Aiming for improved patient safety – the Wellbeing Services County of Northern Savonia invests in cooperation between operators

The Wellbeing Services County of Northern Savonia carries out continuous, multidisciplinary work to improve patient safety. Medanets, the supplier of the mobile solution for nursing used in the wellbeing services county, is involved in the development. 

Patient safety and, in particular, medication safety have received global attention in recent years. Among other things, medication safety was highlighted as the topic of the WHO Global Patient Safety Challenge in 2017–2022¹. It is also part of Finland’s  national Client and Patient Safety Strategy and Implementation Plan 2022–2026². Because of this, medication safety is also the primary strategic goal of the Wellbeing Services County of Northern Savonia and the Kuopio University Hospital. ‘We conduct safety observations every day as part of our usual duties. Reporting an adverse event is also the responsibility of each of our employees,’ says Patient Safety Manager Kaisa Haatainen from the Wellbeing Services County of Northern Savonia. 

I am grateful for each adverse event report. It is extremely important that employees keep making them.

Kaisa Haatainen, Patient Safety Manager, Wellbeing Services County of Northern Savonia 

Reports on adverse events result in closer inspection of the medication process 

The routines of unit supervisors include monitoring adverse event reports.  In 2022, some reports mentioned Medanets. Product Group Manager Päivi Kokkonen from information management of the Wellbeing Services County of Northern Savonia informed Medanets of these reports and they were taken into consideration in product development when designing features to improve patient safety. At the turn of the year, a device management specialist from the information management contacted Patient Safety Manager Haatainen about the overall situation of the adverse events reports related to Medanets.   

The search term ‘Medanets’ yielded several dozens of reports in the report system. Haatainen launched a root cause analysis on the reports as a cooperation between various operators where the reports were depicted as a phenomenon. They were expressly related to the medication process and indirectly to the Medication solution in the Medanets app, which is a tool used in the medication administration process. Representatives from the pharmacy, device management services and information management of the wellbeing services county, Medanets and Istekki, a technology expert service provider of the wellbeing services county, participated in the root cause analysis. Representatives of end users were also involved in the analysis.  

Phenomenon studied from various perspectives by a multidisciplinary team 

Both Haatainen and Kokkonen are extremely pleased with the cooperation of the taskforce. The large, multidisciplinary team studied the phenomenon from various perspectives, improving the scope and quality of the work. ‘The cooperation between different operators was extraordinary. We had a genuine, shared interest and desire to improve patient safety. The representatives of the parties were truly committed to the cooperation,’ says Haatainen. Kokkonen agrees. ‘The cooperation has been fruitful and enriching.’

Medanets app was not the cause of the adverse events 

Upon more detailed inspection, the Medication solution of the Medanets app was indirectly related to the adverse event in about 50% of the reports found with the search term ‘Medanets’.  None of the adverse events were caused by the Medanets app; instead, they were caused by its incorrect use or a failure to use the app. In several reports, the adverse event could have been avoided by using the Medanets app. The other reports involved problems occurring in the medication process that were not related to the Medanets app. Medanets had simply been mentioned in the description of the event as the app had been used in the medication process.  Therefore, the root cause analysis resulted in changes to both the medication process of the wellbeing services county and the Medanets app. The changes were communicated in the Intranet of the wellbeing services country and the measures will be implemented by the end of 2023. 

The root cause analysis reveals the true nature of the phenomenon. Safety-related shortcomings in the medication process proved to be the reason for the adverse event reports. However, elements can be added to the Medanets app to further notify the user of potential risks and help minimise the chance of mistakes.

Päivi Kokkonen, Product Group Manager, Information Management, Wellbeing Services County of Northern Savonia 

The precedence of the electronic authentication of the patient will be a significant process change increasing patient safety. Changes were also made in the Medanets app to support the change in the process. If the patient is selected from the unit’s list of patients, the app displays an authentication window. The user must select ‘I understand’ before the process can continue. The change to the process is still pending for final approval from the management of the wellbeing services county. 

Medanets also benefits from the development  

As a manufacturer of a medical device, Medanets is obligated under the EU’s Medical Device Regulation to monitor the product after introducing it to the market. The development with the Wellbeing Services County of Northern Savonia and other operators offers us valuable information on how we can use our product to further improve patient safety. ‘Even if the product does not have any flaws or errors, patient safety can be improved by increasing its usability or by ensuring that the user acts in the safest way possible. That is why the information we receive from the users is particularly important,’ says Tiina Kotipalo, Head of Quality and Development at Medanets.  

The changes made to the Medication solution have also been presented to other customers, collecting more extensive feedback on further development needs in order to increase the safety of medication processes.

Sources: 

1. WHO (2023): Medication without harm. Accessed 17 May 2023.  

2. Ministry of Social Affairs and Health (2022): The Client and Patient Safety Strategy and Implementation Plan 2022–2026.  Accessed 17 May 2023. 

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