Patient safety, or the minimisation of the risk of causing unnecessary harm as a result of health care, has been included in the Quality Plan for the NHS, as one of the priority strategies of the Ministry of Health and Social Policy, since 2005. The key element of this strategy is ensuring the collaboration of the autonomous communities and the explicit support of professionals and patients (more than 140 scientific societies and 22 patient and consumer associations signed the principles of Patient Safety) and other involved organisations.
Review of 2006-2008
Improving the culture of safety among professionals and patients at all care levels is
vital for changing the behaviour of organisations. For this reason a training programme
is being offered, in which over 5000 professionals have taken part so far, in collaboration
with various Spanish universities, in order to improve their skills in the prevention,
identification and minimisation of adverse events related to health care. Also, special
emphasis has been given to the dissemination of actions and reports using Information
Technology (IT), through the Patient Safety website and by participating in different
national and international forums (WHO, OECD, European Commission, among others)
as an opportunity to exchange experiences.
Research has been carried out to discover the frequency of adverse events associated
with health care, both at the hospital level, with the National Study on Adverse Events
linked to Hospitalisation (ENEAS 2005), and at the primary care level, with the Study on
Patient Safety in Primary Care (APEAS 2008). Studies on the appropriate use of medicines
and on indicators of best practices in NHS hospitals, among other topics, have also
been performed. In addition, 6 million euros have been allocated to the National Plan
for Scientific Research, Development and Innovation, with which to fund projects related
to strategies in health and patient safety in research conducted through the Carlos III
Health Institute in the area of the Evaluation of Health Care Technologies.
Of crucial importance is the development of systems for the reporting of adverse incidents
and events, as such systems can turn mistakes into learning experiences. Three legal
reports have been prepared in which national and international legislation is analysed
and a series of proposals set forth, with the aim of modifying Spain’s current legislation
in order to allow for a system of non-punitive reporting. Also, a reporting system model
is currently being piloted in the NHS in order to analyse its viability.
Through specific agreements with the autonomous communities, approximately 38
million euros have been allocated to funding the implementation of safe practices,
including: unequivocal identification of patients, hand hygiene, appropriate use of
medicines, prevention of Health Care Associated Infections (HCAI) and the preventionof adverse events associated with surgical procedures, among others. Efforts underway
since 2006 with patients and citizens have led to a Citizen Network of Trainers in Patient
Safety and to a virtual classroom offering training and information resources.
Activities planned 2009-2010
In the context of Spain’s presidency of the European Union, the 5th International
Conference on Patient Safety will be held in this country. Continued emphasis will be
given to improving the information and training available to professionals and patients
regarding patient safety.
A document will be drawn up to propose legislative modifications that would allow nonpunitive
reporting in Spain, and a prototype for an adverse event notification and reporting
system for the NHS will be presented. Work will continue in the validation of the indicators
proposed by the OECD and in the identification of key indicators that allow for evaluation of
the patient safety strategy at the NHS level.
Efforts towards increasing knowledge about the frequency of Adverse Effects and their
characteristics in health care facilities will be aimed especially at long-term care centres
and at primary care services during this period.
More steps will be taken to promote projects, both with the autonomous communities and
with scientific societies and other bodies (national and international), that encourage and
evaluate safe clinical practices, especially those related to the prevention of Health Care
Associated Infections (HCAI). In this respect, the results of the project “Bacteraemia Zero:
the prevention of bacteraemias associated with central vein catheters in Spain’s Intensive
Care Units” and of the Hand Hygiene Campaign will be presented. Both projects were
undertaken with the collaboration of the WHO’s World Alliance for Patient Safety, with the
participation of all the autonomous communities.
Participation of patients and citizens in the Patient Safety Strategy will be consolidated by means of the existing Citizen Network of Trainers in Patient Safety.
| Improving patient safety |
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-Improving information and the training of professionals in Patient Safety. -Proposing changes in the existing legislation to allow for non-punitive reporting of adverse events. -Designing and piloting a system for the reporting and notification of adverse incidents and events. -Identifying and validating a series of key indicators in patient safety, recommended by international organisations, by which to evaluate the strategy in place. -Promoting projects that encourage and evaluate safe practices in the NHS, at all levels of care, in conjunction with the autonomous communities and scientific societies. -Improving knowledge about adverse events in long-term care centres. -Consolidating the participation of patients and citizens in the Patient Safety Strategy. |