• 作者：M. Dolores Mené ; ndez^a ; I. Rancañ ; o^b ; V. Garcí ; a^b ; C. Vallina^c ; V. Herranz^d ; F. Vá ; zquez^a ; ^e ; ^{fvazquez@uniovi.es}
• 关键词：Sistemas de notificació ; n ; Seguridad de pacientes ; Eventos adversos
• 刊名：Revista de Calidad Asistencial
• 出版年：2010
• 期刊代码：pca305_1134282X
• 类别：med
• 出版时间：July-August 2010
• 卷：25
• 期：4
• 页码：232-236
• 文件大小：253 K

Objective

Voluntary reporting of patient safety incidents may under-report incidents as well as the scale and severity of them. The aim of this report was to analyse of the adverse events in our hospital by means of different reporting systems.

Material and Methods

Setting: Monte Naranco Hospital (Oviedo, Spain) is an associated University Hospital with 200- beds (mainly geriatric patients, mean age: over 80 years, lengths of stay rate: 8.6 days in these geriatric patients). Design: Prospective and retrospective study of adverse events recorded by: a) A voluntary and confidential notification (IR2 report form, National Health Service), b) Compulsory internal notification (patient falls and injuries in health care workers), c) Internal notification and observational studies (nursery care), d) Hospital- acquired infections (Spanish study of nosocomial infection鈥揈PINE) and Microbiology Laboratory records, e) The Agency for Healthcare Research and Quality indicators through ICD-9-CM diagnoses codes, f) Walk Rounds and Briefings, g) Spanish study of AE prevalence (ENEAS), h) Complaint Patient Unit, i) Spanish observational study of medication errors, j) Study of deaths by Commission of clinical records and k) Global Trigger Tool of the International for Healthcare Improvement. Interventions: Leadership, training in patient safety, incident report and analysis, spread of the patient safety culture, introduction and analysis of the different reporting systems with a clinical risk manager working a full time and ISO certification. We used a theoretical model to know the real scenario of our hospital and the number of adverse events.

Results

The total prevalence of adverse events was 7%(ENEAS- in the year 2005). There was a mean of 43.7 adverse events/1,000 patient days, 50 adverse events/100 admissions, and 43.3 percent of admissions with an adverse events (Global Trigger Tool- in 2007), the prevalence of nosocomial infection was 4.2%(EPINE- 2007) and the prevalence of medication errors of 19.2%(Spanish observational study of medication errors- in the year 2007). We increased the notification and record of adverse events from around 300 in 2004 to 2269 in 2006 (an increase of 756.3%) and the reporting systems from 4 to 10. The theoretical model with the data of voluntary notification (n=300) in 2006 was as follow: No. of adverse events and near misses per patient/day recorded- theoretical number (0.1鈥?7), No. of adverse events and near misses per 1000 patients/day (0.2鈥?88.3), No. of adverse events (290鈥?900), No. of near misses (10鈥?90000), medication errors (150鈥?500).

Conclusions

We have increased the adverse events reporting due the inclusion of the reporting systems and a clinical risk manager working a full time, with a clearer picture of the types of adverse events with an integration of different data and reporting systems, and a better approach to improvement, monitoring and review of the processes. The nature of the sources in the reporting systems does not permit to know the ranking and real figures of the adverse events, and it is necessary to established priorities and to stagger the different reporting systems in the time and in function of the cost effectiveness measures. The reporting systems are the first step to analysis and is necessary to improve and mitigate the adverse events.