Mar LTJ, Morales CI

Language: Spanish
References: 16
Page: 144-153
PDF size: 182.26 Kb.

ABSTRACT

Although “To err is human”, in medicine an error might be fatal. It is necessary to be aware of such an error in order to eliminate it. Ideally, errors should be recorded directly; nevertheless this strategy has shown low efficacy. This is the first study performed at Grupo Angeles with the following objectives: Number of reports increase and selection of the most frequent. Two reporting methods were compared in the Hospital Angeles Mocel Critical Care Unit: Infirmary Incident Format (FIE)§ and the SAFE card. Material and methods: Interventional, re-creative, quasi-experimental, longitudinal, analytic, comparative, retrospective and prospective research study performed in a hospital medical center from February to June 2014. Results: 11 FIE reports were gathered versus 84 SAFE reports. The former reports were mainly medication errors. Most of the SAFE reports were due to delay in attention response time. The resident was the major reporter. 85% were recorded without patient damage and 15% with patient damage. No deaths were recorded. 3% of cases required life support. Conclusion: FIE presented high under-reporting rates. SAFE card proved to be reliable in data gathering and could be implemented as a new reporting system.

REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 1991, pp. 1-3.

2. Stelfox HT, Palmisani S, Sculock C, Orav EJ et al. The “To err in human” report and the safety literature. Qual Saf Health Care. 2006; 15: 174-178.

3. Hewson-Conroy Karena M, Elliott Doug, Burrell. Quality and safety in intensive care- A means to an end in critical. Australian Critical Care. 2010; 23: 109-129.

4. Moreno Rui P, Rhodes Andrew, Donchin Yoel. Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med. 2009; 35: 1667-1672.

5. Martín Delgado MC, Gordo-Vidal F. La calidad y la seguridad de la medicina intensiva en Espańa. Algo más que palabras. Med Intensiva. 2011; 35 (4): 201-205.

6. Kalra Jawahar. Medical errors: an introduction to concepts. Clinical Biochemistry. 2004; 37: 1043-1051.

7. Civetta Taylor y Kirby. Critical Care Philadelphia: Lippincott Williams & Wilkins; 2009: 1-2765.

8. Holzmueller CG, Provonost PJ, Dickman F, Thompson DA et al. Creating the web-based intensive care unit safety reporting system. J Am Med Inform Assoc. 2005; 12: 130-139.

9. Beckmann U, Bohringer C, Carless R, Gillies DM et al. Evaluation of two methods for quality improvement in intensive care: Facilities incident monitoring and retrospective medical chart review. Crit Care Med. 2003; 31 (4): 1006-1011.

10. Osmon S, Harris CB, Dunagan WC, Prentice D et al. Reporting of medical errors: an intensive care unit experience. Crit Care Med. 2004; 32: 727-733.

11. Harris CB, Krauss MJ, Coopersmith CM, Avidan M et al. Patient safety event reporting in critical care: A study of three intensive care units. Crit Care Med. 2007; 35: 1068-1076.

12. Ilan R, Squires M, Panopoulos C, Day A. Increasing patient safety event reporting in 2 intensive care units: a prospective interventional study. J Crit Care. 2011; 26: 431.e11-431.e18.

13. Grober Ethan D, Bohnen John MA. Defining medical error. Can J Surg. 2005; 48 (1): 39-44.

14. Johnstone Megan-Jane. Patient safety ethics and human error management in ED contexts Part I: Development of the global patient safety movement. Australasian Emergency Nursing Journal. 2007; 10: 13-20.

15. Dickens BM. Medical errors: legal and ethical responses. Int J Gynecol Obstet. 2003; 81: 109-114.

16. Jewell Kevin ML. To err is human - To delay in deadly. Ten years later, a million lives lost, billions of dollars wasted. Consumer Reports Health. 2009; pp. 1-13