Sistema de notificación de incidentes sin daño en el sistema de salud de Castilla y León

Abstract

Introduction and objective: Patient safety is an important part of the quality work in the Regional Health Management of Castilla y León. Numerous projects are part of this line, including the no-harm incident reporting system. Objective: Reporting incidents without harm can significantly improve patient safety and improve an organization's safety culture. Material and method: After an exhaustive analysis of the available systems, it was decided to develop an own system, SISNOT (system of notification of incidents without damage), which followed the characteristics recommended by the international organisms in relation to these systems in the health field. Results: 3249 notifications were made through SISNOT, between primary and specialized care, of which 48% could have had high damage in case of reoccurrence of the incident. Conclusions: The implementation of SISNOT has been carried out in all hospitals and in primary care. The results obtained are unequal in each unit. This is due to numerous local barriers: leadership, characteristics of professionals, etc. Although there is a common, lack of safety culture. This is a challenge to keep working.