Original Title: Desarrollo y evaluación de herramientas para la seguridad del paciente que puedan ser incorporadas en la gestión de procesos asistenciales

Authors' objectives: 1) Assess the utility and feasibility of the systematic use, within a system of healthcare process management, of tools used in other areas for proactive risk evaluation and for the systematic cause analysis, 2) Design and evaluate the response to a critical incident notification system with regard to the safety of patients for possible incorporation into the management system of healthcare process nonconformities, 3) Disseminate safety culture.

Authors' results and conclusions: Eighty-eight per cent of process team professionals considered that, following the project, their perception of the possibility of creating a safer working environment had changed a great deal or quite a lot. Of the tools used, the AMFE and the London Protocol (LP) received the most favourable appraisals. 68.4% and 50% of professionals considered that the AMFE and LP were easy to use and no one considered that they were difficult. Everyone pointed out that, according to their experience, they allowed damage-restriction barriers to be introduced in processes. And although 50% of those who had used the AMFE and 25% of those who had used the PL considered that these took up a great deal of time, everyone used them again, pointing out that they considered that a suitable target might be to carry out one AMFE every year within the management of the process. With regard to the notification system, 84.6% of process teams and 38.4% of other professionals considered that it was easy to use, and no one considered that it was complex. The intensity of the notification varied from one process to another (1.4-20.5 notifications/month). The professionals who sent the largest number of notifications were those who had taken part in the information-awareness and feedback sessions organised within the framework of the project. When asked about their motives for not having sent any notification (27.1% of those who answered the questionnaire said that they had not notified incidents that they had witnessed), the motives related to the fact that these professionals were too busy to notify incidents or did not know how to do this. With regard to the utility of the notification system, in more than 60% of the notifications received, information was included concerning the factors that had contributed to the incident or the barriers that had mitigated the damage.

Authors' recommendations: The project has succeeded in changing the perception of professionals concerning the possibility of working in order to improve patient safety. There are numerous points of connection between risk management and process management according to the ISO 9001:2000 standard, which facilitates the integration of both tools. The AMFE and the London Protocol could be used by process teams within a system of healthcare process management. They are useful, simple tools that do not require a great deal of training. In order to improve the response to the notification system it will be necessary to continue working on the information-awareness of all professionals and on the integration of the notification system in the nonconformity system used habitually in process management.

Authors' methods: Non-controlled study. The project consisted of introducing risk management tools into the healthcare process management of six service organisations within the Basque Health Service, Osakidetza. Stages of the project: I) Preliminary Stage in which: 1) The risk management tools, taxonomies and the notification systems available were identified by means of a systematic review of the bibliography, 2) the priority of the tools identified was estimated bearing in mind their efficiency, simplicity and the need for training for use at a local level and in a habitual manner by the process teams, 3) the systems applications required to support the project were developed (design of a critical incidents notification system). II) A project stage that included: 1) the training in safety matters of process teams and other professionals of the units taking part in the project and 2) a test in which the implementation of the notification system and the use of priority risk management tools were tried out. III) An evaluation stage, through the analysis of notified incidents and of the use of anonymous questionnaires designed for process teams and health unit professionals.

Project Status: Completed

Year Published: 2008

URL for published report: https://www.euskadi.eus/contenidos/informacion/2008_osteba_publicacion/es_def/adjuntos/D_08_03_herra_seguri.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Basque Office for Health Technology Assessment (OSTEBA)</p>