1073 / Analysis of critical incidents in surgery

SPAIN
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Surgical / Invasive procedures
There is no specified text here There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
Objective: Implement a list of surgical safety check as a tool available to health professionals to improve safety in surgery and reduce preventable adverse events.

• Operate the right patient at the right place
• Identify and adequately addressing the risks associated with the airway.
• Identify and appropriately address the risks of blood loss and transfusion.
• Prevent inadvertent retention of instruments or gauze
• Communicate effectively and share information about the patient
• Establish surveillance and activity monitoring

Annual index
A. Percentage of implementation of a surgical check list on all surgical services
Description of the Patient Safety Practice
 
Methodology:

Forms collection on the systematic analysis of critical incidents, study, development of recommendations and action for improvement and monitoring and evaluation of these recommendations

Check tool:
It is modeled on the surgical check list items recommended by WHO and adapted to our hospital. (See surgical checklist in the attachment)

Execution:
-The check list is included in the electronic patient report

- Nurse makes the patient questions prior to anesthesia, in the REA (room prior to surgery) and then again re-examines with the anesthetic and surgical team at his arrival to the operating room.
Before the end of the surgery, the circulating nurse confirms with team intravenous and arterial ines, number of pathological anatomy laboratory samples, gauge gavage, gauge urinary catéter, diuresis, Drains with or without suctions, the right count gauze, compresses and puncture-proof materials, transfusión, implants and instrumental.

-Who fills: Circulating nurse and surgeons.

-The hospital reviews monthly completing the check list. if not filled out a notice is sent to the Chief of responsible service. Incidents are reported at the Patient Safety Group and hence the improvement areas are extrapolated to the entire hospital, through the heads of each area.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
SURGICAL CHECKLIST.pdf
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, partly
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
No
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
Qualitative
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
Not known
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
 
Physicians
Nurses
Health care assistants
Clinical manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Not relevant
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
Not known
List of sources where public information is accessible
There is no specified text here
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.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
No motivation among staff
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Yes
Description of used incentives, if any.
publish the results in a research way in a medical congress
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: MARIA MATEO
Country: SPAIN
Organisation: QUIRON UNIVERSITY HOSPITAL
E-mail: maria.mateo@quiron.es
Phone: There is no specified text here
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