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5PSQ-046 Impact of the COVID-19 pandemic on a notification and learning system for patient safety in a psychiatric hospital
  1. J Velasco Costa,
  2. EM Robles Blazquez,
  3. JM Peñalver Gonzalez,
  4. JM Gonzalez Matas,
  5. C Saez Saez,
  6. MD Sanchez Flores,
  7. M Martinez de Guzman
  1. Hospital Psiquiatrico Roman Alberca, Farmacia, Murcia, Spain


Background and importance The incident notification system is a tool that complements others for promoting a patient safety culture and defining the risk profile of a health organisation.

Aim and objectives This study was carried out to find out how the COVID-19 pandemic has influenced the number of notifications of incidents related to patient safety through the evolution of a notification and learning system for patient safety (SiNASP) since its implementation.

Material and methods The classification of reported incidents was done with the matrix of the ‘Severity Assessment Code’ (SAC); SAC=1 extreme risk, SAC=2 high risk, SAC=3, medium risk, SAC=4, low risk, No-SAC=does not reach the patient.

Descriptive study of the results obtained from the analysis of the notifications received from its implementation 2011–2020.

SPSS program (p≤0.05).

Results 295 incidents related to the safety of patients at the psychiatric hospital or one of its resources were reported.

%SAC=2 was 11.9%,%SAC=3 of 24.1%,%SAC=4 of 24.8% and without-SAC 39.3% of the incidents.

94.6% (n=199) of notifications occurred in hospitalisation, with nursing being the professional group that made the most notifications (53.2%).

27.5% were situations with the capacity to cause an incident, 11.9% incidents that did not reach the patient and 60.7% (179) reached the patient; of the latter, 39.3% (116) did not cause damage, 21.0% (62) caused temporary damage and required intervention or prolonged hospitalisation, and 0.3% (1) compromised the patient’s life.

Most frequently recorded incident is related to medication (17.8%), followed by infrastructure problems (13.4%) and altered/aggressive behaviour (12.6%).

By year, a statistically significant decrease (p<0.05) is observed in the number of notifications in 2020 (13) and the increasing annual average of the previous years (34.3).

Average number of reports disseminated/case presentation sessions was 7.1 until 2019 and only 2 in 2020.

Conclusion and relevance Nursing is the group that reports the most, and the notification of incidents should be promoted to the rest of the healthcare personnel.

During the pandemic, a significant reduction in the reporting of incidents was observed, possibly due to the increased workload and attention to other priority activities of healthcare professionals associated with COVID.

The development of newsletters to disseminate the results of the SiNASP among healthcare providers and the holding of training sessions for new staff have also been negatively affected by the pandemic, having previously proven to be a useful tool for promoting a culture of safety among sanitary professionals.

Conflict of interest No conflict of interest

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