1038 / Incident reporting and root cause analysis

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Reporting and learning systems
Patient safety culture / Patient safety climate There is no specified text here
Topic of the reported practice
Incident reporting and learning system
Aim and the benefit of the Patient Safety Practice
 

The main aim of the practice is to get (by incident reporting) and analyze (by RCA) data about incident and near misses
The investigation of the "Incident Reporting dossiers" allows to become aware of problems, negative or adverse events, errors, near misses, risks and unsafe situations, which are experienced as negative by the health staff and which are considered as a strong limit to the quality of performance and the health services offered. In this scenario, the "Incident Reporting" method, through the "Root Causes analysis", represents a precious and unique source of information; in fact, is the correct way to establish if at the origin of the negative situations there are latent failures which can eventually be significantly ameliorated.
Description of the Patient Safety Practice
 
The PSP herein described is divided into the following steps: 1. Reception: the form for reporting events can be downloaded from the intranet system: the compilers can send the form via ordinary mail, fax or e-mail. Once received, the paper form is converted into computer recording. 2. Storage: from the paper form you can record several data, such as free text description of the event, date, time, type of event (as per patient fall, we are implementing an ad hoc reporting form). 3. Analysis: after reporting, each event is investigated by the Risk analyst, in the following ways: EVENT ANALYSIS: carried out for every event reported; SIGNIFICANT EVENT AUDIT: carried out according to the results of the previous one; ROOT CAUSE ANALYSIS: carried out when the results of the previous steps show that a direct comparison between the parties directly or indirectly involved.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
There is no specified text here
There is no specified text here
Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Yes
A baseline measurement before implementation of the reported practice was obtained
Yes
A measurement after full implementation of the reported practice was obtained
Yes
Evaluation of a "positive" effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Hospital
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
No
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation's level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
 
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
No
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
There is no specified text here
Point of time in which service user or their reprasentatives' involvement takes place
There is no specified text here
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
There is no specified text here
Short description of the service users' level of involvement
There is no specified text here
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/practicesedit.aspx?id=4447
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
No
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
No
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
There is no specified text here
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Other
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Yes
Costs of the Patient Safety Practices
 
Completion of cost calculation related to this Patient Safety Practice
No
Total number of person days required to implement this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: There is no specified text here
External consultants: There is no specified text here
Support staff: There is no specified text here
Managerial staff: There is no specified text here
Others: There is no specified text here
Not relevant: There is no specified text here
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here
Contact information
 
Name: Marzia Tomellini
Country: ITALY
Organisation: ISTITUTO NAZ. PER LA RICERCA SUL CANCRO
E-mail: marzia.tomellini@hsanmartino.it
Phone: There is no specified text here
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