[Notification of incidents related to patient safety in hospitals in Catalonia, Spain during the period 2010-2013]. / Notificación de incidentes relacionados con la seguridad del paciente en los hospitales de Cataluña durante el período 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.

[Design, implementation and evaluation of a management model of patient safety in hospitals in Catalonia, Spain]. / Diseño, implantación y evaluación de un modelo de gestión de la seguridad del paciente en hospitales de Cataluña.

Since its inception in 2006, the Alliance for Patient Safety in Catalonia has played a major role in promoting and shaping a series of projects related to the strategy of the Ministry of Health, Social Services and Equality, for improving patient safety. One such project was the creation of functional units or committees of safety in hospitals in order to facilitate the management of patient safety. The strategy has been implemented in hospitals in Catalonia which were selected based on criteria of representativeness. The intervention was based on two lines of action, one to develop the model framework and the other for its development. Firstly the strategy for safety management based on EFQM (European Foundation for Quality Management) was defined with the development of standards, targets and indicators to implement security while the second part involved the introduction of tools, methodologies and knowledge to the management support of patient safety and risk prevention. The project was developed in four hospital areas considered higher risk, each assuming six goals for safety management. Some of these targets such as the security control panel or system of adverse event reporting were shared. 23 hospitals joined the project in Catalonia. Despite the different situations in each centre, high compliance was achieved in the development of the objectives. In each of the participating areas the security control panel was developed. Stable structures for safety management were established or strengthened. Training in patient safety played and important role, 1415 professionals participated. Through these kind of projects not only have been introduced programs of proven effectiveness in reducing risks, but they also provide to the facilities a work system that allows autonomy in diagnosis and analysis of the different risk situations or centre specific safety issues.

[Optimization of radiological scoliosis assessment]. / Optimización del estudio radiológico de la escoliosis.

Most scoliosis are idiopathic (80%) and occur more frequently in adolescent girls. Plain radiography is the imaging method of choice, both for the initial study and follow-up studies but has the disadvantage of using ionizing radiation. The breasts are exposed to x-ray along these repeated examinations. The authors present a range of recommendations in order to optimize radiographic exam technique for both conventional and digital x-ray settings to prevent unnecessary patients' radiation exposure and to reduce the risk of breast cancer in patients with scoliosis. With analogue systems, leaded breast protectors should always be used, and with any radiographic equipment, analog or digital radiography, the examination should be performed in postero-anterior projection and optimized low-dose techniques. The ALARA (as low as reasonable achievable) rule should always be followed to achieve diagnostic quality images with the lowest feasible dose.

Visión y evolución de la seguridad del paciente en Cataluña / No disponible

No disponible

Diseño, implantación y evaluación de un modelo de gestión de la seguridad del paciente en hospitales de Cataluña / Design, implementation and evaluation of a management model of patient safety in hospitals in Catalonia, Spain

Desde su creación en 2006, la Alianza para la Seguridad del Paciente ha tenido en Cataluña un papel muy destacado para impulsar y dar forma a una serie de proyectos relacionados con la estrategia del Ministerio de Sanidad, Servicios Sociales e Igualdad para la mejora de la seguridad del paciente. Uno de estos ha sido el proyecto de creación de unidades funcionales o comisiones de seguridad en los hospitales con el objetivo de facilitar la gestión de la seguridad del paciente. La estrategia se planteó en un determinado número de hospitales de Cataluña seleccionados en función de criterios de representatividad. La intervención se basó en 2 líneas de actuación: una, para enmarcar el modelo y otra, para su desarrollo. En el primer caso se definió la estrategia de gestión de la seguridad basada en el modelo EFQM (European Foundation for Quality Management) con la elaboración de estándares, objetivos e indicadores de seguridad que se proponía implementar, mientras que la segunda línea supuso la introducción de herramientas, metodologías y conocimientos como soporte a la gestión de la seguridad del paciente y a la prevención de riesgos. El proyecto se desarrolló en las 4 áreas del hospital consideradas de mayor riesgo, asumiendo cada una de ellas 6 objetivos de gestión de la seguridad. Algunos de estos objetivos, como el cuadro de mando o el sistema de notificación de eventos adversos, fueron compartidos por las 4 áreas. Se adhirieron al proyecto 23 hospitales de Cataluña. A pesar de las diferentes situaciones de cada centro se alcanzó un alto cumplimiento en el desarrollo de los objetivos. Se elaboró el cuadro de mando de seguridad en cada una de las áreas participantes. Se crearon o reforzaron estructuras estables para la gestión de la seguridad. La formación en seguridad del paciente, que tuvo un papel prioritario, llegó a 1.415 profesionales. A través de este tipo de proyectos no solo se introducen y desarrollan programas de efectividad contrastada en la reducción de riesgos, sino que se dota a los centros de una sistemática de trabajo que les permite la autonomía en el diagnóstico y análisis de las diferentes situaciones de riesgo o problemas de seguridad propios de cada centro (AU)

Since its inception in 2006, the Alliance for Patient Safety in Catalonia has played a major role in promoting and shaping a series of projects related to the strategy of the Ministry of Health, Social Services and Equality, for improving patient safety. One such project was the creation of functional units or committees of safety in hospitals in order to facilitate the management of patient safety. The strategy has been implemented in hospitals in Catalonia which were selected based on criteria of representativeness. The intervention was based on two lines of action, one to develop the model framework and the other for its development. Firstly the strategy for safety management based on EFQM (European Foundation for Quality Management) was defined with the development of standards, targets and indicators to implement security while the second part involved the introduction of tools, methodologies and knowledge to the management support of patient safety and risk prevention. The project was developed in four hospital areas considered higher risk, each assuming six goals for safety management. Some of these targets such as the security control panel or system of adverse event reporting were shared. 23 hospitals joined the project in Catalonia. Despite the different situations in each centre, high compliance was achieved in the development of the objectives. In each of the participating areas the security control panel was developed. Stable structures for safety management were established or strengthened. Training in patient safety played and important role, 1415 professionals participated. Through these kind of projects not only have been introduced programs of proven effectiveness in reducing risks, but they also provide to the facilities a work system that allows autonomy in diagnosis and analysis of the different risk situations or centre specific safety issues (AU)

Notificación de incidentes relacionados con la seguridad del paciente en los hospitales de Cataluña durante el período 2010-2013 / Notification of incidents related to patient safety in hospitals in Catalonia, Spain during the period 2010-2013

El objetivo de este artículo es describir los resultados agregados de un sistema de notificación genérico de incidentes relacionados con la seguridad del paciente, implantado en los hospitales catalanes desde 2010 a 2013. Se trata de un estudio observacional, descriptivo de los incidentes notificados desde enero de 2010 a diciembre de 2013, de todos los hospitales de Cataluña adheridos al proyecto de creación de unidades funcionales de gestión de la seguridad del paciente. Se utilizó el Sistema de Notificación y Aprendizaje para la Seguridad del Paciente (SiNASP), que permite clasificar los incidentes en función del área donde se producen, el tipo de incidente notificado, las consecuencias, la gravedad según el Severity Assessment Code (SAC) y la profesión del notificante como principales variables. El acceso al sistema se realizó a través de internet (portal SiNASP), fue voluntario y anónimo o nominativo con posterior anonimización. Durante el período de estudio notificaron entre 22 y 29 hospitales, con un total de 5.948 incidentes, de los cuales 5.244 fueron gestionados por los centros y son los que se analizan en el estudio. Un 64% (3.380) llegó al paciente, un 18% (950) creó una situación con capacidad de causar un incidente y un 18% (914) no llegó al paciente. De los incidentes que llegaron al paciente, un 26% (864) ocasionó algún daño. La mayoría de incidentes ocurrió en hospitalización (54%) y urgencias (15%), seguidos de UCI (9%) y bloque quirúrgico (8%). Los que más notificaron fueron los enfermeros (71%), seguidos de los médicos (15%) y de los farmacéuticos (9%). Atendiendo a la gravedad, la mayoría fueron clasificados de riesgo bajo (37%) o que el incidente no llegó al paciente (36%). No obstante destacan 40 casos (0,76%) de riesgo extremo. En relación con el tipo de incidente notificado, la mayoría fue por error en la medicación (26,8%), seguido por caídas (16,3%) e identificación del paciente (10,6%). La mayoría de las notificaciones fueron incidentes que llegaron al paciente y de ellos, un 26% ocasionó daño. En general ocurrieron en las unidades de hospitalización y fueron los enfermeros los que más notificaron. El sistema de notificación de incidentes es una herramienta complementaria a otras para promocionar una cultura de seguridad del paciente y definir el perfil de riesgos de una organización sanitaria. La oportunidad para aprender de la propia experiencia es la razón de ser del sistema de notificación (AU)

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 (AU)

Optimización del estudio radiológico de la escoliosis / Optimization of radiological scoliosis assessment

La mayoría de las escoliosis son idiopáticas (80%) y ocurren más frecuentemente en adolescentes y en el sexo femenino. La radiografía simple es el método de imagen de elección, tanto en el estudio inicial como en el seguimiento evolutivo, pero tiene el inconveniente de utilizar radiaciones ionizantes. Las mamas quedan en el campo de exposición durante estos estudios repetidos. Los autores presentan una serie de recomendaciones para optimizar la técnica de las exploraciones y los equipos radiográficos, tanto analógicos como digitales, para evitar dosis de irradiación innecesarias a los pacientes y reducir el riesgo de cáncer de mama en los pacientes con escoliosis. Cuando se utilizan equipos analógicos siempre debe utilizarse protector mamario plomado y, en todos los equipos, sean analógicos o digitales, hay que realizar la radiografía en proyección posteroanterior y con técnicas optimizadas de baja dosis. Hay que seguir siempre el principio ALARA (as low as reasonable achievable) para obtener imágenes diagnósticas de calidad con la dosis lo más baja posible (AU)

Most scoliosis are idiopathic (80%) and occur more frequently in adolescent girls. Plain radiography is the imaging method of choice, both for the initial study and follow-up studies but has the disadvantage of using ionizing radiation. The breasts are exposed to x-ray along these repeated examinations. The authors present a range of recommendations in order to optimize radiographic exam technique for both conventional and digital x-ray settings to prevent unnecessary patients' radiation exposure and to reduce the risk of breast cancer in patients with scoliosis. With analogue systems, leaded breast protectors should always be used, and with any radiographic equipment, analog or digital radiography, the examination should be performed in postero-anterior projection and optimized low-dose techniques. The ALARA (as low as reasonable achievable) rule should always be followed to achieve diagnostic quality images with the lowest feasible dose (AU)