1039 / Standardized assessment of medical records with particular attention to operating theatres records.

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Documentation
Other There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
Usually medical records are not seen by healthcare workers as a legal document and a tool containing information useful for all the poeple participating and contributing to the process of care. This can affect the reconstruction of the pathway of care to achieve safety of patients. The experience aims at monitoring proper filling of medical records by the Operative Units.
Description of the Patient Safety Practice
 
The experience requires assessment to be carried out by a team of evaluators (people who attended the auditor course). To carry out the evaluation, we use the "form for medical records"based upon JCI criteria and UNI EN ISO 9001:2008, based on 3 criteria: 1. Legilibity; 2. Accuracy (relevant data should be included); 3. Traceability (of both the author and date of the record). The results of the evaluations are disseminated during the meetings of the Clinical Risk Unit. The evaluation took place during the Annual Internal Audits; the evaluation team analyze 4 inpatient records referred both to surgical and medical admissions. The results of the analysis are expressed by different outputs: • percentage of lack of 'items • simple averages of the results for each item in relation to each of the dimensions considered (clarity, accuracy, traceability); • comparison of two different types of "average" ( for each parameter considered (clarity, accuracy, traceability); The first is a "simple average", which expresses the average result for each of the three dimensions (clarity, accuracy, traceability) with the same weight; the second is a "weighted average", which expresses the average result for each of the three dimensions (clarity, accuracy, traceability) considering the different "weights" assigned to the items in relation to the commitment that the operators had to apply for the correct compilation . The Quality Department represent graphically the results in order to also assess the trend at hospital level of completeness in the medical documentation. Over the years a general improvement in compilation of all documentation (in particular by the nursing staffI has been assessed. Data about readability, accuracy, traceability are so positive (average scores between good and excellent) to induce to thinking over introducing the evaluation procedure also at different times than the annual audit.
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
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Unit or ward 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
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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
 
Quality manager
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=4440
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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