995 / Sentinel System of Clinical Alerts: electronic and customized alerts to ensure patient safety in the onco/hematological area

SPAIN
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
Early warning
Health IT There is no specified text here
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
 
Drug-related problems and medication errors are frequent in high risk areas, sucha as onco/hematological care. Too many alerts in electronic devices often imply overriding without reading (alert fatigue) and a possible patient damage. On the contrary, a lack of alerts might miss an alert condition in the patient.
Description of the Patient Safety Practice
 
SEDA® (Sentinel System of Clinical Alerts) allows designing customized alerts which helps the professional in the high assistencial workload and in the complexity of the therapeutic chain processes to minimize the adverse events that reach the patient.

Clinical processes, procedures and patients are monitored by SEDA® system, which allows early detection of alert situations (incidents or signs which identify patient’s medication error, drug-related problems or adverse events using predefined criteria)
Due to the wide freedom of the system to set alerts, the problem encountered during the implementation was that too many alerts were created. Most of them were largely ineffective and did not compromise patient safety. This led to "alert fatigue" in health professionals, which caused them to ignore the warnings due to the overload of less important alerts.
In this situation, it was decided that the criteria for the alerts should be agreed, validated and refined in a process of continuous improvement regarding the methodology of creating alerts (see attached file), in order to increase sensitivity and specificity of the safety alerts.
Attachment of relevant written information and/or photos, as appropriate
995.zip
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
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
Hernández Griso M., Gras Colomer E., Albert Mari A.,Climente M. Jiménez Torres N.V. “INDIVIDUALIZACIÓN POSOLÓGICA DE ÁCIDO ZOLEDRÓNICO PARA LA PREVENCIÓN EL INCREMENTO DE CREATININA PLASMÁTICA EN EL PACIENTE ONCO-HEMATOLOGICO”. Congreso de Sociedad Espanola de Farmacia Hospitalaria 2010
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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)
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
Pharmacists
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
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
Yes
Total number of person days required to implement this Patient Safety Practice
Clinical staff: 30
External consultants: 0
Support staff: 90
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: 5
External consultants: 0
Support staff: 10
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
3000
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
2000
Contact information
 
Name: Monica Climente
Country: SPAIN
Organisation: Hospital Universitario Dr. Peset
E-mail: climente.mon@gmail.com
Phone: +34961622552
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