[Implementation of a form for adverse effect notification: results for the 1st year]. / Implementación de un formulario para la notificación de eventos adversos: resultados del primer año.

OBJECTIVES: To describe the introduction of an incident monitoring system by electronic reporting in the Complejo Hospitalario de Toledo (CHT) and to analyse the initial results. MATERIALS AND METHOD: CHT is a public hospital with 750 beds, 59 for critical patients, an ambulatory surgery unit and three outpatient clinics. Access to the electronic reporting system is on the main screen of the hospital intranet. The reporting system is voluntary and confidential. It was introduced at the same time as setting up website on clinical safety and the provision of specific training on the subject. RESULTS: A total of 62 reports were received on the electronic system over a period of 12 months (December 2006 to December 2007), of which 74.5% were reported by nursing staff. The service from where it was reported most often was Geriatrics (43.1%). Most of the incidents were classified by the notifiers themselves as "no injury" (64.7%) and as "avoidable" 92.2%. A total of 56.9% were related to care. Some reports led to the issuing of three documents of recommendations by the Quality Unit and the Pharmacy Department. CONCLUSIONS: Most of the notifications were incidents related to care and were reported by nurses. The reporting system can complement other tools in promoting a clinical safety culture and defining the risk profile of a health organisation.

Implementación de un formulario para la notificación de eventos adversos: resultados del primer año / Introduction of a form for reporting adverse events: results from the first year

Objetivos: Describir la implementación de un programa de notificación de incidentes mediante un formulario electrónico en el Complejo Hospitalario de Toledo (CHT) y analizar los resultados iniciales.Material y método: El CHT es un hopital público que cuenta con 750 camas, 59 de ellas de cuidados críticos, una unidad de cirugía mayor ambulatoria y tres centros de especialidades. El icono para acceder al formulario electrónico de notificación de efectos adversos(FENEA) se encuentra en la pantalla inicial de la intranet, accesible a todos los profesionales. La notificación es voluntaria y anónima. La implementación fue simultánea a la de una web interna sobre seguridad clínica y a la impartición de formación específica sobre el tema.Resultados: Durante los primeros 12 meses (diciembre de 2006 a diciembre de 2007) se recibieron 62 notificaciones a través del FENEA. El personal de enfermería fue el que más notificó (74,5%). El servicio desde donde se notificó con mayor frecuencia fue geriatría (43,1% del total). La mayoría de los incidentes fueron clasificados por los propios notificadores como “sin lesión” (64,7%) y como “evitables” el 92,2%. El 56,9% estuvo relacionado con los cuidados en la atención. A partir de algunas notificaciones la unidad de calidad y el servicio de farmacia realizaron y difundieron tres documentosde recomendaciones.Conclusiones: La mayoría de las notificaciones fueron incidentes relacionados con los cuidados y fueron realizadas por enfermeras. La implementación de un FENEA puede ser una herramienta complementaria a otras para promocionar una cultura de seguridad clínica y definir el perfil de riesgos de una organización sanitaria

Objectives: To describe the introduction of an incident monitoring system by electronic reporting in the Complejo Hospitalario de Toledo (CHT) and to analyse the initial results.Materials and method: CHT is a public hospital with 750 beds, 59 for critical patients, an ambulatory surgery unit and three outpatient clinics. Access to the electronic reporting system is on the main screen of the hospital intranet. The reporting system is voluntary and confidential. It was introduced at the same time as setting up website on clinical safety and the provision of specific training on the subject.Results: A total of 62 reports were received on the electronic system over a period of 12 months (December 2006 to December 2007), of which 74.5% were reported by nursing staff. The service from where it was reported most often was Geriatrics (43.1%). Most of the incidents were classified by the notifiers themselves as “no injury” (64.7%) and as “avoidable” 92.2%. A total of 56.9% were related to care. Some reports led to the issuing of three documents of recommendations by the Quality Unit and the Pharmacy Department.Conclusions: Most of the notifications were incidents related to care and were reported by nurses. The reporting system can complement other tools in promoting a clinical safety culture and defining the risk profile of a health organisation (AU)