335 / Incident reporting system and management of incidents.

SPAIN
Classification of the PSP
Type of Patient Safety Practice Not Proven Effective
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Identification of risk and harm
Reporting and learning systems There is no specified text here
Topic of the reported practice
Incident reporting and learning system
Aim and the benefit of the Patient Safety Practice
 
The objective of this project was to evaluate the results obtained, after the implementation of a new AERS in the Vall d’Hebron University Hospital and the constitution of a patient safety unit PSU).
Description of the Patient Safety Practice
 
Materials and methods: The rate of incidents notified for each 1000 days of stay in 2010 versus 2011 were compared by Fisher’s exact test. Three types of analysis depending on severity or feasibility of improvement proposals were used: Full root cause analysis (FRCA), simple root cause analysis (SRCA) or follow-up. The actions developed were classified into five types: implemented changes, formative action, group work, elaboration or revision of a procedure or protocol and transfer to responsible managers.

Results: In 2011 , the rate of incidents reported increased significantly from 1.5 to 1.7%. Nurse were the major contributors to the AERS, although physicians reported the events with greater severity criteria. Ten of the 93 incidents related to patient safety were analyzed with a FRCA by PSU and66 cases with SRCA. Derived from analysis 98 improvement actions were implemented.
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
Effect not known or the intervention has not yet been evaluated
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results

Background and objective: The Adverse-event-reporting systems (AERS) are excellent sources of knowledge to propose measures for improvement. The objective of this study was to evaluate the results obtained during 2011, after the implementation of a new AERS in the Vall d’Hebron University Hospital and the constitution of a patient safety unit (PSU).

Materials and methods: The rate of incidents notified for each 1000 days of stay in 2010 versus 2011 were compared by Fisher’s exact test. Three types of analysis depending on severity or feasibility of improvement proposals were used: Full root cause analysis (FRCA), simple root cause analysis (SRCA) or follow-up. The actions developed were classified into five types: implemented changes, formative action, group work, elaboration or revision of a procedure or protocol and transfer to responsible managers.

Results: In 2011 , the rate of incidents reported increased significantly from 1.5 to 1.7%. Nurse were the major contributors to the AERS, although physicians reported the events with greater severity criteria. Ten of the 93 incidents related to patient safety were analyzed with a FRCA by PSU and66 cases with SRCA. Derived from analysis 98 improvement actions were implemented.

Conclusions: Implementation of (AERS) and (PSU) has allowed the identification of improvement opportunities in our organization, and has been an impulse for progress in the culture of patient safety

250_WP4_sistema de notificacion.pdf
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
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
No
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
Not sufficient financial resources available
Not sufficient human resources available
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
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: Roser Angles
Country: SPAIN
Organisation: Hospital Universitari Vall d'Hebron, Catalonia
E-mail: rangles@vhebron.net
Phone: 34-93-2746036
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