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978 / Reporting adverse events on medication

CROATIA
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Medication / IV Fluids
Documentation 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
 
According to national law (Medicinal Products Act and Ordinance on Pharmacovigilance), physicians and other medical personell are obliged to report adverse reactions to the Croatian Agency of Medicinal Products and Medical Devices. In Clinical Hospital “Sveti Duh” such practice is implemented within the hospital’s mainframe, where reports can be submitted directly via electronic mail. In the same time, an E-mail notification alert is sent to the clinical pharmacologist in hospital with all information regarding this report, including all physicians involved in prescribing the medication and the department from which the report is generated. This practice leads to improvement of adverse reaction supervision and patient involvement in generating additional information about adverse reactions directly in clinical setting, where adverse reaction has occurred.
Description of the Patient Safety Practice
 
According to the clinical pharmacologist’s critical review of the report, it is possible to go to the department and to visit the patient and the physician who reported an adverse reaction, taking additional information if needed and ensuring better knowledge and circumstances in which this adverse reaction has occurred. Such direct communication leads to better and safer treatment of patients and enables the clinical pharmacologist to supervise medication administration, including possible interactions, dosage, prescription and potential mistakes and to correct them ad hoc on daily basis.
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, 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
Not relevant
A measurement after full implementation of the reported practice was obtained
Not relevant
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
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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
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
Technical support / technician
Quality 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 the evaluation 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
Collaboration, such as co-designing a Patient Safety Practice or active partnership in implementation
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.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Lack of sharing of progress information among involved staff
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
Yes
Description of used incentives, if any.
informing, education
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: Ivana Mikacic
Country: CROATIA
Organisation: Clinical Hospital "Sveti Duh"
E-mail: imikacic@kbsd.hr
Phone: +385913712712
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