109-546 / Risk management through an incident reporting system without damage

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Gerencia Regional de Salud de Castilla y León. Department of Health in Castilla y León


Incident reporting and learning system
Quality improvement project
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
1.-Developing safety culture
2.-Promote learning from the mistakes and introduce barriers to prevent recurrence
Hospital professionals
1. – Project planning (8 stages)
2. – First stage. Development of tools: 1) SISNOT: general notification system, voluntary, anonymous incident unharmed local management (at the hospital or unit). The system has a structure based on the taxonomy of the WHO. The application is accessible to any professional through the intranet without the use of keys and has four user profiles: notifier, unit manager,hospital manager and manager of best practices regionally. The application supports the entire risk management process (notification, notification management, incident analysis, management and reporting enhancements for feedback) 2) material for the training of managers, 3) training material for professionals units, 4) incident analysis tool (London Protocol)
3. – Second stage. Management training (safety culture, Reason risk theory , incident analysis, management reporting system)
4. – Third phase. Professional Training unit by unit managers (culture of safety and incident reporting with sisnot)
5.-Fourth phase. Implementation. Incident analysis, and prioritization of proposed improvements to be made
6. – Fifth phase. Feedback through periodic meetings in the unit (incidents reported, contributing factors and improvements to be made)
7. – Phase Six. – Project evaluation through indicators (no. notifications,% analyzed,% incidents that result in improvements) and perception study (usefulness and ease of use)
Timeframe implementation
Six months
Implementation tools available
General notification system, voluntary, anonymous incident unharmed local management (at the hospital or unit)
Implementation cost
Working time of managers dedicated to the analysis of incidents
Method used to measure the results
Indicators obtained from the application
515 notifications made
42% with high potential damage
68% of closed generate notifications improvements
Analysis of the results
Although only reported incidents don´t have involved damage, 40% would have caused significant damage
if they had reached to the affected patient or even another patient.
The system is effective for improvement to avoid the repetition of incidents
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
1.-Fear of medicolegal repercussions
2.-No value added visibility
3.-Time dedicated professionals needed to manage the system
Describe the strategies used to overcome the barriers (If needed)
Designing a system without damage incidents
Inclusion of feedback as a critical point of the project
Using a software project that supports the entire process of risk management
Participation as managers of professionals who know how to drive their units and can perform a more agile notifications
Using a simple tool for analysis in 10-15 minutes allows the analysis of an incident without damage
Other information
Other information about the GOP that you would like to add (Link or attached document)
There is no specified text here
Contact information
Name: María José Pérez Boillos
Position/function: Head of quality service
Department: DG Planificación e Innovación- Department of Planning and Innovation
Organisation: Gerencia Regional de Salud de Castilla y León- Department of Health in Castilla y León
City: Valladolid
Country: Spain
Region: Castilla y león


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