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977 / Identifying adverse events in clinical services

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
Identification of risk and harm
Analysis 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
 
Identify and characterize the specific adverse events in each of the Clinical Services and facilitate preventive and / or corrective action
Description of the Patient Safety Practice
 
Review of medical records of patients admitted to the Clinical Service once every 15 or 30 days. Performed by medical professionals and nurses directly involved in patient care, supported by the Quality Unit of the hospital. The medical records of patients discharged during the previous week are analyzed.
Identified adverse events and their characteristics are recorded.

The values of a set of variables are recorded:
- Age of the patient.
- Sex of the patient.
- Days of stay.
- Types of adverse events.
- Impact of adverse events on hospitalization.
- How sure are you that health care is causing the adverse event?
- Adequacy of clinical information in the medical record to judge the adverse event.
- Severity of adverse events.

Indicators obtained :
¦ Number of medical records analyzed.
¦ Number of patient-days of stay analyzed.
¦ Number of adverse effects.
¦ Adverse effects per 1000 patient -days of stay.
¦ Adverse effects per patient.
¦ Patients admitted who have had one or more adverse effects.
¦ Patients who have experienced one adverse effect.
¦ Patients who have suffered two adverse effects.
¦ Patients who have suffered 3 or more adverse effects.

Comments from reviewers.

The information is then communicated to the professionals of the Clinical Service for preventive and / or corrective action.
Objective: the professionals evaluate themselves and adopt measures to improve systematically.

The method is currently being implemented in the Clinical Services of Digestive and Pediatric Surgery. This will begin shortly in the Cardiovascular Surgery Service .

For each assessment the physician reviewer needs about 30 minutes and the nurse about an hour.
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
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
No
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
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
 
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
 
Physicians
Nurses
Clinical manager
Quality 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
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
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: Martín Tejedor
Country: SPAIN
Organisation: Hospital Universitario Reina Sofía de Córdoba
E-mail: martin.tejedor.sspa@juntadeandalucia.es
Phone: There is no specified text here
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