49-275 / Patient Safety Reporting and Learning System (SINASP)

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI)
Avedis Donabedian Institute (FAD)


Incident reporting and learning system
Program on quality and safety

GOP Description
Implementation level
Clinical settings
Hospitals (piloting in Primary Care)
1.To improve Patient Safety through the analysis of healthcare incidents and adverse events
2.To promote changes in the system necessary to prevent the repetition of these incidents in the future
3.To learn from healthcare incidents: incident notification analysis and identification of new hazards, trends, risk factors and contributing factors
Healthcare professionals
Risk management units
National and regional patient safety managers and administrators
1.Process: 2007-2012
-Phase 1:
*Bibliographic review and visits to other countries’ experiences (UK-DK)
*Experts consultation: 18 Health Regions-HR representatives and 12 patient safety experts
*Focus groups with patients’ associations representatives
*Healthcare professionals consultation: 59 representatives from 53 scientific societies
*Definition of basic principles for the system
-Phase 2:
*Questionnaire design (based on WHO framework, systems already implemented in 3 other countries and 4 HR and specific Spanish medication error reporting system) and on-line platform development
*Pilot test at hospital level (2 hospitals from 2HR)
*Pilot test at HR level (32 hospitals from 2 HR)
-Phase 3:
*Gradual implementation in other HR
*Pilot test in Primary Care
2.System attributes:
-Voluntary, non-punishable, confidential
-Anonymous notification (or initially identified and unidentified post-analysis)
-Analysis oriented to local learning and improvement
-System-oriented analysis
3.System structure and information/analysis flow:
Local healthcare professional: incident notification
Local safety unit: analysis, action and feedback at local level
Regional unit: local support and regional analysis and feedback
National coordination: technical support and global analysis
4.Implementation process (hospital level): structured and guided process including:
Face-to-face instruction and training to trainers
Local cascade training
Work circuits definition
Project launch
Start of reporting and technical support
Timeframe implementation
3-6 months for local implementation
Implementation tools available
On-line platform
Guide for implementation
Training materials for local sessions
On-line course
System manager guide
User guide
Letter for hospital executives
Commitment form for Health Region authorities and for hospital management
Root cause analysis tools and real examples
Implementation cost
Design and pilot: 210,000 €
Technical support (2009-2012): 359,638.50 €
Health Regions dissemination: 40,800 €
Method used to measure the results
At NHS level, global monitoring indicators:
Volume of reporting (no of incidents at national/regional,etc)
Characteristics of reporting (by professional, by risk, etc)
Management of reporting (time needed;actions initiated..)
Analysis of reporting (Cause-root analysis, group meetings..)
Feedback performed (by Web and email, newsletters,etc)
System implemented in 5 Health Regions: 66 hospitals
2,952 notifications received in 2011; 8,239 in 2012
28,750 healthcare professionals trained till the end of 2012
Analysis of the results
SiNASP has been gradually implemented and the results obtained (local implementation, reports, analysis, feedback) also follow a gradual process. High variability which mainly depends on regional support and local leadership. More than 50% of reporters identify themselves, which shows no worry about punitive actions around the reporting system although no legal protection exists in Spain for reporters.
Feedback reports elaborated and disseminated at local level are increasing, as well as case discussion sessions.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
-Human resources, time and support provided to the hospitals by Health Regions is variable and this circumstances highly affect local implementation. -Local changes in hospital management and patient safety responsibilities also jeopardized the project in some cases
-The lack of legal protection for reporters.
Describe the strategies used to overcome the barriers (If needed)
Direct contact with Health Regions authorities in charge of patient safety
Direct technical support to the hospitals
Other information
Other information about the GOP that you would like to add (Link or attached document)
Link to SiNASP web: https://www.sinasp.es/