[Implementation of a form for adverse effect notification: results for the 1st year]

Abstract

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.