiny, ktoré by inak mohli zostať nepovšimnuté, pokiaľ  by udalosti neboli hlásené a analyzované. Hlásenie je základom pre zistenie problémov bezpečnosti pacientov. Následná analýza, poučenie a prevencia vzniku nežiaducich udalostí sú základom  neobviňujúcej kultúry.

MEDIUS: Aké zmeny  (systémové, ale aj iné) by si vyžadovala implementácia neobviňujúcej kultúry?

Je to dlhodobý proces, ktorý si vyžaduje zmeny v postojoch verejnosti, zdravotníckych pracovníkov a pacientov. Bude si vyžadovať zaviesť problematiku bezpečnosti pacientov do učebných osnov pregraduálneho a postgraduálneho vzdelávania zdravotníckych pracovníkov. Významnú úlohu v tomto procese môžu zohrať média, ktoré by mali skôr poukazovať na systémové riešenia problémov ako škandalizovanie a kriminalizovanie jednotlivcov. Kľúčovým pilierom tohto procesu však je vytvoriť také legislatívne prostredie, aby zdravotnícki pracovníci mohli hlásiť nežiaduce udalostí bez rizika následného postihu. Pre správne fungovanie systému hlásení a poučení je dôležité dosiahnuť v spoločnosti neobviňujúcu kultúru- no blame, no name, no shame  tj. nehľadať vinníka, nemenovať a nezahanbovať. Zdravotnícki pracovníci, ktorí hlásia nežiaduce udalosti musia mať pocit, že im za hlásenie neúmyselnej chyby nehrozí trest alebo sankcia a že údaje, ktoré dobrovoľne nahlásia nebudú použité proti nim, ale cieľom hlásenia je analýza, spätná väzba a poučenie ostatných zdravotníckych pracovníkov.

MEDIUS: Čo je podľa Vás osobne fundamentom vzťahu lekára a pacienta?

Základom vzťahu lekára a pacienta je vzájomná dôvera, informovanosť a zapojenie pacienta do diagnostického a liečebného procesu, otvorenosť pri vzniku komplikácie a ospravedlnenie pri výskyte nežiaducej udalosti.

MEDIUS: Čomu sa budete venovať v príspevkoch hosťa mesiaca?

V prvom príspevku oboznámim čitateľov s prebiehajúcim projektom Európskej komisie Bezpečnosť pacientov a kvalita zdravotnej starostlivosti( PaSQ) o  snahe o vytvoriť permanentnú sieť Bezpečnosti pacientov a kvality zdravotnej starostlivosti v rámci krajín EÚ. V druhom príspevku by som sa chcel venovať výsledkom a odporučeniam Pracovnej skupiny pre bezpečnosť pacientov a kvalitu zdravotnej starostlivosti (PSQWG) pri Európskej komisii v oblasti úspešného zavedenia systému hlásení a poučení z nežiaducich udalostí a vytvoreniu systému rýchleho hlásenia a reakcie na závažné nežiaduce udalosti medzi členskými štátmi EÚ.

Ďakujem za rozhovor.


Spracovala: Zuzana ZOLÁKOVÁ



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