Table 1 Content and data collection of the five patient safety themes to evaluate implementation of the Safety Program

Theme 1. Wrong surgery

Reducing the amount of wrong patient, wrong site, wrong procedure events. The aim is 0 events.

Time-out verification before surgery during which the total OR team is present and checks patient name, procedure to be performed and where to perform procedure (site and side).

Observational research with 6–10 observations of operations during 10 measurements in 18 hospitals.

Percentage of operations in which all 3 steps of the Time Out Procedure were performed correctly.

Theme 2. Contrast- induced nephropathy

Prevention of contrast-induced nephropathy by identifying all high-risk patients and taking suitable preventive measures

1. Identifying high risk patients (eGFR and medication review)

2. General prevention measures

3. Specific prevention measures

Patient record review with 20–25 randomly selected records during 10 measurements in 19 hospitals.

Percentage of high-risk patients who were hydrated before undergoing contrast administration.

Theme 3. Early recognition and treatment of pain

Reduce avoidable suffering by early recognition and treatment of pain.

1. three times a day: a standardized pain measurement

2. Register the pain scores

3. Take action at a pain score of 4 and higher

Patient record review with 20–25 randomly selected records during 10 measurements in 19 hospitals.

Percentage of postoperative patients who were in pain was measured in a standardized way three times a day in the first three days after surgery

Theme 4. Medication reconciliation

Medication reconciliation on admission and discharge.

Bundle 1. Medication reconciliation on admission

1. Obtain the primary medication history from the central pharmacy

2. Interview by a trained practitioner.

3. Develop a current and accurate medication review

Bundle 2. Medication reconciliation at discharge

1. Develop a current and accurate medication review

2. Make an overview of discharge description authorized by the main specialist

3. At discharge review with the patient and/or responsible family member previous medication lists alongside the list of medication prescribed at discharge and reconcile the differences.

4. Communicate changes to a patients’ medication regimen to the pharmacist, general practitioner en other caregivers.

Patient record review with 20–25 randomly selected records during 10 measurements in 19 hospitals.

Percentage of patients for whom the bundle of medication reconciliation on admission and discharge had been implemented completely.

Theme 5. High-risk medication

Implementing the described process for preparing and administering parenteral medication

1. Process of preparing parenteral medication in non-acute situations

2. Process of administration of parenteral medication in non-acute situations (only this one was focus of the evaluation)

3. Process of preparing and administration in acute situations

Observational research with 20–25 observations of administration processes of parenteral medication at the intensive care unit, internal medicine and general surgery departments within during 10 measurements in 19 hospitals

Percentage of administration processes in which all recommended steps have been followed by the person administering the drug