medigraphic.com

2010, Número 5

<< Anterior

Cir Cir 2010; 78 (5)


Aprendiendo del paciente para mejorar los sistemas de informes de eventos de seguridad

Greenberg LG, Battles JB, Haskell H

Idioma: Español
Referencias bibliográficas: 27
Paginas: 463-468
Archivo PDF: 266.41 Kb.


RESUMEN

Introducción: Todos los individuos tienen una historia personal, familiar o de un amigo, acerca de algún daño ocasionado por la atención de la salud. En 2004, uno de cada tres norteamericanos (34%) indicó que él o un miembro de su familia había experimentado un error médico prevenible, de ellos 21% señaló que el error causó “consecuencias graves de salud” como la muerte (8%), discapacidad a largo plazo (11%) o dolor severo (16%).
Discusión: La información que proporciona el paciente es importante y podría formar parte de un modelo estratégico para realizar cambios generales con la finalidad de mejorar la atención a la salud. Se ha identificado que una barrera para aceptar las quejas de los pacientes como informes de daños es que los profesionales de salud consideran que aquellos no son capaces de juzgar adecuadamente la calidad técnica de la atención. Se propone que en el informe de los eventos de seguridad se involucre activamente a los pacientes y a sus cuidadores para reunir información acerca de los riesgos y peligros en el escenario del cuidado de la salud.
Conclusiones: Los pacientes pueden ser agentes efectivos del cambio para mejorar su seguridad al dar a conocer sus preocupaciones o quejas, ya que pueden identificar condiciones inseguras y prevenir futuros daños. Los datos obtenidos con esa estrategia deberán servir para implementar cambios generales en la atención a la salud y en la forma de evaluar la calidad, para una mejoría continua y una práctica clínica con base en las evidencias.


REFERENCIAS (EN ESTE ARTÍCULO)

  1. Kaiser Family Foundation, Agency for Healthcare Research and Quality, and Harvard School of Public Health. National survey on consumers’ experiences with patient safety and quality information, 2004. Available at http://www.kff.org/kaiserpolls/pomr111704pkg.cfm

  2. Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005;20:830-836.

  3. Wu AW, Lipshutz AKM, Pronovost P. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299(6):685-687.

  4. Wu AW, Phan JC, Pronovost P. Root cause analyses: are we looking for keys under the lamp post? National Patient Safety Fundation. Focus Patient Saf 2008;11:3-5.

  5. National Quality Forum. Safe Practices for Better. Healthcare- 2010 Update: A Consensus Report. Washington, DC: NQF; 2010. Available at www.qualityforum.org/WorkArea/linkit.aspx? LinkIdentifier=id...25690

  6. Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004;140(6);409-418.

  7. Kohn LT, Corrigan JM, Donaldson MS; Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. A Report of the. Washington, DC: Institute of Medicine, National Academies Press; 1999.

  8. Aspden P, Corrigan JM, Wolcott J, Erickson SM; Committee on Data Standards for Patient Safety, Board on Health Care Services. Patient safety: achieving a new standard for care. Washington, DC: Institute of Medicine/National Academies Press; 2004. Available at http://www.nap.edu/openbook.php?record_id=10863&page=R1

  9. When Things Go Wrong: Responding To Adverse Events. A Consensus Statement of the Harvard Hospitals. Cambridge, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

  10. Weissman JS, Schneider EC, Weingart SN, Epstein AM, David-Kasdan J, Feibelmann S, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med 2008;149(2):100-108.

  11. U.S. Department of Health and Human Services, Office of the Inspector General. Adverse Events in Hospitals: Methods for Identifying Events. Washington, D.C. : U.S. Department of Health and Human Services; 2010.

  12. Berwick D. What ‘patient-centered’ should mean: confessions of an extremist. Health Affairs 2009;28(4):w555-w565.

  13. Berwick, D. Escape Fire: Lessons Learned for the Future of Health Care. New York, NY: Commonwealth Fund; 2002. Available at http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf

  14. Klitzman R. When Doctors Become Patients. New York, NY: Oxford University Press; 2008.

  15. Quaid D, Thao J, Denham CR. Story power: the secret weapon. J Patient Saf 2010;6(1):5-14.

  16. Mardon R. Survey of Patient Safety Culture in U.S. Hospitals: External Validity Analyses. Presented at the 2008 AHRQ Annual Research Conference, Bethesda, MD. Available at http://www.cahps.ahrq.gov/content/community/events/files/F-3-P_Mardon-Final_fwp.pdf

  17. Brady C, Leape L. Integrating quality and safety with patient-centered care. In: Frampton SB, Charmel P, editors. Putting Patient First. Best Practices in Patient Centered Care. 2nd ed. Derby, CT: Planetree; 2008. pp. 249-265.

  18. Greenberg, MD, Haviland, AM, Ashwood, JS, Main R. Is Better Patient Safety Associated with Less Malpractice Activity? Evidence from California. Santa Monica, CA: RAND Institute for Civil Justice; 2010.

  19. Joint Commission [website]. Facts about Speak Up Initiatives. Available at http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm

  20. National Patient Safety Foundation [website]. Ask me 3. Available at http://www.npsf.org/askme3/

  21. Lazar, A. AHRQ Uses Tools to Educate Consumers. Managed Healthcare Executive [website]. April 1, 2009. Available at http://managedhealthcareexecutive.modernmedicine.com/mhe/Quality+Strategy/AHRQ-uses-tools-to-educate-consumers/ArticleStandard/Article/detail/592262

  22. Hospital Care Quality Information from de Consumer Perspective [website]. CAHPS Hospital Survey. Available at http://www.hcahpsonline.org/home.aspx

  23. Pichert JW, Hickson G, Moore I. Using Patient Complaints to Promote Patient Safety. Advances in Patient Safety: New Directions and Alternative Approaches. Volume 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; 2008.

  24. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002;287(22):2951-2957.

  25. Hickson GB, Federspiel CF, Blackford J, Pichert JW, Gaska W, Merrigan MW, et al. Patient complaints and malpractice risk in a regional healthcare center. South Med J 2007;100(8):791-796.

  26. U.S. Department of Health and Human Services, Office of the Inspector General, Adverse Events in Hospitals: State Reporting Systems. Washington, D.C. ; U.S. Department of Health and Human Services; 2008.

  27. Weingart SN, Pagovich O, Sands D, Li JM, Aronson MD Davis RB, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005;20(9):830-836.




2020     |     www.medigraphic.com