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186-1107 / Up-dated reporting system of adverse events and errors in Slovak hospitals

Slovakia
GOP Information  
 
Organisation sharing the GOP
Related practices from PaSQ database
Health Care Surveillance Authority

Topic

Incident reporting and learning system
Clinical risk management
Category
Identification of risk and harm
Analysis of risk and harm
GOP Description
 
Implementation level
National
Clinical settings
The departments and units of impatient healthcare facilities in Slovakia.
Objectives
The updated reporting system better reflects to the goals and objectives of the Council Recommendation 2009/C. The objective of reporting system is the safety of patients during the time of hospitalization in Slovak hospitals.
Population
All health professionals in Slovak hospitals that identify an adverse event or errors can report it.
Methods
 
Methodology
The reporting of adverse events (AE) in Slovak hospitals is mandatory, the reporting of errors is voluntary. The reporters have the option to remain anonymous. The system is not punitive. The majority of the activities is locally rooted on the level of hospitals. The reporting systems are designed as a bottom-up process. The point is that AE and errors have been rooted locally and should have been analyzed and corrected locally. This approach has a considerable impact on the development of a safety culture. The analysis and risk assessment of AE and errors are typically carried out by the HC professionals (head of the department, frontline personnel & quality manager of hospital) locally, where the AE or errors occurred. On the basis of the local analysis the summary of AE, errors & claims are reported to the HCSA once a year (end of January the following year) to ensure further system analysis and learning on national level. The new extended classification of AE in the pre-defined Form of the Methodological guidance No. 3/2014 is more consistent with international standards and AE are divided into eight specific groups.
Timeframe implementation
The time of implementation first Slovak reporting system was 3 months in the year 2006. The time of implementation of the new updated version of reporting systems (year 2014) is expected for 4 month.
Implementation tools available
The precise structure and scope of data which should be reported is well defined in the new Methodological guideance No. 3/2014. The hospitals have still options to make notifications in two forms:
1.    reporters of AE and errors can provide these reports, by filling out the paper forms (smaller hospitals),
2.    or in some large hospitals they can use IT form, which is available for healthcare workers in the own hospital information system.
Implementation cost
We do not know the data or information about the cost of implementation in hospitals of Slovakia.
    
Results
 
Method used to measure the results
We are gathering information and data related to the appearance of AE and errors. We have a set of indicators to monitor the use of the reporting system.
Results
The hospital leaders observed a change of approach and organizational culture in patient safety. The reporting system has resulted an increased focus on AE and hence patient safety. On this background a number of initiatives about PS & QC have been initiated locally and regionally. Regarding to the results of reporting systems of AE and errors, the hospitals implemented specific improvements actions on different departments for different priority area of patient safety.
Analysis of the results
Summary of information from hospitals have been gathered, analyzed and evaluated by HCSA. The aggregated data gives specific information about the trends of PS events at national level. The breakdown of national aggregated data to regional data allow to HCSA experts compare the results of 8 self-governing regions in Slovakia. Expert analysis of data and facilitated discussions provide system improvement input. These discussions are attended by representatives of HCSA and specialists of hospitals.
Implementation barriers
 
Did you find implementation barriers?
Yes
Please describe implementation barriers
The main barrier in Slovakia are still lack of safety awareness, non existing patient safety legislation and fear of legal consequences by professionals.
Describe the strategies used to overcome the barriers (If needed)
Training and information for professionals.
Other information
 
Other information about the GOP that you would like to add (Link or attached document)
New advanced classification of AE:    
1.    Falls & injuries :
2.    Bedsores (decubitus): into 2 groups
III. AE related to the surgical procedures:
wrong site surgery, surgery procedure performed to another patient,incorrect surgical procedure, foreign body left during the surgical procedure, death during/after surgical procedure,postoperative wound infection,
IV. HC related infections: n. nosocomial infection/n. of discharged patient
V.     AE related to obstetric care:
VI.    AE related to the hematology & transfusion procedures
VII. AE related to the psychical disorders :
suicide,serious injury by suicide attempt, injury by use of restrictive devices, by physical assault of patients or health professionals,
VIII. AE related to the health care management:
use of drugs, associated with the diagnosis,
failures in monitoring of patients and AE which were not mentioned above.



There is no specified text here
Contact information
 
Name: Eugen Nagy
Position/function: senior officer for patient safety
Department: Department of HCSA
Organisation: HCSA
City: Bratislava
Country: Slovakia
Region: Bratislava Self-Governing region
E-mail: eugen.nagy@udzs-sk.sk
Phone: 00421910 697 110
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