[Implementation of a form for adverse effect notification: results for the 1st year].
OBJECTIVE
To describe the introduction of an incident monitoring system by electronic reporting in the Complejo Hospitalario de Toledo (CHT) and to analyse the initial results.


METHODS
CHT is a public hospital with 750 beds, 59 for critical patients, an ambulatory surgery unit and three outpatient clinics. Access to the electronic reporting system is on the main screen of the hospital intranet. The reporting system is voluntary and confidential. It was introduced at the same time as setting up website on clinical safety and the provision of specific training on the subject.


RESULTS
A total of 62 reports were received on the electronic system over a period of 12 months (December 2006 to December 2007), of which 74.5% were reported by nursing staff. The service from where it was reported most often was Geriatrics (43.1%). Most of the incidents were classified by the notifiers themselves as "no injury" (64.7%) and as "avoidable" 92.2%. A total of 56.9% were related to care. Some reports led to the issuing of three documents of recommendations by the Quality Unit and the Pharmacy Department.


CONCLUSIONS
Most of the notifications were incidents related to care and were reported by nurses. The reporting system can complement other tools in promoting a clinical safety culture and defining the risk profile of a health organisation.
Pérez Blanco
Verónica
V
Unidad de Calidad, Complejo Hopitalario de Toledo, Toledo, Spain. vperez@sescam.jccm.es
Rubio Gómez
Isabel
I
Alarcón Gascueña
Piedad
P
Mateos Rubio
José
J
Herradón Cano
Matilde
M
Delgado García
Amadeo
A
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003195:Computer Communication Networks; D003219:Confidentiality; D001330:Electronic Data Processing; D005260:Female; D005568:Forms and Records Control; D019983:Guideline Adherence; D006779:Hospitals, Public / Q000458:organization & administration*; D006784:Hospitals, Teaching / Q000458:organization & administration*; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D009726:Nurses / Q000523:psychology; D015279:Organizational Culture; D016134:Organizational Policy; D010564:Personnel, Hospital / Q000523:psychology; D011785:Quality Assurance, Health Care; D012308:Risk Management / Q000379:methods / Q000458:organization & administration* / Q000706:statistics & numerical data; D013030:Spain; D035141:Voluntary Programs / Q000458:organization & administration; D035642:Whistleblowing; D055815:Young Adult