PART I – STRUCTURE FOR THE RISK MANAGEMENT ASSISTANCE
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PART I – STRUCTURE FOR THE RISK MANAGEMENT ASSISTANCE
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Awareness
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Awareness
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1. Did the hospital promote any awareness-raising action for patient safety in the last year (event, campaign, etc.)? |
7 |
7 |
7 |
6 |
1. Has the institution promoted any awareness-raising action for patient safety in the last 12 months (event, campaign, etc.)? |
7 |
7 |
7 |
7 |
2. Are there posters, folders, posters or videos in the hospital drawing attention to patient safety? |
5/7 |
7/7 |
7/7 |
5/6 |
2. Are there in the institution posters, folders, posters or videos drawing attention to patient safety? |
7 |
7 |
7 |
7 |
Accountability
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Accountability
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3. Is there an organizational unit responsible for improving patient safety (called from now on National Patient Safety Program – PNSP)? |
7 |
7 |
7 |
7 |
3. Is there an organizational unit responsible for coordinating the actions of patient safety (called from now on to National Patient Safety Program – PNSP)? |
7 |
7 |
7 |
7 |
4. Does it have a PNSP coordinator been appointed? |
6 |
7 |
7 |
6,5 |
4. No adjustment |
7 |
7 |
7 |
7 |
5. Does the PNSP have a record of at least six meetings in the last 12 months? |
5/6 |
6/6 |
5/6 |
5/6 |
Eliminated after group discussion |
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6. Is there a National Patient Safety Plan running? |
7 |
6,5 |
7 |
7 |
5. No adjustment |
7 |
7 |
7 |
7 |
Ability
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Ability
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7. Does the NSP have professionals with formal workload dedication to risk management activities? |
6,5 |
7 |
6,5 |
6 |
6. Does the institution have professionals with formal workload dedication to risk management activities? |
7 |
7 |
7 |
7 |
8. Does the PNSP coordinator have exclusive dedication to risk management activities? |
6/6 |
6/7 |
5/6 |
5/6 |
Eliminated after group discussion |
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9. Is there allocation of financial resource for promotion of patient safety actions? |
6/6 |
6/6 |
4/5 |
6/5 |
Eliminated |
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10. Does the PNSP have adequate physical infrastructure? |
5/6 |
5/6 |
4/6 |
4/7 |
7. No adjustment |
7 |
7 |
7 |
7 |
11. Does the hospital provide adequate inputs for risk management actions? |
4/6 |
6/6 |
5/7 |
5/7 |
8. Does the institution provide adequate inputs for risk management actions? |
7 |
7 |
7 |
7 |
12. Did the hospital promote training to its professionals in the area (risk management, quality management, patient safety, etc.)? |
7 |
7 |
7 |
7 |
9. Did the institution promote training to its professionals in the area (risk management, quality management, patient safety, etc.)? |
7 |
7 |
7 |
7 |
Safety Culture
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Promoting patient safety culture
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13. Was the safety culture assessed in the last 12 months? |
5/7 |
7/7 |
5/7 |
6/7 |
10. Was the patient safety culture assessed in the last 24 months ? |
7 |
7 |
7 |
7 |
14. If it assessed the safety culture, were the results reported to clinical, administrative and care professionals? |
5/7 |
7/7 |
7/7 |
6/7 |
11. Did it communicate the results of the patient’s safety culture assessment to clinical, administrative and care professionals?
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7 |
7 |
7 |
7 |
15. If it assessed the safety culture, were implemented any interventions to improve the results identified in the assessment? |
7 |
7 |
6,5 |
7 |
12. Did it implement any intervention to improve the results identified in the assessment of the patient’s safety culture?
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7 |
7 |
7 |
7 |
PART 2 – PROCESSES FOR THE RISK MANAGEMENT ASSISTANCE Risk identification
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PART 2 – PROCESSES FOR THE RISK MANAGEMENT ASSISTANCE Risk identification
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16. Does the hospital have a general list of the care risks identified in the institution? |
6 |
7 |
7 |
7 |
Eliminated after group discussion |
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17. Does it use an internal system to notify incidents? |
6 |
7 |
6 |
7 |
13. No adjustment |
7 |
7 |
7 |
7 |
18. Did the hospital disclose a list of sentinel events or never events for notification among professionals? |
6 |
6,5 |
7 |
6 |
14. No adjustment |
7 |
7 |
7 |
7 |
19. Does it monitor adherence to international patient safety goals? |
6,5 |
6 |
6 |
6 |
15. Does it monitor indicators of adherence to international patient safety goals? |
7 |
7 |
7 |
7 |
20. Does the hospital use information on complaints and appeals (ombudsman’s office) to identify risks? |
7 |
7 |
7 |
7 |
16. No adjustment |
7 |
7 |
7 |
7 |
21. Does it use triggers or result tracker indicators to identify risks? |
7/6 |
7/7 |
5/7 |
6/7 |
17. Does it use tracker indicators ( clues to the existence of security incidents ) or result indicators to identify risks? |
7 |
7 |
7 |
7 |
22. Does it have a death review committee with meetings in the last six months (minutes)? |
6 |
6 |
6 |
6 |
18. Does it use the information on the death review committee to identify risks?
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7 |
7 |
7 |
7 |
23. Does it use the litigious processes of the hospital for risk identification? |
6/7 |
6/7 |
6/7 |
5/7 |
19. Does it analyzes the litigious processes of the hospital for risk identification? |
7 |
7 |
7 |
7 |
24. Does it use direct observation to identify risks? (e.g. examination of hand hygiene, contact precautions with patients in isolation, protective barriers in the insertion of Central Venous Catheter, etc.)? |
7 |
6 |
7 |
7 |
20. No adjustment |
7 |
7 |
7 |
7 |
25. Does it use electronic alert or support system for decision-making in electronic medical records (e.g. drug interactions, standardized discharge recommendations for specific patients, etc.)? |
5/6 |
5/7 |
6/6 |
7/6 |
21. Does it use electronic alert system in electronic medical records (e.g. drug interactions, standardized discharge recommendations for specific patients etc.)?
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7 |
7 |
7 |
7 |
26. Does it use checklists for patient safety? |
7 |
7 |
7 |
7 |
22. No adjustment |
7 |
7 |
7 |
7 |
27. Does it use risk mapping? |
7 |
7 |
7 |
7 |
23. Did it carry out risk mapping of the health service? |
7 |
7 |
7 |
7 |
28. Do security officials conduct security rounds in sectors to identify risks? |
6 |
7 |
7 |
6 |
24. Are patient safety rounds performed in the sectors to identify risks? |
7 |
7 |
7 |
7 |
29. Does it confirm the use of external source to identify possible risks of at the institution (e.g. health alerts, media news, etc.)? |
6 |
7 |
7 |
6 |
25. Does it use external source for risk identification (e.g. health alerts, media news, etc.)?
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7 |
7 |
7 |
7 |
Risk assessment analysis
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Risk assessment analysis
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30. Did it investigate (analysis of causes and contributing factors) any adverse events in the last 12 months? |
7 |
7 |
7 |
7 |
26. Did it perform analysis of causes and contributing factors for adverse events in the last 12 months?
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7 |
7 |
7 |
7 |
31. Does it use instruments for qualitative analysis of causes and contributing factors (flowchart, cause-effect diagram, force-field analysis, Bow Tie, brainstorming, etc.)? |
7 |
7 |
7 |
7 |
27. No adjustment |
7 |
7 |
7 |
7 |
32. Does it use instruments for quantitative analysis of causes or contributing risk factors (histogram, stratification, Pareto diagram and control chart)? |
7 |
7 |
7 |
7 |
28. No adjustment |
7 |
7 |
7 |
7 |
33. Does it use any risk prioritization matrix based on severity and frequency criteria? |
7 |
7 |
7 |
7 |
29. No adjustment |
7 |
7 |
7 |
7 |
34. Does it assess the adequacy of risk control or reduction measures? |
7 |
7 |
7 |
7 |
Eliminated after group discussion |
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Risk treatment
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Risk treatment
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35. Did it implement basic clinical protocols for patient safety? |
7 |
7 |
7 |
7 |
30. No adjustment |
7 |
7 |
7 |
7 |
36. Did it implement action plans in reaction to investigated adverse events? |
7 |
7 |
7 |
7 |
31. No adjustment |
7 |
7 |
7 |
7 |
37. Does the hospital describe the responsible for the implementation for risk reduction actions? |
7 |
7 |
7 |
7 |
Questions adjusted in the 2nd vote to: 32. Does it present a complete action plan (schedule, responsible, resources and indicators) for risk reduction actions?
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7 |
7 |
7 |
7 |
38. Does the hospital describe the implementation schedule for risk reduction actions? |
7 |
7 |
7 |
7 |
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39. Does the hospital describe and measure indicators of implementation and effectiveness of risk reduction actions? |
6 |
7 |
7 |
7 |
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40. Does the hospital describe the resources needed for care risk reduction actions? |
5/7 |
6/7 |
6/7 |
6/7 |
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Risk communication
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Risk communication
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41. Does the high management receive periodic communication on the activities and results of care risk management? |
7 |
7 |
7 |
7 |
Do stakeholders of questions 33-35 receive periodic communication on the activities and results of care risk management? 33. High Management 34. Intermediary managers and clinical leaders 35. Care professionals
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7 |
7 |
7 |
7 |
42. Do intermediary managers and clinical leaders receive periodic communication on the activities and results of care risk management? |
7 |
7 |
7 |
7 |
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43. Do care professionals receive periodic communications on the activities and results of care risk management? |
7 |
7 |
7 |
7 |
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44. Is the communication to patients about the adverse events (open disclosure of errors) that occurred standardized through any institutional norms, protocol or policy? |
6 |
7 |
6 |
6 |
36. No adjustment |
7 |
7 |
7 |
7 |
45. Does the hospital have sent external notifications (e.g. NOTIVISA) regularly in the last 12 months? |
7 |
7 |
7 |
7 |
37. Does it perform external notification by the NOTIVISA system monthly?
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7 |
7 |
7 |
7 |
Integration of risk management processes
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Integration of risk management processes
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46. Did the hospital perform a complete cycle of risk management (identification, analysis, assessment, treatment and monitoring of risk) in the last 12 months? |
7 |
7 |
7 |
7 |
38. Did it perform a complete cycle of risk management (identification, analysis, assessment, treatment and monitoring) or cycle of quality improvement focused on patient safety (PDCA, assessment and improvement cycle) in the last 12 months? |
7 |
7 |
7 |
7 |
47. Did it record the conduction of Root Cause Analyses or the London Protocol in the last 12 months? |
6 |
7 |
6 |
7 |
39. Did the hospital conduct the Root Cause Analyses or the London Protocol in the last 12 months? |
7 |
7 |
7 |
7 |
48. Did it record the conduction of Failure Mode and Effect Analysis (FMEA) in the last 12 months? |
6 |
7 |
6 |
6 |
40. Did it perform the Failure Mode and Effect Analysis (FMEA) in the last 12 months? |
7 |
7 |
7 |
7 |