648 / Implementation of a safety program in an Intensive Care Unit

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
Reporting and learning systems
Implementation of Patient Safety initiatives / Activities There is no specified text here
Topic of the reported practice
Incident reporting and learning system
Aim and the benefit of the Patient Safety Practice
 
Patient safety plays a critical role in Intensive Care Units (ICU) because acute ill patients are particularly sensitive to health care errors and ICU is a high risk environment.
The aim of this study was to implement a Safety Program in our ICU and introduce patient safety improvements.
Description of the Patient Safety Practice
 
METHODS
Prospective observational study.During one year period(January 10-January 11) a Safety Program was implemented in our ICU.The Safety Program consisted in:Education in safety culture.Creation of a safety team.Implementation of daily goals worksheets and meetings.Elaboration of an incident report system.The report included details about patient(demographic data,APACHE II,reason of admission,length of stay) and incident(type,consequences,contributing factors).The report forms were entered into a computer database.We evaluated the kind of incident,severity and preventability every three months.Identification of potential risk factors according to the classification of the National Patient Safety Agency.Analysis of the incidents were regularly given back to the ICU team.Discussion of strategies of prevention.Introduction of patient safety improvements.

RESULTS
A total of 300 patients were included.108 incidents were reported in 63 patients.The median age was 66 years.The mean APACHE II was 20±8.The reason of admission was in a 87,4% medical.The length of stay was 17,4 days.Most incidents were reported during daytime.The main types of incidents were related to medication errors(25%),equipment failures(17%), nosocomial infections(14%),tubes,catheters and drains(11%),airway management failure(11%),diagnostic errors(11%), invasive procedures(6,5%) and care of patients(4,5%).19,5% of the incidents reported were incidents without damage and 80,5% adverse events(AE).Severity of AE was:11,5% minor(minimal harm,no treatment required),54% moderate(harm,requiring treatment) and 34,5% severe(long term harm), none caused death.86% were considered avoidable or potentially avoidable.The main contributing factors were related to: communication, teamwork issues, education and training,professionals and work conditions.Improvements were introduced:Review,elaboration and implementation of guidelines and check-lists.Introduction of preventive strategies such as regular equipment training meetings.Promotion of team work and communication in such a way as to optimize patient care.Adecuation of workload. The aims are a risk reduction for the patient and to standardize diagnostic and therapeutic procedures and patient´s care.

CONCLUSION
The implementation of a Safety Program has improved the quality of care administered in our ICU.The continuous monitoring and evaluation of the incidents has changed tasks and procedures,has introduced strategies of prevention and has got a safer health care environment.
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
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation's results
Int Care Med 11; 37(S1):S224
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
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
Regular data feed back to involved 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
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
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Contact information
 
Name: concepcion valdovinos mahave
Country: SPAIN
Organisation: Hospital Obispo Polanco, Aragon
E-mail: mcvaldovinos@salud.aragon.es
Phone: 667966260
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