1119 / The risk matrix as a governance tool

ITALY
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Assessment of risk and harm
Identification of risk and harm There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
Hospitals are complex organizations and a complete risk analysis may be difficult to implement without a tool that considers consequence and likelihood scores. Nevertheless a correct risk analysis is necessary to identify the high priority areas for allocation of resources. Usually hospitals collect lots of data but this information may be fragmentary or not correctly reported. These data must be aggregated to identify the most dangerous areas which need priority interventions.
The objective of this practice is to carry out an objective analysis of risks in a complex organization defining areas of intervention and how to allocate resources.
Description of the Patient Safety Practice
 
The project herein described has begun in the early 2014 and the steps carried out are: literature analysis and definition of the model to be used; definition of an internal procedure for clinical risk management.
Data from about 300 indicators were aggregated into 7 macro areas and analyzed with a matrix model adapted from NPSA of NHS (a risk matrix for risk managers). The first implementation has demonstrated the areas in which the risk is acceptable and the ones in which the risk is very high.
A report with risk indication was sent to the hospital management as a tool to address a correct resource allocation.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
Risk matrix_attachment.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, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
No
A baseline measurement before implementation of the reported practice was obtained
No
A measurement after full implementation of the reported practice was obtained
No
Evaluation of a "positive" effect of the reported practice on Patient Safety
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
There is no specified text here
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
 
Physicians
Nurses
Pharmacists
Clinical support
Technical support / technician
Administrative support (secretary, clerk, receptionist etc.)
Environmental support (Housekeeping)
Clinical manager
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/questionnaire.aspx?id=4654
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
Strong knowledge in implementation
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
No
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: Alfredo Perulli, Daniela Monteverdi, Alessio Rebelli
Country: ITALY
Organisation: AOU OSPEDALI RIUNITI DI TRIESTE
E-mail: daniela.monteverdi@aots.sanita.fvg.it
Phone: +39 0403994289
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