460 / Incident reporting system for adverse events occurred across transitions of care

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
Reporting and learning systems
Implementation of Patient Safety initiatives / Activities 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
 
Reporting systems of clinical safety incidents are the best way to provide information about what is happening in a health organization. Through such systems professionals make voluntary and anonymous notifications, about the circumstances in which an adverse event occurred in order to learn from each case.
Incident reporting is the beginning of a long chain of work passing through:
- analyze the causes and the contributing factors
- manage these risks
- propose and implement improvement measures
- establish the necessary feedback mechanisms to communicate results to the healthcare organization's professionals
- monitor results of the implemented improvements
The principal aim is to implement the use of a computer application for reporting incidents by professionals from both organizations(Primary Care and Hospital)and subsequently the issues affecting both sides of the health system are treated together.
Description of the Patient Safety Practice
 
1. Method:
1.1. Computer application development for incident reporting
1.2. Computer application operation piloting process by staff trained in patient safety, quality managers and technical support/technician
1.3. Review of the application's characteristics and installation of the proposed improvements
1.4. Assignment of responsibility (incident managers) according to the incidents' type

2. Implementation:
2.1. Delivery of clinical sessions on patient safety (taxonomy and general concepts)
2.2. Information and training in the use of the reporting system for all professionals
2.3. Permission for the use of the reporting system to all professionals

3. Evaluation. In our organization we have performed an annual assessment of the results ( this incident reporting system was implemented in 2012), taking into account the following items:
3.1. Total number of reported incidents
3.2. Percentage of reported incidents concerning patient safety and their classification according to the type
3.3. Percentage of incidents that have been answered (feedback information to professionals who have notified)
3.4. Recommendations issued by the Commission on Quality and Patient Safety
3.5. Improvements implemented in the primary care organization based in the management of security incidents

4. The incident reporting and learning system provides the following improvements:
4.1. Improves the degree of involvement of professionals, getting more involved in the detection and reporting of incidents
4.2. Improves knowledge of the health system (of the characteristics and peculiarities of health system's different parts)
4.3. Provides a very important information that facilitates joint approach to the issues that arise from the interaction between the two levels of care
4.4. Improves learning (lets learn from mistakes)
4.5. Helps to work to improve patient safety:
- Analyzing and managing incidents
- Proposing improvement measures to prevent or reduce incidents, or to mitigate the consequences of the incidents
TRAINING FOR INCIDENTS REPORTING SYSTEM:
GOAL: Implement a computer application for the reporting and management of patient safety incidents
ADDRESSED TO:
-Professionals working in quality teams both in Primary Care and Hospital Units, emergency services’ professionals and general services´ professionals.
-People who attend this training will be responsible for performing the training in their own Unit or Service.
SHEDULE: 3 hours
GROUPS TO ESTABLISH: maximum 9 professionals
PROGRAM:
oGeneral presentation of the computer application
oGeneral concepts: near-misses, incidents, adverse events
oAction protocol in a safety incident
oManagement software application:
oHow to report a new incident
oHow to consult (check the status of a previously reported incident)
oHow to manage and respond in the application for conveying information to professionals who have reported
oAnother level of care-related incidents

COSTS:
1.Cost for Primary Healthcare (20.770 €):
•Primary Care managements´ two preliminary meetings: 810 €
•Two meetings between personal of quality service both Primary Care and Hospital Care: 324 €
•Working time of clinical safety´s Commission professionals (two meetings to design strategy to implement computer system in Primary Care, 10 people): 2.700 €
•Course “Management of computer system for reporting incidents” to teach the application handle, in two phaseS, with a total cost in euro 780 € each (1.560 €), including:
o12 hours of teaching: four editions with a duration of three hours each, training a total of 50 people.
oThese participants were responsible for transmitting this training and information to other staff of the 17 Primary Care Units (a total of 700 people). This activity is free because it is included in the time spent on a regular basis to ongoing training.
•Cover costs of all the staff who attends the training course: 15.000 €
•Elaboration and dissemination of user manual for professionals to clarify doubts: 378 €

2.Cost for Hospital (49.100 € - see the breakdown of cost in the attached excel table) including:
•Creation of the specific software
•Implementation
•Staff training
•Maintenance
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
460_Detailed_Hospital_Costs.xlsx
460-2012 PS incidents.pptx
460_User manual.pdf
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
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
Not relevant
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
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.
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: Rosa María Anel Rodriguez
Country: SPAIN
Organisation: Osakidetza - Servicio Vasco de Salud, Basque Country
E-mail: rosamarianel@gmail.com
Phone: 696307326
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