[Analysis of clinical Risk and adoption of shared procedures: experience of nephrology and dialysis unit of ASL BA]

Abstract

Currently, English scientific literature is lacking in studies showing that medical assistance may be delivered without errors. Since two years ago, the department of nephrology and urology of ASL BA has been establishing a process of clinical risk management.Starting with the reporting of a single error, a related database was subsequently developed, in order to validate technical and organizational procedures that would be of common use in the daily clinical practice.With regard to error reporting, the system of incident reporting was adopted: that is a structured collection of significant events for the safety of patients with a specific form for reporting to be filled out by health professionals. Reports have been collected, coded and analysed. Finally measures were adopted to reduce the recurrence of the error.This first phase consisted on writing the procedures in order to create structured diagnostic-therapeutic protocols. In 18 months of observation adopting the incident reporting form, 48 errors have been reported: 52% due to adverse events; 12.5% to adverse reactions; 31.2% near misses and 2% to sentinel events. In 35.4 % of cases the error occurred in the administration or prescription of drug therapies, in 18.7% of cases it occurred in the organizational stage, in 12.5% it was a surgical error, in 18.7% of cases the error was due to incorrect asepsis, in 8.3% of cases it occurred during the medical examination and finally in 8.3% during dialysis. An analysis of the error database resulted in the choice of more urgent procedures. It is our view that only the observation of procedures can ensure the achievement of a high quality with improved clinical outcomes, reduction of complications, elimination of inappropriate interventions and increased patient satisfaction.