735 / Risk mapping and patient safety in diagnostics

ITALY
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
Identification of risk and harm
Analysis of risk and harm There is no specified text here
Topic of the reported practice
Clinical risk management
Aim and the benefit of the Patient Safety Practice
 
The issue of patient safety has become, in recent years, one of the priorities of health policy. Among the methods available for the analysis of proactive risk management risk is the Failure Mode and Effect Analysis/Failure Mode Effect and Criticality Analysis (FMEA/FMECA).
The FMEA/FMECA is a technique to estimate the risk analysis, born in engineering, that can also be applied in health care settings to identify and address potential risks in clinical processes, with the aim of preventing errors and accidents before they happen.
Description of the Patient Safety Practice
 
In IRCCS Rizzoli Orthopaedic Institute in Bologna has been applied the technique FMEA/FMECA to map the main diagnostic processes by identifying, proactively, the potential risks, even before the event occurs in order to identify priorities for risk on which remedial action for improvement.
Following the analysis were defined potential errors, identify the activities with higher risk of errors and accidents, made the most appropriate interventions for the prevention of the same and reduced the possibility of errors. Subsequent to risk mapping 75 improvement actions were carried out: training and information activities (18,7%), organizational change (53,3%), purchaising maintenance of equipment (10,7%), procedures/protocols development and review (16%), structural changes (1,3%).
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
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
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
Quantitative
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
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
Technical support / technician
Clinical manager
Quality manager
Risk manager
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
Yes
List of sources where public information is accessible
http://buonepratiche.agenas.it/practicesdetail.aspx
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.
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
Motivated 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
There is no specified text here
Contact information
 
Name: Patrizio Di Denia
Country: ITALY
Organisation: IRCCS Rizzoli Orthopaedic Institute in Bologna
E-mail: patrizio.didenia@ior.it
Phone: 051-6366043
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