Patient safety, why is it important?


Dr. Mercedes Martínez, Medical Auditor, Adverse Event Analyst of the Patient Risk Management Unit, Quality Management of the General Hospital of the Plaza de la Salud.

Although it has been more than fifteen years since the Institute of Medicine of the United States published the report "To err is human", due to the high prevalence of adverse events still reported in the world literature, patient safety It remains a global priority.

This report scandalized the world of health by calculating that, in the United States of America alone, about one hundred thousand patients died each year, not as a result of their illnesses, but as a result of errors in medical care.

Unsafe actions are a serious problem in health services. It is estimated that in developed countries one in ten patients has suffered damage while receiving hospital care.

So much so that air transport has a 20 times lower risk than a hospital stay, and this is equally true if we compare traffic accidents with hospital care, the risk is 20 times higher in the hospital (PAHO / WHO).

In any clinical scenario where there is a patient, adverse events can occur, this is a significant indicator of the final result of care and show, like no other, the quality of care of a health institution.

Constant changes in the clinical conditions, health workers around them, the complexity of each clinical or surgical procedure, human factors related to the care, the equipment and technology to be used and processes occur during a patient's care. of attention, among others. These factors lead to incidents and secondary adverse events.

More than one hundred million people require surgical treatment every year, and half of the avoidable adverse events that cause death or disability in developed countries are due to surgical events.

More than 1.4 million people worldwide acquire infections associated with health care (IASS) in health centers, for failure to comply with the hand hygiene procedure.

For this reason, it is important to highlight the need for regulatory organizations, national and international, to implement safe practices within the context of a patient safety policy and program that will minimize adverse events and incidents that occur in Health care

Health organizations are committed to promoting a culture of reporting aimed at improving and creating strategic plans through research that identifies the contributing factors and active failures that caused the event.

The continuous improvement of health system performance is key to the reduction of adverse events.

It is necessary to create guidelines for the investigation of adverse events, identifying the root cause through a thorough analysis that is based on the evidence, in the records of the medical history, and in interviews with the staff that provided the attention. This will help us correct the error, which should not be punitive, so as not to create fear in the staff.

Steps for the interview:

• It should be done in a private, relaxed place, away from the place where the incident occurred.
• The interviewee may be accompanied by whoever they want.
• Explain to the interviewee the reason for the interview.
• Avoid confrontational style and value judgments.
• Ensure that what you say will not be subject to retaliation and will be kept under strict confidentiality.
• Set the chronology of the incident.
• Compare this information with the general sequence known so far.

There are different methods to classify events, among which is the London Protocol. This is an organizational model of causality of errors and adverse events, it is based on the organization, culture and contributory factors, which are divided into: patient factors, task factors and technology used.

Posted in: Hoy Digital newspaper.

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