140-729 / Reporting and learning system for patient safety: SiNASP (Sistema de Notificación y Aprendizaje para la Seguridad del Paciente)

Spain
GOP Information  
 
Organisation sharing the GOP
Related practices from PaSQ database
Cantabrian Health Service

Topic

Incident reporting and learning system
Quality management system
Category
Reporting and learning systems
Surveillance of Patient Safety
GOP Description
 
Implementation level
Regional
Local
Clinical settings
In Cantabria it has been implemented in all the Hospitals in the Cantabrian Health Service (3 hospitals in total).
Objectives
The objective of this learning and reporting system is to improve patient safety from the analysis of situations that caused or could have caused damage to patients.
The study of these problems is carried out in order to encourage the necessary changes so these problems do not happen again.
Population
All health professionals in our hospitals that identify an incident related to patient safety may report it.
Methods
 
Methodology
It is a voluntary reporting system and guarantees the confidentiality of the notifications. The notifiers have the option to remain anonymous or give their details, which are automatically removed from the system a few days later. It is not punitive, since the purpose is for improvement and implementation of corrective actions.
Management and notifications analysis is done locally (in each hospital) and not regionally. In each centre there is a SiNASP manager and a security group that is responsible for the analysis and management of notifications.
Timeframe implementation
About 3 or 4 months until the system is up and running
Implementation tools available
There is an Internet application where notifications are made and managed. We have designed a plan for professional training.
Implementation cost
We do not know the cost of implementing in Cantabria, as the necessary tools for the implementation of the GOP were provided by the Ministry of Health, without any cost to the region.
Results
 
Method used to measure the results
We have a set of indicators to monitor the use and operation of the reporting system
Results
From the date of implementation of SiNASP in Cantabria (May 2012), we have managed 144 reported incidents, and in more than 70, we have implemented improvements actions
Analysis of the results
Every three months each Hospital issues a report that lists the following information: number of reported incidents and incidents managed; classification of incidents taking into account different variables: the area where the incident occurred, the profession of the notifier, the type and risk of the incident, and contributing factors.
At regional level a report is produced with aggregated data and performs benchmarking with other regions that use the same reporting system (SiNASP)
Implementation barriers
 
Did you find implementation barriers?
Yes
Please describe implementation barriers
The main barrier is a lack of safety awareness which is a cultural problem. Another problem is the fear of legal consequences by professionals. Although it has been said that this is a voluntary reporting system and anonymous, and whose purpose is not punitive, but to improve.
Describe the strategies used to overcome the barriers (If needed)
Training and information for professionals.
Other information
 
Other information about the GOP that you would like to add (Link or attached document)
There is no specified text here
There is no specified text here
Contact information
 
Name: Lara Pino Domínguez
Position/function: Quality Manager
Department: Subdirection of Develovement and Care Quality
Organisation: Cantabrian Health Service
City: Santander
Country: Spain
Region: Cantabria
E-mail: lara.pino.dguez@gmail.com; lara.pino@scsalud.es
Phone: +34646684557
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