PMU23 - ANALYSIS OF PATIENT SAFETY INCIDENTS REPORTS AT A UNIVERSITARY HOSPITAL

Abstract

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. Retrospective analysis of the notified PSIs, from January 1st to December 31st 2017. Data were retrieved from the SIMS, a non-punitive voluntary report system. The following data were collected: classification of incident types (description of what and when happened), hospital unit (and where happened), level of risk (according to the risk matrix proposed by the SIMS), health professional who notify, and pharmacist’s recommendations given to avoid such incidents. The acceptance of the recommendations was audited after three months for each PSI. 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. 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.