833 / Implementation of an ICT system to support the management of adverse incidents and near misses

IRELAND
Classification of the PSP
Type of Patient Safety Practice Potentially Safe
 
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Reporting and learning systems
Analysis of risk and harm There is no specified text here
Topic of the reported practice
Incident reporting and learning system
Aim and the benefit of the Patient Safety Practice
 
This clinical risk management practice is aiming to improve the management of adverse incidents and near misses and create a culture where shared learning
occurs.
Description of the Patient Safety Practice
 
The hospital had a paper-based system for reporting adverse incidents and near misses. Each incident was entered onto an Excel spread sheet which was provided to insurers on a monthly basis. No level of analysis took place, no trends were explored and no accountability or responsibility existed relating to management and prevention of incidents.
A new ICT system was introduced along with a structure to manage and review the incidents. Reports are now reported directly onto the web-based ICT system and alerts are sent to line managers immediately. A web-based document has been implemented to facilitate the recording of analysis, contributory factors, recommendations and actions required.
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, partly
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
No
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
Not known
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
 
Mental health care
Transferability
 
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Yes
Specification of implementation in another health care setting(s)
Community care facility
Successful implementation's level  of this Patient Safety Practice across settings
Yes, across multiple specialities across different health care settings
Involved health care staff
 
Nurses
Pharmacists
Technical support / technician
Risk manager
Other or not relevant
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
No
List of sources where public information is accessible
There is no specified text here
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.
Yes
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
Lack of knowledge on implementation strategies
Not sufficient human resources available
Specially trained staff not available
Other
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
There is no specified text here
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Yes
Description of used incentives, if any.
The steering group involved members of the main
areas where the system was required. Training on Adverse Incident Reporting and Near Miss occurred pre the introduction of the new ICT system which gave staff
more knowledge and confidence of when to report and why. 5 areas were chosen to pilot the system which assisted with the going ’live’ date. There was a great awareness of the Datix System before the date went live. It got
people interested and there was a great attendance at training for the actual system
once it was offered.
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
Yes
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 40
External consultants: 4
Support staff: 40
Managerial staff: 60
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 33
External consultants: 2
Support staff: 10
Managerial staff: 4
Others: 0
Not relevant: 0
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
0
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Onagh O' Grady
Country: IRELAND
Organisation: St John of God Hospital
E-mail: onagh.ogrady@sjog.ie
Phone: 00 353 1 277 1461
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