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that should define the way the institution and each
of its professionals works.
Once the code was approved, a number of outreach
actions and evaluation strategies were planned,
which included the creation of a monitoring and
evaluation committee. At the same time, a process of
benchmarking was initiated with other institutions
that have carried out similar experiments and we
have been invited to present it at the 2nd Conference
on the Health Plan.
Patient Safety
Risks of medication
One-third of adverse events are due to the risks
associated with medication. Using the risks map, the
professionals have been able to highlight problems
in this area that they encounter in routine clinical
practice. The results show that, in half of cases, the
limitations associated with the computer application
prevent correct prescribing; as a result, changes
have been made and training sessions have been
reinforced.
Reducing the risk of hepatitis C transmission
Reducing the risk of hepatitis C transmission is one
of the more noteworthy lines of work in terms of
patient safety. With this goal in mind, the action
protocols for invasive procedures of a large part
of the departments in Hospital del Mar have been
revised in a process that will be extended to include
the other PSMAR centers.
Nursing care alerts
In the conventional hospitalization units, in with
clinical work station, a nursing care alert tool is
already in operation, linked to the quality indicators
that make it possible to identify problems within
24-48 hours and apply the corresponding corrective
actions.
Hand hygiene
Compliance with correct hand hygiene in our centers
is at between 61.1% and 76.3%. The @pren online
training platform has allowed 140 professionals to
follow one of the six editions of the course provided
by the Ministry of Health.
Emergency discharge reports
The emergency discharge reports have been
evaluated in order to detect areas for improvement
that make it possible to prevent adverse events.
The results show the need to better document the
different concepts, the medication indicated on the
discharge report and any additional tests.
Surgical check-list
The surgical check-list is followed 100% in scheduled
operations, but not always in major outpatient
surgery. Marking of the site to be operated on needs
to be improved, together with provision for risk of
major hemorrhages and antibiotic prophylaxis.
Communication with patients to
encourage empowerment
We have reviewed sources of information available
on the Internet in order to provide patients
with reliable, quality references. Furthermore,
a multidisciplinary team of professionals has
developed and presented a protocol for breaking
bad news, which is available over the intranet to the
entire organization.
Star projects
In the 2012 call for these projects, the objective of
which is to encourage initiatives for improving
quality of care, a total of 17 projects were submitted,
of which three were chosen: Clinical route of fracture
of proximal femur in the elderly patient, Intrahospital
sepsis code and Continuity of care in critical patients.
Quality > Objectives
>
Achieving accreditation from the Department
of Health by means of the external verification
mechanism allows PSMAR to continue to maintain
its contract with the main funder, CatSalut. The
accreditation also certifies our level of quality and
skill as an organization before third parties.
