1
|
Pintado Delgado MC, Sánchez Navarro IM, Baldominos Utrilla G. Medication errors reported in an adult Intensive Care Unit in a level 2 hospital in Spain. Med Intensiva 2023; 47:736-738. [PMID: 37867117 DOI: 10.1016/j.medine.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/31/2023] [Accepted: 08/20/2023] [Indexed: 10/24/2023]
Affiliation(s)
| | | | - Gemma Baldominos Utrilla
- Hospital Pharmacy Service, Príncipe de Asturias Universitary Hospital, Alcalá de Henares, Madrid, Spain
| |
Collapse
|
2
|
Martínez-Sabater A, Saus-Ortega C, Masiá-Navalon M, Chover-Sierra E, Ballestar-Tarín ML. Spanish Version of the Scale "Eventos Adversos Associados às Práticas de Enfermagem" (EAAPE): Validation in Nursing Students. NURSING REPORTS 2022; 12:112-124. [PMID: 35225898 PMCID: PMC8883960 DOI: 10.3390/nursrep12010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Healthcare carried out by different health professionals, including nurses, implies the possible appearance of adverse events that affect the safety of the patient and may cause damage to the patient. In clinical practice, it is necessary to have measurement instruments that allow for the evaluation of the presence of these types of events in order to prevent them. This study aims to validate the "Eventos adversos associados às práticas de enfermagem" (EAAPE) scale in Spanish and evaluate its reliability. The validation was carried out through a cross-sectional study with a sample of 337 nursing students from the University of Valencia recruited during the 2018-19 academic year. An exploratory factor analysis was carried out using principal components and varimax rotation. The factor analysis extracted two factors that explained 32.10% of the total variance. Factor 1 explains 22.19% and refers to the "adverse results" of clinical practice (29 items), and factor 2 explains 9.62% and refers to "preventive practices" (24 items). Both factors presented high reliability (Cronbach's alpha 0.902 and 0.905, respectively). The Spanish version of the EAAPE is valid and reliable for measuring the perception of adverse events associated with nursing practice and the presence of prevention measures.
Collapse
Affiliation(s)
- Antonio Martínez-Sabater
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 València, Spain; (A.M.-S.); (M.L.B.-T.)
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 València, Spain;
- Grupo Investigación en Cuidados (INCLIVA), Hospital Clínico Universitario de Valencia, 46010 València, Spain
| | - Carlos Saus-Ortega
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 València, Spain;
- Nursing School “La Fe”, Generalitat Valenciana, 46026 València, Spain
| | | | - Elena Chover-Sierra
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 València, Spain; (A.M.-S.); (M.L.B.-T.)
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 València, Spain;
- Internal Medicine, Consorcio Hospital General Universitario de Valencia, 46014 València, Spain
| | - María Luisa Ballestar-Tarín
- Nursing Department, Facultat d’Infermeria i Podologia, Universitat de València, 46010 València, Spain; (A.M.-S.); (M.L.B.-T.)
- Nursing Care and Education Research Group (GRIECE), GIUV2019-456, Nursing Department, Universitat de Valencia, 46010 València, Spain;
| |
Collapse
|
3
|
Torres Y, Rodríguez Y, Pérez E. [How to improve the quality of healthcare services and patient safety by adopting strategies from the aviation sector?]. J Healthc Qual Res 2021; 37:182-190. [PMID: 34887228 DOI: 10.1016/j.jhqr.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/26/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE The World Health Organization recognizes patient safety as a priority as part of its global strategy to improve the quality of health services. However, several initiatives need to be integrated and systematized to increase the reliability of healthcare systems. This article discusses several management strategies developed in the aviation sector that have led to a drastic decrease in the accident rate. The aim is to describe each strategy and contrast them with their application in the healthcare sector. METHODS Different results and recommendations from the literature and institutions such as the World Health Organization and the International Civil Aviation Organization were consulted and compiled. A synthesis of the identified strategies was made, highlighting examples of their application and impact. RESULTS Five key strategies were identified: 1) no-blame incident reporting systems, 2) systematic use of checklists, 3) recurrent training and use of simulation, 4) management of fatigue and work schedules, and 5) management of teamwork. CONCLUSIONS The strategies from the aviation sector are presented as a valuable reference for improving patient safety and the quality of healthcare services. They should be consolidated and harmoniously integrated into the design and management of health systems.
Collapse
Affiliation(s)
- Y Torres
- Department of Mechanical Engineering, École de Technologie Supérieure, Montreal, Canadá.
| | - Y Rodríguez
- Facultad Nacional de Salud Pública, Universidad de Antioquia, Medellín, Colombia
| | - E Pérez
- Facultad de Ingeniería Industrial, Universidad Pontificia Bolivariana, Medellín, Colombia
| |
Collapse
|
4
|
Ramírez E, Martín A, Villán Y, Lorente M, Ojeda J, Moro M, Vara C, Avenza M, Domingo MJ, Alonso P, Asensio MJ, Blázquez JA, Hernández R, Frías J, Frank A. Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: Prospective evaluation through real-time observations of patient safety incidents. Medicine (Baltimore) 2018; 97:e12509. [PMID: 30235764 PMCID: PMC6160204 DOI: 10.1097/md.0000000000012509] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The effectiveness of a hospital incident-reporting system (IRS) on improve patient safety is unclear. This study objective was to assess which implemented improvement actions after the analysis of the incidents reported were effective in reduce near-misses or adverse events.Patient safety incidents (PSIs), near misses and adverse events, notified to the IRS were analyzed by local clinical safety leaders (CSLs) who propose and implement improvement actions. The local CSLs received training workshops in patient safety and analysis tools. Following the notification of a PSI in the IRS, prospective real-time observations with external staff were planned to record and rated the frequency of that PSI. This methodology was repeated after the implementation of the improvement actions.Ultimately, 1983 PSIs were identified. Surgery theaters, emergency departments, intensive care units, and general adult care units comprised 82% of all PSIs. The PSI rate increased from 0.39 to 3.4 per 1000 stays in 42 months. A significant correlation was found between the reporting rate per month and the number of workshop-trained local CSLs (Spearman coefficient = 0.874; P = .003). A total of 24,836 real-time observations showed a statistically significant reduction in PSIs observed in 63.15% (categories: medication P = .044; communication P = .037; technology P = .009) of the implemented improvements actions, but not in the organization category (P = .094). In the multivariate analyses, the following factors were associated with the reduction in near misses or adverse events after the implementation of the improvement actions: "adverse event" type of PSI (odds ratio [OR], 3.67; 95% confidence interval [CI], 1.93-5.74), "disussion group" type of analysis (OR, 2.45; 95% CI, 1.52-3.76), and root cause type of analysis (OR, 2.32; 95% CI: 1.17-3.90).The implementation of a hospital IRS, together with the systematization of the method and analysis of PSIs by workshop-trained local CSLs led to an important reduction in the frequency of PSIs.
Collapse
Affiliation(s)
- Elena Ramírez
- Functional Risk Management Unit
- Department of Clinical Pharmacology, School of Medicine, Autonomous University of Madrid
| | - Alberto Martín
- Functional Risk Management Unit
- Department of Management Control
| | - Yuri Villán
- Functional Risk Management Unit
- Quality Medical Unit
| | | | - Jonay Ojeda
- Functional Risk Management Unit
- Quality Medical Unit
| | - Marta Moro
- Functional Risk Management Unit
- Department of Hospital Pharmacy
| | - Carmen Vara
- Functional Risk Management Unit
- Quality Nurse Unit
| | - Miguel Avenza
- Functional Risk Management Unit
- Physiotherapy, Rehabilitation Department
| | | | - Pablo Alonso
- Functional Risk Management Unit
- Department of Neurology
| | | | - José A. Blázquez
- Functional Risk Management Unit
- Department of Cardiac Surgery, University Hospital La Paz-Cantoblanco-Carlos III, IdiPAZ, Madrid, Spain
| | - Rafael Hernández
- Department of Clinical Pharmacology, School of Medicine, Autonomous University of Madrid
| | - Jesús Frías
- Department of Clinical Pharmacology, School of Medicine, Autonomous University of Madrid
| | | |
Collapse
|
5
|
Caba Barrientos F, Rodríguez Morillo A, Galisteo Domínguez R, Del Nozal Nalda M, Almeida González CV, Echevarría Moreno M. What have we learned from reporting safety incidents in the Surgical Block?: Cross-sectional descriptive study of two-years of activity of a multidisciplinary analytical group. ACTA ACUST UNITED AC 2018; 65:258-268. [PMID: 29373190 DOI: 10.1016/j.redar.2017.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 12/12/2017] [Accepted: 12/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Incident Reporting Systems (IRS) are considered a tool that facilitates learning and safety culture. Using the experience gained with SENSAR, we evaluated the feasibility and the activity of a multidisciplinary group analyzing incidents in the surgical patient notified to a general community system, that of the Observatory for Patient Safety (OPS). MATERIAL AND METHOD Cross-sectional observational study planned for two years. After training in the analysis, a multidisciplinary group was created in terms of specialties and professional categories, which would analyze the incidents in the surgical patient notified to the OPS. Incidents are classified and their circumstances analyzed. RESULTS Between March 2015 and 2017, 95 incidents were reported (4 by non-professionals). Doctors reported more than nurses, at 54 (56.84%) vs. 37 (38.94%). The anaesthesia unit reported most at 46 (48.42%) (P=.025). The types of incidents mainly related to the care procedure (30.52%); to the preoperative period (42.10%); and to the place, the surgical area (48.42%). Significant differences were detected according to the origin of the notifier (P=.03). No harm, or minor morbidity, constituted 88% of the incidents. Errors were identified in 79%. The analysis of the incidents directed the measures to be taken. CONCLUSIONS The activity undertaken by the multidisciplinary analytical group during the period of study facilitated knowledge of the system among the professionals and enabled the identification of areas for improvement in the Surgical Block at different levels.
Collapse
Affiliation(s)
- F Caba Barrientos
- Grupo local de SENSAR, Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España.
| | - A Rodríguez Morillo
- Grupo local de SENSAR, Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - R Galisteo Domínguez
- Subdirección de Enfermería del Bloque Quirúrgico, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - M Del Nozal Nalda
- Subdirección Médica y Calidad del Bloque Quirúrgico, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| | - C V Almeida González
- Unidad de Metodología y Estadística de Investigación, Universidad de Sevilla, Sevilla, España
| | - M Echevarría Moreno
- Dirección de la Unidad de Gestión Clínica de Anestesia y Reanimación, Hospital Universitario Nuestra Señora de Valme, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, España
| |
Collapse
|
6
|
Guerra-García MM, Campos-Rivas B, Sanmarful-Schwarz A, Vírseda-Sacristán A, Dorrego-López MA, Charle-Crespo Á. [Description of contributing factors in adverse events related to patient safety and their preventability]. Aten Primaria 2017; 50:486-492. [PMID: 29183678 PMCID: PMC6836922 DOI: 10.1016/j.aprim.2017.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 11/13/2022] Open
Abstract
Objetivo Evaluar el grado en que los sucesos adversos (SA) ligados a la asistencia sanitaria alcanzan al paciente y su severidad. Analizar los factores contribuyentes a la aparición de SA, la relación con el daño provocado y el grado de evitabilidad. Diseño Estudio descriptivo retrospectivo. Emplazamiento Servicio de Atención Primaria de Porriño desde enero de 2014 a abril de 2016. Participantes y/o contexto Se incluyeron notificaciones de SA en el Sistema de Notificación y Aprendizaje para Seguridad del Paciente (SiNASP). Método Variables de medida: incidente adverso (IA) si no alcanzó al paciente o no produjo daño, evento adverso (EA) si llegó al paciente con daño. Grado de daño clasificado como mínimo, menor, moderado, crítico y catastrófico. Evitabilidad registrada como escasa evidencia de ser evitable, 50% evitable y sólida evidencia de ser evitable. Análisis de datos: porcentajes y test de chi-cuadrado para variables cualitativas; p < 0,05 con SPSS.15 Fuente de datos: SiNASP. Consideraciones éticas: autorizado por el Comité de Ética de Investigación (2016/344). Resultados Se registraron 166 SA (50,0% hombres, 46,4% mujeres; edad media: 60,80 años). El 62,7% alcanzaron al paciente. EA: 45,8% produjeron daño mínimo y 2,4%, daño crítico. Los profesionales fueron factor contribuyente en el 71,7% de los EA, encontrándose tendencia a la asociación entre deficiente comunicación y ausencia de protocolos con el daño producido. Grado de evitabilidad: 96,4%. Conclusiones La mayoría de los SA alcanzaron al paciente, estando relacionados con la medicación, pruebas diagnósticas y errores de laboratorio. El grado de daño se asoció con problemas de comunicación, ausencia o deficiencia de protocolos y escasa cultura en seguridad.
Collapse
Affiliation(s)
- María Mercedes Guerra-García
- Farmacia de Atención Primaria, Servizo de Atención Primaria de Porriño, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, O Porriño, Pontevedra, España.
| | - Beatriz Campos-Rivas
- Medicina Familiar y Comunitaria, Hospital Álvaro Cunqueiro, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, Vigo, Pontevedra, España
| | - Alexandra Sanmarful-Schwarz
- Medicina Familiar y Comunitaria, Servizo de Atención Primaria de Porriño, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, O Porriño, Pontevedra, España
| | - Alicia Vírseda-Sacristán
- Medicina Familiar y Comunitaria, Servizo de Atención Primaria de Porriño, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, O Porriño, Pontevedra, España
| | - M Aránzazu Dorrego-López
- Medicina Familiar y Comunitaria, Hospital Álvaro Cunqueiro, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, Vigo, Pontevedra, España
| | - Ángeles Charle-Crespo
- Medicina Familiar y Comunitaria, Servizo de Atención Primaria de Porriño, Estructura Organizativa de Xestión Integrada de Vigo, Servizo Galego de Saúde, O Porriño, Pontevedra, España
| |
Collapse
|
7
|
[Analysis of an incident notification system and register in a critical care unit]. ENFERMERIA INTENSIVA 2016; 27:112-9. [PMID: 27320867 DOI: 10.1016/j.enfi.2015.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/26/2015] [Accepted: 12/29/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To analyse the incident communicated through a notification system and register in a critical care unit. METHODOLOGY A cross-sectional descriptive study was conducted by performing an analysis of the records of incidents communicated anonymously and voluntarily from January 2007 to December 2013 in a critical care unit of adult patients with severe trauma. STUDY VARIABLES incident type and class, professional reports, and suggestions for improvement measures. A descriptive analysis was performed on the variables. RESULTS Out of a total of 275 incidents reported, 58.5% of them were adverse events. Incident distributed by classes: medication, 33.7%; vascular access-drainage-catheter-sensor, 19.6%; devices-equipment, 13.3%, procedures, 11.5%; airway tract and mechanical ventilation, 10%; nursing care, 4.1%; inter-professional communication, 3%; diagnostic test, 3%; patient identification, 1.1%, and transfusion 0.7%. In the medication group, administrative errors accounted for a total of 62%; in vascular access-drainage-catheter-sensor group, central venous lines, a total of 27%; in devices and equipment group, respirators, a total of 46.9%; in airway self-extubations, a total of 32.1%. As regards to medication errors, 62% were incidents without damage. Incident notification by profession: doctors, 43%, residents, 5.6%, nurses, 51%, and technical assistants, 0.4%. CONCLUSIONS Adverse events are the most communicated incidents. The events related to medication administration are the most frequent, although most of them were without damage. Nurses and doctors communicate the incidents with the same frequency. In order to highlight the low incident notification despite it being an anonymous and volunteer system, therefore, it is suggested to study measurements to increase the level of communication.
Collapse
|
8
|
Anglès R, Llinás M, Alerany C, Garcia MV. [Incident reporting system and management of incidents: Implementation and improvement actions derived for patient safety]. Med Clin (Barc) 2013; 140:320-4. [PMID: 23246168 DOI: 10.1016/j.medcli.2012.09.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/27/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Roser Anglès
- Unidad Funcional para la Seguridad del Paciente, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | | | | | | |
Collapse
|
9
|
Sánchez-Muñoz LA, Monteagudo-Nogueira B, Aceves-Gamarra H, Mayor-Toranzo E. [Medication errors map and patient safety]. Aten Primaria 2012; 44:444-5. [PMID: 22209296 PMCID: PMC7025223 DOI: 10.1016/j.aprim.2011.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 09/29/2011] [Indexed: 10/14/2022] Open
|
10
|
Pallarés-Carratalá V, Gil-Alcamí J, Marzá-Albalate F, Vitaller-Burillo J, Gil-Guillén V, Segarra-Castelló L, Oliva-García S, Gala-Fernández J, Aranaz-Andrés JMA. [Analysis of a register for reporting adverse events to a mutual insurance society for accidents at work. Adverse event reporting of occupational injuries]. REVISTA DE CALIDAD ASISTENCIAL : ORGANO DE LA SOCIEDAD ESPANOLA DE CALIDAD ASISTENCIAL 2012; 27:204-211. [PMID: 22497883 DOI: 10.1016/j.cali.2012.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 01/09/2012] [Accepted: 02/07/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To describe the results of a voluntary reporting system for adverse events in a Patient Safety Program of an occupational injuries mutual insurance company. METHOD In 2008 a system of notification and registration of adverse events (actual or potential) was introduced in 2008 by the Union de Mutuas, an occupational injuries insurance company with 36 health centres, and provides coverage for 259,922 workers. The reporting questionnaire covers all areas of health care provided by the mutual company. Access to the questionnaire was conducted through the intranet, was voluntary and anonymous. The notifications registered between 1 January 2009 and 31 December 2010 are analysed. RESULTS A total of 16 questionnaires were completed, with a total of 205 incidents. The profile of the reporter was first-level health care (57.7%), and seniority in their job for 5-10 years. Of all the notifications, a health care cause of the incident was seen in 43.5% of cases, of which 85.9% of the incidents were preventable. Of all reported events, 71.7% were related to an ambulatory care medical centre, and only 2.4% was related to a surgical procedure. CONCLUSIONS Most of the notifications were preventable incidents, and recorded by first-level medical care. The reporting questionnaire was shown to be a valid tool in our work environment for the detection of adverse events in the care process.
Collapse
|
11
|
Menendez MD, Alonso J, Rancaño I, Corte JJ, Herranz V, Vazquez F. Impact of computerized physician order entry on medication errors. ACTA ACUST UNITED AC 2012; 27:334-40. [PMID: 22465826 DOI: 10.1016/j.cali.2012.01.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 01/30/2012] [Accepted: 01/30/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Information is scarce on the impact of the clinical electronic record on the frequency and severity of medication errors in acute geriatric patients. MATERIAL AND METHODS An analytical and descriptive pre-post study was conducted on the implementation of computerized provider order entry systems (CPOE), over a 6 year period. A voluntary reporting system was used to detect the medication errors using the IR2 report form of the UK National Health Service, the Global Trigger Tool and the walk rounds with the Pharmacy Service. The severity categories were taken from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index Categorizing Errors. RESULTS A total of 1887 medication errors (1553 patients) were detected in the period of study, and represented the first adverse event reported (29.3%). 8.5 adverse events per 100 admissions were found (0.24 in the categories E through I) and the prescription errors represented a 27.6%. By drugs dispensed, adverse events were 2.07 times more frequent in the 3 year period (2007-2009) with electronic clinical record than in the 3 year period with the hand-written system (2004-2006), being more frequent with antibiotics (1.92 times), antipyretic (2.21 times) and opiates (2.72 times). For serious errors and by doses dispensed, there were 5.18 times less frequent serious errors in the period related to the electronic record, drug omission (46.8 times less frequent), wrong dose (10.53 times) and antibiotics (10.84 times). CONCLUSION Frequent medication errors were found in acute geriatric patients. An increase in medication errors and a decline in the severity of the detected errors were found in relationship to the electronic clinical record. For these reasons, the implementation of the electronic clinical record should be monitored.
Collapse
Affiliation(s)
- M D Menendez
- Unidad Calidad y Gestión del Riesgo Clínico, Hospital Monte Naranco, Oviedo, Spain
| | | | | | | | | | | |
Collapse
|
12
|
[An adverse event continuous surveillance system in surgical services of the autonomous region of Cantabria (Spain)]. Med Clin (Barc) 2011; 135 Suppl 1:12-6. [PMID: 20875536 DOI: 10.1016/s0025-7753(10)70015-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To design a continuous surveillance system for adverse events (AEs) in surgical services in the Autonomous Community of Cantabria. Through homogeneous methodology, this system will provide the information needed to prevent and control AEs and avoid their recurrence. MATERIAL AND METHODS We performed a prospective study of the population undergoing inpatient surgery in our service. The methodology used was an adapted version of the IDEA (Identification of Adverse Events) project. Surgeons had access to an intranet website and introduced the data by using a personal login. A web application allowed feedback through report-generation. RESULTS During the pilot phase, limited collection of variables requiring calculations and of those related to location and causality was observed. Assessment of the system indicated the need for simplification to obtain valid and useful information, as well as the need to provide help windows. The system was redesigned with two data input screens and currently allows for automatic report generation of registered AEs. Information was gathered on 70% of the patients and an incidence of 11.2 AEs/100 admissions was found. Of these, 47% were defined as surgical complications. CONCLUSIONS Establishing a continuous surveillance system for AEs is feasible if professionals participate in the process, data input is easy and feedback from the system is rapid and useful for implementing corrective measures. This system can be considered highly useful for obtaining information on AEs and consequently on the potential areas of improvement in surgical activity in Spanish hospitals.
Collapse
|
13
|
Prieto Rodríguez MA, March Cerdá JC, Suess A, Ruiz Azarola A, Terol E, Casal Gómez J. [Patient perceptions on healthcare safety]. Med Clin (Barc) 2009; 131 Suppl 3:33-8. [PMID: 19572451 DOI: 10.1016/s0025-7753(08)76459-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Patient Safety is an issue of growing interest in healthcare politics and specialized bibliography, but there are limited studies that include the perspective of the public on healthcare safety. MATERIAL AND METHOD Qualitative research performed in 4 Spanish Autonomous Regions, using focus groups and semi-structured interviews with patients and representatives of associations. Discourse analysis and result triangulation. RESULTS For the patients interviewed, the concept of safety is not limited to absence of error, but includes aspects such as confidence, communication, information and participation. In the process of resolving of adverse events, an apologetic attitude by the professionals is considered a key element. Existing interventions such as protocols and notification systems are positively valued, at same time pointing out difficulties in the implementation process. As regards information, the patients demand that the professional is trained in communication skills. More participation in their own healthcare process and clinical management is considered appropriate, at same time, it was stated that few members of the public have the opportunity to participate in current safety policies. CONCLUSIONS Regarding healthcare safety, patients and key agents indicate the importance of moving from a blame culture to a confidence culture.
Collapse
|
14
|
[Implementation of a form for adverse effect notification: results for the 1st year]. ACTA ACUST UNITED AC 2009; 24:3-10. [PMID: 19369136 DOI: 10.1016/s1134-282x(09)70069-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Accepted: 10/09/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVES 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. MATERIALS AND METHOD 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.
Collapse
|
15
|
Grigorov Tzenkov I, Fernández S, Ferrer A, Baena M, Valentí P, Tomas M, Poua J, Luis Aguilara J, Gargoulas F. [Not Available]. ACTA ACUST UNITED AC 2008; 23:230-5. [PMID: 23040230 DOI: 10.1016/s1134-282x(08)72612-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The purpose of this article is to present a model for clinical risk management based on technological and organisational advances with proven effect. Designed for a single clinical Unit, the model is open to other notification systems and health care clinical units. MATERIAL AND METHOD The model has three implementation phases. The first phase involved studying the existing safety system and objectively measured the culture of patient safety. The second phase included development and implementation of a system for the management of critical incidents with creation of a team of specialists. The third phase was the development of the technological and organizational base for horizontal and vertical integration, for internal and external training, and opening the system to other clinical units. RESULTS We found an unstructured, non-confidential, potentially punitive model of clinical risk management without efficacy criteria. There was an unsatisfactory safety culture level for all of the evaluation issues. The introduction of a system for critical incident management gave the basis for the optimization and evaluation of the patient safety related processes. CONCLUSIONS Our model for clinical risk management is a simple, useful and efficient example for introducing a patient safety strategy in a hospital clinical unit.
Collapse
|
16
|
Abstract
Health care interventions entail a risk of adverse events (AE), that may cause lesions, incapacities and even death in the patients. Given the complexity of the care of the critical patient, the Critical Care Services are a high risk setting for the appearance of AE in these patients, many of them avoidable. Several studies show the influence of organizational factors focused on the system in the reduction of care risk and on the result of the critical patients. The voluntary and anonymous registry and reporting systems make it possible to identify a significant percentage of these incidents, analyze the factors related (that contribute or limit), establish preventive strategies, permitting management of risk, and potentially reduce the appearance and consequences of avoidable AE with all this. Initiatives such as the ICU Safety Reporting System (ICUSRS), that use a web database as registry system and includes contributions from different sites, favor the safety and risk culture, essential in the improvement of health quality of critical patients.
Collapse
Affiliation(s)
- M C Martín
- Servicio de Medicina Intensiva, Centro Médico Delfos, Barcelona, España.
| | | |
Collapse
|
17
|
|