Mappatura dei rischi clinici mediante l’integrazione delle fonti informative

Abstract

[Mapping of clinical risks through the integration of information sources]

At the IRCCS Rizzoli Orthopaedic Institute in Bologna (Italy) has been active a program of risk management since 2007. It provides integrated and systematic use of tools and sources of information related to the safety of patients, workers and environment and to the management of claims and litigation.

To define priorities for actions included in the «Plan to Safety» and to address appropriately the resources available for the reduction of adverse events, it was developed a mapping of risks through the integration of data from different information sources related to patient safety and obtained at the company level (Incident Reporting, Patient Complaints, Claims).
To classify the events was utilized the International Classification of Patient Safety (ICPS) developed by the World Health Organization (WHO).
It were used 875 reports derived from the three sources of information and they were related to the categories of class «Incident Type» of ICPS. Four categories of accidents were most frequently observed: «Clinical Process/Procedures» (20.0%), «Clinical Administration» (16.8%), «Documentation» (11.3%),«Medication/IV Fluids» (10.2%). For the class «Patient Outcomes» of ICPS were more frequently events with «None» harm (64.6%) and those with «Mild» harm (29.9%).

The classification with the ICPS system has proven to be a useful tool for a preliminary mapping of risks and identify critical areas to be tackled as a priority.
The ICPS introduces a conceptual framework for patient safety with which it is possible to make comparisons of the results of activities related to risk management both locally and at a regional and national level.