72-441 / Implementation of a Patient Safety Reporting and Learning System in Galician hospitals

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database


Incident reporting and learning system
Program on quality and safety
Reporting and learning systems
GOP Description
Implementation level
Clinical settings
All hospitals in the Galician region
Implement an electronic system of voluntary, non-punitive reporting of adverse events, directed at gaining knowledge in order to improve safety.

Standardize and strengthen structures to manage a reporting system and implement improvements (Safety Cores) in all our hospitals.

Reinforce safety.

All 15 hospitals in the Galician Health Service
–    Develop a computer program. In our case, we used a system which the Spanish Ministry of Health had offered us.
–    Training reporters. This was structured in two stages. First stage: Train those personas who were to become managers and responsible for further training. Second stage: training all healthcare professionals.
–    Training regional managers and hospital managers.
–    Design and develop a procedure dealing with the reporting.
–    Reporters begin reporting.
–    Planning and developing improvement plans.
–    Managers monitor reporting indicators..
–    Methodological support in order to apply root cause analysis.
–    Develop feedback reports for health professionals.
–    Divulge benchmarking reports.
Timeframe implementation
1 year for an organization of our size.
Implementation tools available
–    The computer program, which includes tools for reporting, managing and elaborating follow-up reports.

–    Training material for those reporting professionals, both electronic and on paper.-    Training material for region managers and local managers (hospital)-    Models for monitoring training and implementation.

–    Recommendation guidebook for managing serious adverse events.

Implementation cost
In our case, this project was sponsored by the Spanish Health Ministry.

In terms of training and implementation: one health professional for one year.

Method used to measure the results
Automatic monitoring of the 14 most important indicators in all hospitals, both monthly and yearly. These indicators register and compare number of reportings per health professional, the characteristics (number of reportings considered very serious with regards to the total); quick reply and efficiency of the system managers (number of group meetings, reportings processed in less than a month); hospital management’s commitment with the system (number of information and results sessions, number of improvement actions taken on, number of feedback reports…)
Between 2011 and 2012, 2.711 reportings took place (1007 in 2011 and 1904 in 2012). 87% resulted in improvement actions. Medication and identification errors were the main fields where reporting took place.

47% of those who reported identified themselves voluntarily.

A sum of 244 group meetings and 92 results presentation sessions took place, to “learn from one’s mistakes”.

4 manager meeting took place to interchange experiences and there was an anual benchmarking conference with hospital directors.

In its second year, all hospitals exceeded the goal that was set out in the hospital management contracts.

Analysis of the results
During 2011, we focused on training and system implementation in all Galician hospitals. In 2012 we maintained and perfected the system with an important improvement as to level of reporting.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
1)    Big differences in terms of safety in different hospitals.
2)    Insufficient committment on behalf of hospital management initially.
3)    Fear of possible punitive measures and/or legal repercussions.
Describe the strategies used to overcome the barriers (If needed)
Multidisciplinary intensive training focused on many professionals., specific reinforcement in those hospitals which needed it most; meetings with managers from different hospitals and setting forth best practices.
Include Hospital directors in Security Cores and training seminar.
Awareness and information meetings between the project managing and hospital directors in their own hospital.
Include an indicator dealing with the use of this system in management contracts between the Galician Health Service and hospitals.
Benchmarking conferences.
Information and clarifications as to the program’s functioning; possibility of reporting anonymously; no personal information about patients nor health professionals in the reporting procedure.
Other information
Other information about the GOP that you would like to add (Link or attached document)
1.    The use of an incident reporting system is a powerful tool for gaining knowledge and improvement in patient safety matters and is beneficial for the whole organization.
2.    It allows us to understand, analyze and gain knowledge of incidents, adverse events and risky situations that take place in hospitals and which health professionals detect.
3.    It acts as a guidebook for improvement and adverse event prevention.
4.    Encourages team work and sets forth improvement initiatives. It also decreases variability and is thus beneficial for all citizens.
5.     Since there is one data base for reporting all incidents, we can learn about specific problems that hospitals have in terms of patient safety and thus establish improvement actions in order to solve these problems.
6.    Those health professionals that work more closely with patients are able to report situations, that would otherwise never have seen the light, so those in charge can solve them.