69-606 / Clinical Risk Recommendations

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Italian Ministry of Health


Clinical risk management
Identification of risk and harm
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
Give information and organizative actions to reduce SE occurrence
Healthcare workers, patients, managers and other stakeolders
14 Recommendation have been published, based on sentinel events occurred or on the basis of international experiences.
They are drawn up by Working group,reviewed by scientific societies, National and Regional Agencies.
They are available on MoH web site (www.salute.gov.it)
List of MoH Recommendations:
?    Preventing errors during anticancer drug therapy
?    Preventing patient falls in health facilities
?    Preventing therapy errors using drugs “Look-alike/sound-alike”
?    Death or severe injury due to malfunctioning of the transport system iside or outside hospital
Recommendation for the prevention of bisphosphonate associated osteonecrosis of the jaw/ mandibular bone
?    Recommendation for the prevention of adverse events consequent to malfunctioning of medical devices and electromedical instruments
?    Recommendation to prevent acts of violence against healthcare workers
?    Recommendation for the prevention of death, coma or severe bodily harm originating from an error in pharmacological therapy
?    Recommendation for the prevention of maternal death correlated to childbirth and/or labour
?    Recommendation for the prevention of a transfusional reaction due to ABO incompatibility
?    Recommendation for suicide prevention of hospital patients
?    Recommendation for the correct identification of patients, surgical site and procedure
?    Recommendation to prevent the retention of gauze, instruments or other material in a surgical site
?     Recommendation for the correct use of concentrated solution containing Potassium Cloride –KCL- and other concentrated solutions containing Potassium
Timeframe implementation
It depends on the Recommendation. Some of them are easy to implement, it is up to each Health Facilities to implement the Recommendations and it depends on their priorities
Implementation tools available
There is a monitoring system to verify the Recommendations implementation. The Data Base is managed by Agenas.
Other tools for the implementation are training programs, workshops and meetings
Implementation cost
The cost of Monitoring System for the Recommendations Implementation is about 200.000 Euro.
The implementation of each recommendation depends on the health organization and on the type of recommendation.
Method used to measure the results
We have in place a Monitoring System for the Recommendations Implementation
We have data for each Recommendation about the implementation inside the healthcare organizations, these data are available on Monitoring System.
Analysis of the results
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Cultural Barriers and Economical barriers. Also other priorities previous defined and lack of commitment
Describe the strategies used to overcome the barriers (If needed)
There is no specified text here
Other information
Other information about the GOP that you would like to add (Link or attached document)
There is no specified text here