998 / Reporting of Adverse Events in Perfusion through the Website of the Professional Organisation, Spanish Perfusionists Association

SPAIN
Classification of the PSP
Type of Patient Safety Practice Not Evaluated
 
Clinical Practice (CP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Surgical / Invasive procedures
There is no specified text here 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
 
The main objective of this PSP is the creation of a “Register of adverse events in Perfusion” at a national level database, to identify, study and establish areas of improvement in our clinical practice and increase the safety of patients under extracorporeal circulation (ECC).
Secondary objectives:
• Identify errors that can cause adverse events in ECC
• Register their impact on clinical practice.
• Know the latent conditions that may contribute to trigger them.
• Provide advice to those affected by adverse events.
• Learn from the mistakes of others to take the necessary measures so that they ar not repeated in our working environment.
• Know the areas for improvement and implement continuous training of professionals.

BENEFITS
•    The results after two years working with the WEB-declaration of adverse events show that it is gaining trust among professionals.
•     It is an essential tool to improve patient safety in perfusion.
•     This tool is low cost, easy to use and fast.
•     The requirement for its implementation is a strong organisational structure.
Description of the Patient Safety Practice
 
• Informed on Contributing Factors given by the "Joint Commission International " , adapted to nine for ECC.
• Each factor composed of forms that list the criteria agreed at national level , of the Spanish Model of Patient Safety in Perfusion .
• The report statement is sent to the restricted area of the Spanish Perfusionists Association's (AEP) Quality Commission for study and evaluation.
• The scope of registration is national for public and private centres.
• The characteristics of the register are: Voluntary , Anonymous , Confidential , Professional, Independent and not punitive.
IMPLEMENTATION OF PRACTICE:
In Spain there are currently 210 active perfusionists . They all have access to the online declaration tool , through the website of the AEP .
Adverse events reported come from public and private assistance centres. And affect all cardiac surgeries performed in the country.
The tool is based on the Spanish Patient Safety in Perfusion model, where the agreed criteria and standards are set nationally .
Areas for improvement contained in the information received, are developed at zonal area meetings of area in which the professional organization is divided .
Security alerts that are detected have direct diffusion through e- mail to all professionals in the country through the professional organization.

NOTE : Attached are two files :
1.    With the description of the tool.
2.    With the proposal on the European Board of Cardiovascular Perfusion , implementation and creation of a database at European level .
Attachment of relevant written information and/or photos, as appropriate
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AEP REPORTING TOOL DESCRIPTION.pdf
EUROPEAN DATABASE PROPOSAL.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
Regional or national 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
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
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)
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Successful implementation's level  of this Patient Safety Practice across settings
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Involved health care staff
 
Nurses
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
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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.
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
No
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
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Contact information
 
Name: Carmen Luisa Díaz
Country: SPAIN
Organisation: Asociación Espanola de Perfusionistas
E-mail: carmenluisa@telecable.es
Phone: There is no specified text here
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