422 / A tool for a proactive barrier analysis

SPAIN
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
Analysis of risk and harm
Assessment 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
 
The aim of this tool is to make an approach to the weaknesses in the defensive barriers established in the system. Those barriers are in place to develop safe practice. We will identify the holes in the barriers with a system failure approach and propose solutions to prevent harm to the patient (we will strengthen the barriers so that the harm trajectory does not reach the patient). This methodology aims to be a useful and simple tool for proactive analysis of our everyday practice.
Description of the Patient Safety Practice
 
It is a proactive barrier analysis tool to take actions to prevent risk and strengthen the system and it is based in the Reason's Swiss cheese theory (see the picture in the attached document)
First of all, the barrier (technological, human or administrative barrier) must be selected. When the barriers are broken there is a hazardous situation that could harm the patient. The basic criteria for risk assessment and make the selection could be frecuency and severity of the risk.
It is a qualitative methodology (as The London Protocol , reactive barrier analysis, etc) and it's carried out by a multidisciplinary team.
The methodology is showed in the attached document.

Attachment of relevant written information and/or photos, as appropriate
517_WP4_Proactive defensive barrier analysis tool_System analysis.doc
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, partly
Level of implementation of reported practice
Unit or ward level
Specific and measurable outcome for the reported practice were defined
Not relevant
A baseline measurement before implementation of the reported practice was obtained
Not relevant
A measurement after full implementation of the reported practice was obtained
Not relevant
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
 
Primary care
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
Nurses
Pharmacists
Administrative support (secretary, clerk, receptionist etc.)
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
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
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
Yes
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 6
External consultants: 0
Support staff: 0
Managerial staff: 2
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 6
External consultants: 0
Support staff: 0
Managerial staff: 2
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
0
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Kristina Lekube Angulo
Country: SPAIN
Organisation: Osakidetza - Servicio Vasco de Salud, Basque Country
E-mail: cristina.lecubeangulo@osakidetza.net
Phone: 605740218
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