942 / Managing the risk of fall

ITALY
Classification of the PSP
Type of Patient Safety Practice Safe
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Patient falls
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Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
The problem of patient falls during horpitalization is of paramount importance. That is the reason why, within the clinical risk management plan of the Hospital Carlo Poma a 2 year-project was developed. The main objective of this project was to develop strategies for analysis and prevention of adverse events related to accidental falls of patients and visitors.
Description of the Patient Safety Practice
 
The project included the setting up of a multidisciplinary working group, having the task of analyzing about 890 cases of patient and visitors falls from 2005 until 2010. It was produced a report of the events, that was then discussed with the risk manager and the Heads of the different departments. The report allowed the implementation of a new shared procedure based on the Conley scale. It was then produced a poster for users, together with a survey form investigating environmental risk, filled in once a year by the wards coordinators.
The following indicators will be used to evaluate the procedure outlined above:
- patient falling/ number of hospitalization days
- % of patient falls with severe prognosis and/or death
- % of forms reporting risk of falls out of the total number of reporting forms
Attachment of relevant written information and/or photos, as appropriate
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Effectiveness of the Patient Safety Practice
 
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Unit or ward 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
44° National conference of Public Health of Venice - 2010; oral communication "Sviluppo del progetto di prevenzione del rischio di caduta presso l'azienda Ospedaliera Carlo Poma" Auth. Burato E., Borsatti G., Barbera A.

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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)
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Successful implementation's level  of this Patient Safety Practice across settings
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Involved health care staff
 
Physicians
Nurses
Scientific staff / researchers
Quality manager
Risk manager
Patient Involvement
 
Direct service user's involvement as integral part of this Patient Safety Practice
Yes
Specification of the service users or their representatives' involvement in the implementation of this Patient Safety Practice
Patient(s)
Relative(s)
Patient representative(s)
Patient organisation(s)
Point of time in which service user or their reprasentatives' involvement takes place
During the evaluation of the Patient Safety Practices
Active seeking of service users' opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Yes
Short description of the service users' level of involvement
Consultation, such as asking for information
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?id=3637
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
No motivation among staff
List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
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Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
No
Description of used incentives, if any.
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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: 0
External consultants: 0
Support staff: 0
Managerial staff: 0
Others: 0
Not relevant: 0
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff: 0
External consultants: 0
Support staff: 0
Managerial staff: 0
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
10587.80
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
0
Contact information
 
Name: Enrico Burato
Country: ITALY
Organisation: AO Carlo Poma
E-mail: enrico.burato@aopoma.it
Phone: 0376 201440
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