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809 / Learning from incidents in health care

NETHERLANDS
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Reporting and learning systems
Identification 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
 
This Patient Safety Practice aims to reduce incidents by systematically learning from reported incidents.
Description of the Patient Safety Practice
 
Too often, health care managers do not have means in order to learn from incidents or suboptimal care. The Learning from Incidents in Healthcare tool does provide such a means. It is closely relation to the implementation of a Safety management system and helps to systematically inventory and control risks in order to reduce or eliminate these a much as possible.

This PSP is a website for health care professionals (also managers, team leaders, quality coordinators etc) to support them with systematically learning from incidents in the care process.

The website provides them with 3 tools:
1. A guideline for implementation of the learning system in the health care organization. (steps: report, analyse, prioritise, improve, juridical aspects).
2. A model of the learning system, with background information on how the different parts of the model contribute to learning from the incident. (registration, juridical setting, willingness to report, division of responsibilities etc.)
3. A checklist with 14 important points to check the implementation of the learning system into the organization.
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, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
Not known
A baseline measurement before implementation of the reported practice was obtained
Not known
A measurement after full implementation of the reported practice was obtained
Not known
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
There is no specified text here
Health care context where the Patient Safety Practices was implemented
 
Primary care
Community care facility
Mental health care
Nursing facility
Hospital
Home care
Dental care
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
Clinical support
Scientific staff / researchers
Technical support / technician
Administrative support (secretary, clerk, receptionist etc.)
Dentist
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
www.nivel.nl\liz
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.
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: Cordula Wagner
Country: NETHERLANDS
Organisation: NIVEL
E-mail: c.wagner@nivel.nl
Phone: There is no specified text here
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