953 / Safety in verbal commands

SPAIN
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
Implementation of Patient Safety initiatives / Activities
Carrying out Patient Safety campaigns There is no specified text here
Topic of the reported practice
Quality improvement project
Aim and the benefit of the Patient Safety Practice
 
The Nursing Management of the Hospital Santa Cristina, has implemented the project: “Security in the verbal commands " .

After performing a situation analysis and problem identification, the need for consensus and the issuing of general rules for the entire organization were priorized, focused on patient safety and the use of verbal orders in the administration of medication to the patient.

GENERAL OBJECTIVE:

Prevent errors in healthcare - medication administration when use of verbal commands is required.
Description of the Patient Safety Practice
 
INTRODUCTION

Having found that there has been confusion over the similarity of drug names on verbal orders and in order to minimize medication errors, clear and precise instructions for patient care have been developed, reported and disseminated to healthcare professionals throughout the organization, including sessions and a poster presentation.

We define “verbal orders" as “medication orders between senders and receivers face to face, by telephone, or other device aural medium".

METHODOLOGY

1-->Situation analysis and information gathering:
a)-. Of anonymous reports received from patients and the analysis of the voice of the healthcare professional.
b)-. Identify potential risks

2---> Prioritizing problems identified.

3---> Selection of viable solutions issued by health care professionals.

4--->Validation of the poster with the pharmacy unit and the nursing care committee of the hospital
5--->Dissemination of good practice:
a). Inform, educate and sensitize all professionals in the organization about how to act with verbal orders .

6--->Material and financial resources: Assumed by the hospital itself

RESULTS

1. Informative POSTER verbal orders designed. = 100%

2. Validation and pilot study of content (information, understandable, and viable, clear and easy commissioning). = 100 %

3.-. Designed circuit = 100 %

4.-. Dissemination of the official poster for the entire organization, healthcare units = 100 %.

5.-. 48% of nurses who perform the administration of medications sensitized for a verbal order.

6.-. Feed -back to professionals, related to compliance and the impact of poster rules in practice.

CONCLUSIONS

A project for the proper performance of verbal orders = completed.

Rules made to administer medication with verbal orders, prevent errors in emergencies or special situation.

Rules of behavior, clear , safe , common and mandatory for all professionals in the organization , are disseminated by official , poster is presented , explained and distributed by all units and placed in a strategic location ( medication center preparation ) for better visibility and understanding by all professionals .
Attachment of relevant written information and/or photos, as appropriate
201403070248512534_WP4_poster en ingles - verbals orders.pdf
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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
Not known
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
Both/mixed (qualitative and 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
Not known
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
 
Nurses
Health care assistants
Pharmacists
Therapists
Clinical support
Scientific staff / researchers
Technical support / technician
Clinical manager
Quality manager
Risk manager
Other or not relevant
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
Other
Point of time in which service user or their reprasentatives' involvement takes place
During the development of the Patient Safety Practices
During the implementation of the Patient Safety Practices
During the application of the Patient Safety Practice
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
User-led, where the service users control the development and implementation of the PSP
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
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
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List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Regular data feed back to involved 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
Not relevant
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: Ma Teresa Perez y Pérez-Medrano
Country: SPAIN
Organisation: Hospital Universitario Santa Cristina. Madrid
E-mail: tperez.hscr@salud.madrid.org
Phone: +34636737552
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