1130 / Reduce Medical Errors: Therapeutical Single Data Sheet

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
Implementation of Patient Safety initiatives / Activities
Assessment of risk and harm There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
Medication errors are among the leading causes of injury and death in healthcare organizations in developed countries. Medication errors occur more frequently in the early stages of prescription and administration while nearly 50% of the errors is due to an error in communication during the take on responsibility of the patient. This aspect is also the cause of not less than 20% of the adverse events medications that occur in hospital. The responsibility of the therapy depends on professionals and organizational systems that ensure the correct dosing. Dosing is a medical practice that should be performed by one person only, in a very structured way (following a specific sequential and chronological procedure). However, there is a specific phase between prescription and administration that might increase the risk of errors: the transcription. To avoid this risk and reduce the incidence of errors, an organization can develop and adopt of a Therapeutical Single Data Sheet (SDS) for prescription, preparation and administration of medications. Specific suggestions in this regard can be found in the Recommendation . 7 of the Ministry of Health published in March 2008. The main objective of this practice is to reduce medication errors and to reduce the risks related to the prescription, preparation and administration of medications. The specific objectives pursued are: 1 – Implementation of the procedure for the correct use of the SDS 2 – Periodic monitoring of the implementation of the procedure 3 – Verification of the feasibility to adopt a standardized SUT model in all structures 4 – Evaluation of a possible integration of the SUT and the recognition/reconciliation registry in the same template 5 – Setting up of an electronic format for the SDS as part of a digital medical record.
Description of the Patient Safety Practice
 
CRO Aviano started a process towards the adoption of a Single Medical Data Sheet at institutional level. The features of the data sheet should be standardized in all operating units and for this reason it has been necessary to define the criteria and the procedures to be followed by the staff, in order to reduce individual variability and the possibility of errors in the management of the drug therapy. These steps are coherent with the current legislation, ministerial and literature recommendations. In this framework, the Medical Directorate has developed an operating instruction (namely: Criteria and methods for the compiling the Single Medical Data Sheet) in which "basic requirements" to ensure the efficiency of the therapeutic process through the Single medical Data Sheet are listed. Specific attention is given to drugs prescription and administration.
The selected indicators are: Presence of the Single Medical Data Sheet: No. of patient records with the Single Medical Data Sheet / number of folders checked in the semester. Completeness of the Single Medical Data Sheet: No. of folders with Single Medical Data Sheet correctly compiled / number of folders checked in the semester.
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
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
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
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
 
Physicians
Nurses
Health care assistants
Pharmacists
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=4613
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
Motivated staff
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: Raffaele Collazzo, Monica Masutti
Country: ITALY
Organisation: CENTRO RIFERIMENTO ONCOLOGICO
E-mail: mmasutti@cro.it
Phone: There is no specified text here
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