54-459 / Patient Safety Improvement by operating a reporting and learning system

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Semmelweis University Health Services Management Training Centre


Incident reporting and learning system
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
We receive reports from 5-10% of hospitals, but there are more institutes which use the report sheets without reporting to us. The regular forums on patient safety are attended by representatives from 30-40% of all hospitals.
Improving patients’ and workers’ safety
•    patient safety related researches, exploring and distributing existing practices
•    operating a reporting system (NEVES) and forming a recommendation (NEKED) to support root cause analysis of adverse events and organisational learning
•    developing recommendation to support AE prevention
•    distribute recommendations to providers
•    improve organizational culture
Reporting system: front-line staff, quality managers, healthcare workers with managerial duties
Forum: quality managers, healthcare workers with managerial duties, both in primary and secondary care, representatives of patient associations, patient rights representatives, front-line staff
Operating a complex patient safety program
Reporting system: voluntary, anonymous.
Reports are submitted on a pre-defined structured online form, in various topics, and are sent to the system operators (independent experts on PS data analysis).
The questionnaire aims to explore the underlying causes of AE-s. Their development is performed by experts on the given area of healthcare.
The selection process of events is the following:
–    frequent enough
–    the result of well identified processes
–    processes are responsibilities of more people (to avoid unwillingness to report)
–    possible to reduce the occurrence of events by intervening into the processesThe reportable events are adverse events, incidents or activities holding great risk.Data analysis is performed partly by the reporting institute when they receive the aggregated data of their reports.
The other part is immediate, supported by default statistical analyses. The institutes receive results automatically both in written and graphic form.
Every institute is able to see the aggregated anonymous results, and statistics of their own reports.

Patient safety forums: bimonthly events, aiming to distribute knowledge on patient safety, gather initiatives and exchange experiences. They start with keynote speech, followed by active discussion with the participants, who may share their experiences on the selected issue.

Timeframe implementation
1 year
Implementation tools available
•    Online form
•    Software for data analysis and national comparison
•    Case studies to support implementation and interpretation of results
•    All presentations of all forums are available and organised by topic
Implementation cost
oftware development: 3.000.000 HUF
IT tools 1.000.000 HUF
HR: 15 expert days/data collection sheet
methodology of analysis and feedback: 15 expert day/ data sheet
Method used to measure the results
Number of institutions/ reports/ participants
Analysis of results is performed on institute level. A survey was performed to assess opinions on the program. (Results in the next field)
Analysis of the results
83% of participants stated that their approach have changed due to the program. In 89% of the institutes, participants discuss what they have learnt. 63% of respondents stated that they have changed some practices in their institutions. (based on 62 responses)
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
–    willingness to report changes
–    difficult to implement changes
–    late feedback
–    organisational culture (fear of consequences)
–    management not committed
–    not enough knowledge to analyse results (statistics, root cause analysis)
–    data used for wrong purposes (e.g. comparing different units)
Describe the strategies used to overcome the barriers (If needed)
Involving management, changing organisational culture through the forums. There were opportunities for the institutional management to get acquainted with the importance of the program and the managerial duties and opportunities.
The presentation pointed out the importance of patient safety, showed the logic of our reporting system, the purpose and methodology of the root cause analysis, the possible conclusions, and the work of the Patient safety forums altogether.
Other information
Other information about the GOP that you would like to add (Link or attached document)
Get in touch with the institutional management, their involvement is necessary. Our experiences suggest that convincing is a successful method. The maintenance of the program requires immediate feedback to the reporters, because this is the base of a quality improvement strategy. If the feedback is late or nonexistent, the willingness to report decreases. After introducing the immediate feedback, the increase in willingness to report was perceptible. Institutions should be helped throughout their activity in the program (reporting, data analysis, RCA, appropriate methodologies). The forums aim to support this; the necessary knowledge on methodology is included in the presentations.