490 / Voluntary incident reporting in hospital setting

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
Reporting and learning systems
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
 
Adverse events are unanticipated events occurring during the care-delivery process, which can cause unintentional and undesirable damage to the patient. Reporting systems for such events are fundamental tools to gain greater knowledge about the causes and contributing factors and, according to the “learning from error” principle, they allow to prepare preventive strategies and patient safety improvement actions.
It is important to point out that errors in clinical practice can be limited but never completely eliminated; therefore, the highest number of errors will be reported not by who makes the most mistakes but by who is most sensitive to this issue.
Description of the Patient Safety Practice
 
Incident reporting system is a fundamental tool to gain more profound knowledge about causes and contributing factors and it allows to implement appropriate strategies and patient safety improvement actions; by reporting adverse events, healthcare-related risks for patients can be identified and analyzed. Incident reporting is a voluntary reporting system based on an organized collection of data; preventable adverse events are reported on specific forms.
The are different forms available:
- Inpatient or outpatient fall reporting form
- Medication error reporting form
- Voluntary adverse event reporting form
- Sentinel event reporting form
These forms are sent to the Clinical Risk Management Unit where any event is analyzed and managed according to a risk index assigned by the risk management group. In agreement with this index one of the follow methods is applied to manage the event: Safety Walkround – SWR, Healt Care Failure Mode and Effect Criticality Analysis – HFMECA, Root Cause Analysis – RCA, Significative Event Audit - SEA. All the events are entered in a database for periodic reports to all the care units.
Attachment of relevant written information and/or photos, as appropriate
102_WP4_Some data from the incident reporting system.pdf
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
Regional or national 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
Incident reporting: 2009 results in a teaching hospital. EUPHA Conference. Amsterdam 2010
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
Pharmacists
Technical support / technician
Clinical manager
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
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/practices.aspx
Implementation of the Patient Safety Practice
 
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Yes
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
Sharing of progress information among involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Not known
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: Castriotta Luigi
Country: ITALY
Organisation: Azienda Ospedaliero-Universitaria "S. Maria della Misericordia" di Udine
E-mail: castriotta.luigi@aoud.sanita.fvg.it
Phone: 00390432559959
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