499 / Implementing the trigger tool in an Neonatal Intensive Care Unit

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Other
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Topic of the reported practice
Incident reporting and learning system
Aim and the benefit of the Patient Safety Practice
 
Adverse events (AEs) and incidents are frequent, although underreported, in the Neonatal Intensive Care Unit (NICU), as well as in other area of critical care. Actually, detection of AEs has focused on voluntary reporting and tracking of errors. However, only a minority of errors are reported (10 to 20 percent). A more effective way to identify events that do cause harm to patients is needed, in order to identify area and items of changes to reduce harm.
Description of the Patient Safety Practice
 
Trigger tools are an easy and feasible method for accurately identifying AEs (harm from medications, tests and treatments) and measuring the rate of AEs over time. Deployment of NICU-focused trigger tools (developed and tested within the Vermont-Oxford Network) within the electronic medical record (EMR) has the potential to improve the rate of detection of events underlying AEs, thus getting more accurate estimates of AEs. Principal aims of the project are: development of a system aimed to enhance detection rate and managing of AEs; deployment of the system within the EMR; test and validation of the system within NICUs in an experimental setting; development of a system for managing AEs and corrective plans within the NICUs and the hospital system.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Unit or ward 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
Quantitative
Enclosure of a reference or attachment in case of published evaluation's results
There is no specified text here
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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
Yes
Specification of implementation in another health care setting(s)
Hospital
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities within the same setting
Involved health care staff
 
Physicians
Nurses
Clinical manager
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Relative(s)
Point of time in which service user or their reprasentatives' involvement takes place
During implementation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Yes
Short description of the service users' level of involvement
Consultation, such as asking for information
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/practicesdetail.aspx
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
Equipment was enhanced or new
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: 20
External consultants: 15
Support staff: 6
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: 0
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
11759,47
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Roberto Bellu
Country: ITALY
Organisation: A.O. OSPEDALE DI LECCO
E-mail: r.bellu@ospedale.lecco.it
Phone: 0341-489231
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