ANALYSIS OF PATIENT SAFETY INCIDENTS REPORTS AT A UNIVERSITARY HOSPITAL

Author(s)

Mora-Santiago MR, Moya-Carmona I, Estaun-Martinez C, Ortiz J, Rodriguez Nieto A
HOSPITAL VIRGEN DE LA VICTORIA, MALAGA, Spain

OBJECTIVES: Patient safety team pharmacists are electronically notified when patient safety incidents (PSI) are submitted through the safety incident management system (SIMS) provided by the regional Quality Agency.The objective of the study was to analyze the PSI reported at a universitary hospital, and to evaluate pharmacist’s activity in this area according to acceptance of recommendations on how to avoid such incidents.

METHODS: Retrospective analysis of the notified PSIs, from January 1st to December RESULTS: During the reporting period, 49 reports from the SIMS were reviewed.

-Half of the reports originated from the surgery department and emergency room (30,62% and 22,45% respectively).-The most frequent types of PSI were related to medication management process (57%), isoappearance (19%) and patient identification (13%).-The PSIs were categorised according to risk into 4 groups, very high (24.49%),high (44.89%),moderate (20.42%)and low risk (10.20%).-Recommendations made by the pharmacist included working on information diffusion through the electronic prescription system, new drugs administration, and drug management. Pharmacists also improved the electronic prescription system by introducing Tall Man Letters in the medicine description. In 87% of cases suggestions were accepted.

CONCLUSIONS: Pharmacists must actively engage in quality improvement and patient safety programs to analyze PSIs, barriers to patient safety, and strategies to improve this area. The inclusion of a pharmacist in the patient safety team not only provides more security for the patients, but also strengthens the relationship between pharmacists and other healthcare professionals.

Conference/Value in Health Info

2018-11, ISPOR Europe 2018, Barcelona, Spain

Value in Health, Vol. 21, S3 (October 2018)

Code

PMU23

Topic

Epidemiology & Public Health

Topic Subcategory

Safety & Pharmacoepidemiology

Disease

Multiple Diseases

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