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110-640 / Reporting and Learning System.

GOP Information  
Organisation sharing the GOP
Related practices from PaSQ database
The National Agency for Patients' Rights and Complaints


Incident reporting and learning system
There is no specified text here
Reporting and learning systems
Patient safety culture / Patient safety climate
GOP Description
Implementation level
Clinical settings
The Act requires frontline personnel to report adverse events, the institution managers to act on the reports, and The National Agency for Patients' Rights and Complaints to communicate experience
from the reports.
The purpose of the Reporting and Leaning System is to gather, analyse and communicate knowledge of adverseevents in order to reduce the number of adverse events in the Danish health care system.
The entire health care system.
The system is designed as a bottom-up process where the majority of the work is locally rooted. The point is that adverse events that are rooted locally should be analysed and corrected locally. This is also thought to have a considerable impact on the development of a safety culture.
The analysis and risk assessment of an adverse event are typically performed locally by the head of the department where the adverse event occurred. This is often done in cooperation with the department’s patient safety officer and the hospital’s risk
manager, as well as with frontline personnel and representatives from middle management.
On the basis of the local analysis the adverse events are reported to the regional and national level to ensure further learning at these levels.
Timeframe implementation
Approximately 1.5 years if you start from scratch.
Implementation tools available
A web-based system accessible to all.
Implementation cost
About 1 million euros in initial costs. This does not include resources for receiving and analyzing reports.
Method used to measure the results
So far there has been no evaluation of the effect of the reporting systems on patient safety incidents in general. A formal evaluation is planned for end of 2013 / beginning of 2014. Please see further below in the section on the “Analysis of results”
The Reporting and Learning System has resulted in an increased focus on adverse events and hence patient safety. On this background a number of initiatives about patient safety and quality of care have been initiated locally and regionally. A formal evaluation is planned for end of 2013 / beginning of 2014.
Analysis of the results
There has been no formal evaluation of the effect of the reporting and learning system yet, it is planned for 2013-2014. However in terms of enhancing the reporting culture, it is evident, that more and more adverse events and near misses are reported; the number of reports increases year by year, which is promising in terms of building a learning culture and speaks for the presence of a just-culture at clinical level. When the reporting and learning system was first introduced there was only mandatory reporting according to the Danish Law for incidents occurring in the hospital setting. The reporting and learning system seemed after a few years so promising in terms of health care professional’s consciousness about risk and harm, that the mandatory reporting was extended to cover the Danish Health care system as such.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Only of a technical nature. Health care staff had a great understanding of the value of learning from their own mistakes - and to spread the knowledge to the rest of health care system.
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
Other information
Other information about the GOP that you would like to add (Link or attached document)
There is no specified text here
There is no specified text here
Contact information
Name: Helle Krarup
Position/function: Special Advisor
Department: Hospital Policy
Organisation: Ministry of Health
City: Copenhagen
Country: Denmark
Region: Capital Region of Denmark
Phone: 0045 7226 9601
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