584 / Tools for reporting, evaluating and improving sentinel adverse events

SPAIN
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
Implementation of Patient Safety initiatives / Activities There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
Hospital Foundation Calahorra (La Rioja, Spain), is committed to continuous improvement, excellence in the management and safety of the patients it serves.
On many occasions the hospiitals are a "hostile" environment to their patients and can cause damage with varying severity, but most preventable.
When the damage it causes serious consequences, even death, the perspective of quality and safety is completely eclipsed, being essential that such events can be detected and prevented
To analyze the Adverse Event arises the proposal to create a team of experts multidisiciplinar, which we will call “ Managing Team of Sentinel Adverse Event Surveillance” , with the following aims:
• General aim: Ensuring safe care, and excellent and of quality to the users of HFC , looking for the incident "zero" of the sentinel adverse events.
• Specifics Aims: 1) To spread inside the organization a non-punitive culture of adverse events declaration ; 2) To identify systemic and latent factors that contribute or facilitate the mistake; 3) To analyze WHAT, HOW and WHY it happened, in search of the root cause ; 4) To orientate the results obtained to the improvement of the processes that integrate our organization , 5) To report and to spread the conclusions obtained
Description of the Patient Safety Practice
 
For the working methodology takes into account the continuous improvement tool DMAIC (Six Sigma): Define, Measure, Analyze, Implement and Control, which helps us to manage every Sentinel Adverse Event (SAE) reported.

1. Sentinel Adverse Event Definition, according the Joint Commission on the Accreditation of Healthcare Organizations: “A sentinel event is an unexpected death or serious injury, or the risk of these types of death or injury. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. The terms “centinela event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events
Accepting this definition, our hospital has adapted and defined adverse events to its own complexity. Attached in Appendix I are adapted from those collected by the Joint Commission itself, the Agency for Healthcare Research and Quality (AHRQ) and our NHS.

2. Measure: The management team drives a culture of safety in the hospital, to promote nonpunitive and confidential statement of error (characteristics of successful reporting system: nonpunitive, confidential, independet, expert analysis, timely, system oriented). We have created a simplified form for the statement (Appendix II), and scored an objective indicator integrated in the dashboard

3. Analyze: Each time you declare a case, the management team meets and conducts an initial assessment, after which it is decided whether there is a need for analysis with others involved with the event reported, and that may be helpful in analysis.
For reactive analysis Root Cause Analysis tool is used, and some of the associated tools that the Ministry of Health proposes and advises (for example: Decission Tree; Chronology narrative; Timeline, Table person time; Technical Group Nominal; Fishbone; Pareto diagram; reactive barrier analysis; control charts)
The analysis data are collected in a table (Appendix III)


4. Implement improvement actions: After making root cause analysis, it is essential to have the ability to use the causes identified as opportunities for improvement, making each one become operational objective improvement action, as set out in the table (Appendix III)

5. Control: In this phase, that far from being the last, is involved in each of the above, will be evaluated improvement actions implemented and decreased other similar SEA.
Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
There is no specified text here
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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
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
NON
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
Health care assistants
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
Patient(s)
Point of time in which service user or their reprasentatives' involvement takes place
During implementation of the Patient Safety Practices
During evaluation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
No
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
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
Yes
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Lack of knowledge on implementation strategies
No motivation among staff
Not sufficient financial resources available
Not sufficient human resources available
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
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: Jesús Castiella
Country: SPAIN
Organisation: Fundación Hospital Calahorra, La Rioja
E-mail: jcastiella@riojasalud.es
Phone: There is no specified text here
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