1221 / Look alike/Sound alike - Safe medication

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
Implementation of Patient Safety initiatives / Activities
Identification of risk and harm There is no specified text here
Topic of the reported practice
Quality improvement project
Aim and the benefit of the Patient Safety Practice
 
Errors in medication therapy that most frequently occur are related to the use of LASA (Look-Alike/Sound-Alike) medicines. Several factors can contribute to the exchange, including lack of knowledge regarding the use and management of these medicines.
To improve the quality of health service processes, the Pharmacy Service and the Clinical Governance, Risk Management Structure at the University Hospital of Parma have created the informative tool "How to do for…preventing errors in therapy related to LASA medication use", dedicated to all the professionals involved in the medication therapy process.
Description of the Patient Safety Practice
 
"How to do for" is a tool that has been already adopted at the University Hospital of Parma to train healthcare staff about clinical risk management issues in an easy and quick fashion. The "How To do for... preventing errors in therapy related to LASA medication use" describes what LASA drugs are and the actions to be taken in each phase of medication management (supply, storage, prescription, preparation / distribution / administration to the patient) to avoid mixups. The document contains in brief concepts, examples and drawings that facilitate the text understanding. It can be put on ward's notice board and is available for all professionals on the Intranet site. In 2014, 4 training events have been organized with the aim of raising awareness about medication safety among health professionals, with a focus on the use of LASA drugs. The “How to do for” tool has been presented during the training events. Along with the "How to do for" tool, an Alert label has been developed and distributed to be put on the packaging of LASA medication in the medicine cabinets and administration carts. A reporting pathway has also been defined in order to allow healthcare workers to point out the presence of LASA medicines into the ward. An ad-hoc reporting form has been prepared to be sent directly to the Pharmacy Service or electronically through a dedicated internal mailbox. The high participation at the training events and the “How to do for” tool have contributed to raise awareness of healthcare staff about the risks related to the use of LASA drugs. As a result, more reports have been received by the Pharmacy Service. These reports have been collected into a database, allowing to develop the first list of LASA medication of our hospital, that will be periodically updated and disseminated, according to the 12th Recommendation of the Italian Ministry of Health. The increase in knowledge about the issues related to the use of LASA medication has been measured looking at percentage of participants at each training session on the total of available places and through case analysis of the groups’ learning tests. The increased awareness about medication safety has been measured looking at the number of reports received by the Pharmacy Service. Some results A) 100% participation (50 participants / 50 available per edition) in the first three training courses held on "Risk Management: Ministerial Recommendations. Safety in Pharmacological Therapy ". B) The results of learning tests, carried out within the training courses through work in small groups on the analysis of cases, demonstrate learning by the participants of the contents and their possible application in their professional context. (2) Following the implementation of the guide "How to: prevention of errors in treatment related to the use of LASA drugs", the first reports of LASA drugs were performed (number 11 reports in 4 months).
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
 
Physicians
Nurses
Health care assistants
Pharmacists
Administrative support (secretary, clerk, receptionist etc.)
Dentist
Other member of the dental team (dental assistant, dental hygienist, dental technician, dental therapist etc.) or dental technicians
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient representative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the implementation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
No
Short description of the service users' level of involvement
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
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=4819
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
Specially trained 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: Alessandra Zanardi; Giovanna Campaniello
Country: ITALY
Organisation: AZIENDA OSPEDALIERA DI PARMA
E-mail: azanardi@ao.pr.it
Phone: There is no specified text here
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