522 / Risks map and analysis of patient safety in a hospital

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
Identification of risk and harm
Assessment 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
 
Conducting a situation analysis of patient safety in our hospital, using validated methodology
Description of the Patient Safety Practice
 
In 2010 became the Hospital Clinico Universitario de Valladolid (HCUV) the Commission for Patient Safety, with the mission to take the steps necessary to identify health risks in patients treated at the HCUV for evaluation and to propose measures to avoid or reduce risks identified and prioritized.
Therefore within the objectives of the Commission in 2011, was raised a study of the security situation in our patient, using validated methodology.

STEP 1.
Self-evaluation of security level of care that patients have in HCUV, using the "Self-Assessment Tool" given by the MSPS in Seneca Project, consisting of 100 items. "Quality Standards of care for patient safety in NHS hospitals. Seneca Project ": technical report 2008. Madrid: Ministry of Health and Social Policy, 2009” In its application were obtained strengths and areas for improvement in patient safety.

STEP 2.
Obtaining improvement areas after assessing the patient safety recommendations contained in the documents:
• "Safe Practices for Better Healthcare-2010 Update: A Consensus Report". National Quality Forum. (34 items)
• "30 projects and a framework for advancing quality in the public health system of Castilla y León. Strategies for improving orientation ". Ministry of Health of the Government of Castile and Leon (27 items)
• Inclusion of areas for improvement suggested by the members of the Commission.

STEP 3
Prioritization of the areas for improvement identified in patient safety, using as criteria both the recommendations of the reference documents used as the document "30 projects" of the Ministry of Health.

STEP 4.
Each commissioner individually perform a prioritization of 10 measures.
From his sharing, priority areas for improvement in patient safety in our hospital were proposed to the management team
Attachment of relevant written information and/or photos, as appropriate
582_WP4_analysis.zip
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
Institution level
Specific and measurable outcome for the reported practice were defined
No
A baseline measurement before implementation of the reported practice was obtained
No
A measurement after full implementation of the reported practice was obtained
No
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
 
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
Nurses
Pharmacists
Quality 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.
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
Specially trained 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
Not relevant
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: Luis Angel Sánchez
Country: SPAIN
Organisation: Hospital Clínico Universitario de Valladolid, Castile and León
E-mail: lsanchezmunoz@gmail.com
Phone: There is no specified text here
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