536 / Procedure for reporting adverse events and near misses in the AREU

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
Analysis of risk and harm
Identification 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
 
One of the main objectives of the Regional Agency for Emergency and Urgency (AREU) is that of implementing and making the emergency services homogeneous within the territory of Lombardia. In this field adverse events/errors may occur. They have to be collected and analyzed at the central level so as to identify the causes and suggest shared solutions applicable throughout the Region.
Description of the Patient Safety Practice
 
A procedure for reporting adverse events and near misses was developed and implemented within the 12 local departments of AREU. During 2012 some workshops were organized in order to make healthcare workers aware of the procedure. The procedure is divided into the following steps: - healthcare workers report to an ad hoc working group (made up by risk manager, quality manager and general affairs manager) the difficulties experienced during work, through methods defined and shared at the regional level; - the working group identifies possible corrective actions aimed to remove the causes of the difficulties and and possible preventive actions; - once these actions are shared upon, they are implemented in specific settings or- more frequently- at the regional level; - Twice/three times a year informal meetings are organized to discuss on the interventions carried out. Further information available at: http://buonepratiche.agenas.it/practicesdetail.aspx?id=3672
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
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
There is no specified text here
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Transport services (incl. ambulances)
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
Technical support / technician
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
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
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
Regular data feed back to involved staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Not relevant
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: 0
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: 0
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
3194.42
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Daniele Cafini
Country: ITALY
Organisation: Azienda Regionale Emergenza Urgenza A.R.E.U.
E-mail: rischio@areu.lombardia.it
Phone: 02 67129064
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