Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP

Challenges to the Implementation of the World Health Organization's International Classification for Patient Safety in Slovenia

BACKGROUND AND OBJECTIVES

Slovenia lags behind international recommendations for reporting and learning from patient safety incidents and risk management in health care. To counter this, the country established the SenSys project, which receives technical support from the European Commission's Structural Reform Support Service, in cooperation with the Danish Patient Safety Authority, and pertains to an initiative to improve health care. A subproject of the SenSys project works to adapt and implement the International Classification for Patient Safety of the World Health Organization (ICPS-WHO). This article presents a case study of the national research process to identify the necessary Slovenian national adaptation and upgrade of the ICPS-WHO, the ICPS-SL, particularly regarding types of patient safety incidents. Our aim was to reflect on how we used the insights from different research elements and learned from different aspects of our project/system development.

METHODS

We used the SQUIRE 2.0 (Standards of Quality Improvement Reporting Excellence) to present our case study. The methods used to collect information on the necessary adaptations to establish an optimal ICPS-SL included a literature review, qualitative analysis of national consultation meetings, and a 2-cycle Delphi study. This process took place between January 2018 and August 2019, and we found 18 useful articles. Participants such as providers, users, and national bodies from national consultation meetings were all key stakeholders.

RESULTS

The relevant stakeholders agreed upon changes to the ICPS-WHO to implement in the ICPS-SL as an integrated part of a Slovenia's incident reporting and learning system. Notably, they implemented changes in terminology in the translation of some English terms. They also added or hierarchically reordered some patient safety incident types: for example, they added the nation-specific point "treatment of pain" as a type of patient safety incident. The stakeholders will also partially integrate the following indicators: monitoring systems, vigilance systems, and complaint systems.

CONCLUSION

Different research elements contributed to the ICPS-SL's new knowledge and more reliable development. We emphasized a cooperative process with a consensus-building approach while linking the knowledge, experience, and needs of various stakeholders. All interested parties adopted this process, aiming to establish conditions for national learning from patient safety incidents and better preventive action for health care quality and safety. Vertical and horizontal multidisciplinary teamwork was a focal point as well. Technical assistance proved especially useful. It is now necessary to clinically test the ICPS-SL classification framework as Slovenia's internationally harmonized standard, and have the Health Council adopt it for use both online and in practice.

[How to improve the quality of healthcare services and patient safety by adopting strategies from the aviation sector?]

BACKGROUND AND OBJECTIVE

The World Health Organization recognizes patient safety as a priority as part of its global strategy to improve the quality of health services. However, several initiatives need to be integrated and systematized to increase the reliability of healthcare systems. This article discusses several management strategies developed in the aviation sector that have led to a drastic decrease in the accident rate. The aim is to describe each strategy and contrast them with their application in the healthcare sector.

METHODS

Different results and recommendations from the literature and institutions such as the World Health Organization and the International Civil Aviation Organization were consulted and compiled. A synthesis of the identified strategies was made, highlighting examples of their application and impact.

RESULTS

Five key strategies were identified: 1) no-blame incident reporting systems, 2) systematic use of checklists, 3) recurrent training and use of simulation, 4) management of fatigue and work schedules, and 5) management of teamwork.

CONCLUSIONS

The strategies from the aviation sector are presented as a valuable reference for improving patient safety and the quality of healthcare services. They should be consolidated and harmoniously integrated into the design and management of health systems.

PROTOTYPE FOR MONITORING INCIDENTS IN THE HEALTH SERVICES: INNOVATION FOR PATIENT SAFETY

ABSTRACT Objective: to describe the participatory process of building a prototype to support the development of an information management system for notification, investigation and monitoring of health incidents. Method: a methodological research study on technology development, carried out in two stages: 1) documentary analysis of primary and secondary sources related to forms and legislation on incident notification systems, from September to October 2018; 2) deliberative dialog in two sessions, with 12 managers and coordinators of the Quality and Patient Safety Center of public hospitals in the Federal District, held in November 2018. In the deliberative session there was a presentation of the prototype and discussion of its applicability and functionality for the development of an information system for risk management in the health services. Results: creation and prototyping of a tool with 4 (four) screens representing the systematic flow of data. Screen 1: Simplified notification for patients and companions. Screen 2: Notification for the health professional. Screen 3: Investigation of the event and action plan. Screen 4: Intervention and monitoring by means of indicators. Conclusion: this is a tool capable of integrating actions to reduce the occurrence of incidents based on the identification and timely intervention on the risk factors. It can be used as a facilitating basis for the development or improvement of new instruments for risk management in the health services.

What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group

BACKGROUND AND OBJECTIVES

Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS).

MATERIAL AND METHOD

Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed.

RESULTS

Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken.

CONCLUSIONS

The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels.

[Description of contributing factors in adverse events related to patient safety and their preventability]

Objetivo

Evaluar el grado en que los sucesos adversos (SA) ligados a la asistencia sanitaria alcanzan al paciente y su severidad. Analizar los factores contribuyentes a la aparición de SA, la relación con el daño provocado y el grado de evitabilidad.

Diseño

Estudio descriptivo retrospectivo.

Emplazamiento

Servicio de Atención Primaria de Porriño desde enero de 2014 a abril de 2016.

Participantes y/o contexto

Se incluyeron notificaciones de SA en el Sistema de Notificación y Aprendizaje para Seguridad del Paciente (SiNASP).

Método

Variables de medida: incidente adverso (IA) si no alcanzó al paciente o no produjo daño, evento adverso (EA) si llegó al paciente con daño. Grado de daño clasificado como mínimo, menor, moderado, crítico y catastrófico. Evitabilidad registrada como escasa evidencia de ser evitable, 50% evitable y sólida evidencia de ser evitable. Análisis de datos: porcentajes y test de chi-cuadrado para variables cualitativas; p < 0,05 con SPSS.15 Fuente de datos: SiNASP. Consideraciones éticas: autorizado por el Comité de Ética de Investigación (2016/344).

Resultados

Se registraron 166 SA (50,0% hombres, 46,4% mujeres; edad media: 60,80 años). El 62,7% alcanzaron al paciente. EA: 45,8% produjeron daño mínimo y 2,4%, daño crítico. Los profesionales fueron factor contribuyente en el 71,7% de los EA, encontrándose tendencia a la asociación entre deficiente comunicación y ausencia de protocolos con el daño producido. Grado de evitabilidad: 96,4%.

Conclusiones

La mayoría de los SA alcanzaron al paciente, estando relacionados con la medicación, pruebas diagnósticas y errores de laboratorio. El grado de daño se asoció con problemas de comunicación, ausencia o deficiencia de protocolos y escasa cultura en seguridad.

[Integral incident management system in primary care: Beyond patient safety]

OBJECTIVE

To describe an integral system of notification and management of incidents, created by the Primary Care Team of Guineueta, as well as the main results after 18 months of implementation.

MATERIAL AND METHOD

Using a simple online form, health professionals notified any type of, already categorised, incident. Each of them were distributed to an improvement team that assessed and performed the necessary actions. In addition, the Quality Committee immediately assessed the ones that affected patient safety, as well as the most relevant or repetitive ones every 6 months.

RESULTS

During the first 18 months of operation of the system, the health professionals reported 1,267 incidents, most notably informatics, maintenance/technical assistance, and errors in scheduling, in internal circuits and protocols. Eight of them were considered to significantly affect patient safety.

CONCLUSIONS

The implementation of the described system has been consolidated into our team, facilitating the detection of problems, the accomplishment of improvement actions and involving the professionals in the improvement of the quality.

[Notification of incidents related to patient safety in hospitals in Catalonia, Spain during the period 2010-2013]

The aim of this paper is to discover the aggregated results of a general notification system for incidents related to patient safety implemented in Catalan hospitals from 2010 to 2013. Observational study describing the incidents notified from January 2010 to December 2013 from all hospitals in Catalonia forming part of the project to create operational patient safety management units. The Patient Safety Notification and Learning System (SiNASP) was used. This makes it possible to classify incidents depending on the area where they occur, the type of incident notified, the consequences, the seriousness according to the Severity Assessment Code (SAC) and the profession of the notifying party, as the principal variables. The system was accessed via the Internet (SiNASP portal). Access was voluntary and anonymous or with a name given and later removed. During the study period, notification of a total of 5,948 incidents came from 22-29 hospitals. 5,244 of the incidents were handled by the centres and these are the ones analysed in the study. 64% (3,380) affected patients, 18% (950) created a situation capable of causing an incident and 18% (914) did not affect patients. 26% of incidents that affected patients (864) caused some kind of harm. Most incidents occurred during hospitalisation (54%) and in casualty (15%), followed by the ICU (9%) and the surgical block (8%). The most frequent notifying parties were nurses (71%) followed by doctors (15%) and pharmacists (9%). In terms of severity, most incidents were classified as low-risk (37%) or incidents that did not affect the patient (36%). However, 40 cases (0.76%) of extreme risk should be highlighted. In terms of the types of incident notified, most were due to a medication error (26.8%), followed by falls (16.3%) and patient identification (10.6%). The majority of notifications were incidents that affected patients and, of these, 26% caused harm. In general, they occurred in hospitalisation units and notification was mostly given by nurses. The incident notification system is a tool that complements others for promoting a patient safety culture and defining the risk profile of a health organisation. The opportunity for learning from experience is the reason for the existence of the notification system.