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77-603 / Online tool to manage safety incidents and to disseminate quality improvement actions

GOP Information  
Organisation sharing the GOP
Related practices from PaSQ database
Andalusian Agency for Healthcare Quality


Incident reporting and learning system
There is no specified text here
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
Primary care, hospitals, emergency teams.
"Management of the whole safety incidents life cycle.
Promotion of the implementation of improvement actions to prevent new incidents and to share them with other centers/units working on the system.
To offer a tool that allows the healthcare centers/units to manage their incidents locally."
Universal. Aimed at healthcare professionals as well as citizens.
"Literature review.
Development of the incidents reporting module, based on the International Classification for Patient Safety, open to healthcare professionals and patients, and with two different forms available, an extended one and its reduced version.
Development of the management module, where every incident linked to a healthcare center/unit can be managed by the center/unit designated responsible, evaluating the risk level, analyzing the incident and establishing improvement areas, which can be shared with other users in the system.
Review of the tool in collaboration with patient safety experts and improvement of the tool. "
Timeframe implementation
Two months, including the translation of the tool to a different language.
Implementation tools available
Comprehensive reporting and learning system, composed by two different modules: one for reporting the incidents and getting statistical reviews, and a second one for managing the reported incidents, only accessible for a responsible person for every healthcare center/unit registered in the system. When new incident is reported, linked to the center/unit where it happened, the responsible person in system receives notification message. Then, the incident can be analyzed in the managing module, where improvement areas can be defined and assigned to a person in charge, and the detected improvement areas can be shared with other centers/units registered in the system
Implementation cost
Minimum cost. No special training is required to handle the tool and no software acquisition is needed.
Method used to measure the results
In order to measure the level of development of the project the following variables have been used: number of healthcare centers/units registered in the application and number of reported incidents.
386 healthcare centers/units registered into the system (12 of them are from outside Andalusia and even outside Spain) 2049 notifications reported to the system (1845 from healthcare professionals and 204 from citizens) since 2009.
Analysis of the results
Of the total amount of reported incidents , 135 have been or are being managed through this tool and 94 of them have been already solved. 243 improvement actions have been collected, 218 of which have been shared with other users of the system. The area from where more incidents have been reported is primary care, mainly incidents involving the care process or the clinical procedure, followed by drug-related incidents, in the case of incidents reported by healthcare professionals. Regarding the notifications from citizens, those related to the healthcare (diagnosis, treatment, surgery, diagnostic tests) and medication are the most common.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Reluctance of healthcare professionals to report due to the fear of retaliation and, mainly, due to time constraints.
Describe the strategies used to overcome the barriers (If needed)
We are working currently on the readjustment of the reporting forms, to make them simpler, more intuitive and shorter, so less effort is needed form the user. On the other hand, one mobile app version of the system is planned, pursuing the same improvements and providing the system with new possibilities that enrich the reporting (e.g. geolocation)
Other information
Other information about the GOP that you would like to add (Link or attached document)
The system is able to connect with other reporting systems, either national or international.

There is no specified text here
Contact information
Name: Jerónimo Pachón Díaz
Position/function: Quality, Research, Development and Innovation General Director
Department: Directorate of Quality, Research, Development and Innovation
Organisation: Andalusian Regional Ministry of Health and Social Welfare
City: Seville
Country: Spain
Region: Andalusia
Phone: 0034 955006548
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