ABSTRACT
OBJECTIVES: In 2014 our department starts to apply the PatientSafety Strategic in Pediatric Surgery. Our aim is to describe the results obtained. METHODS: For the measurement of adverse events (AE) we used a modification of the Global Trigger Tool of the Institute for Healthcare Improvement. Population analysed: patients undergoing surgery with hospitalization. On a monthly basis, audits of the medical records of 12 patients discharged in the prior week of the assessment were performed. The evaluation team was composed by experienced pediatric surgeon, two staff nurses, and a doctor and nurse from the Quality Department. RESULTS: 95 clinical records and a total of 406 days of hospital stay were reviewed. 31 patients (32.6%) experienced one or more AE. Total AE: 43. The AE/1000 patients/day ratio: 105.9. The most common AE were: vomiting, itching and pain. 28 EA were considerd mild and 3 moderate in severity, according to the classification of the National Coordinating Council for Medication Error Reporting and Prevention. No EA were considered serious or critical. CONCLUSIONS: The analysis of prevalence through regular assessments of medical records is an easy method to obtain information about the frequency of occurrence, exact understanding of the AE types and the implementation of corrective measures. The main limitation of this method is that it can miss some of the serious EA and miss the records and analysis of sentinel events that may occur in the period between assessments.
OBJETIVOS: Durante el año 2014 se aplica el Plan de Seguridad del Paciente en un Servicio de Cirugía Pediátrica, elaborado previamente por nuestro Servicio. Se describen los resultados. MATERIAL Y METODOS: El método empleado para la medición de eventos adversos (EAs) es una modificación del Global Trigger Tool del Institute for Health care Improvement. Población analizada: pacientes intervenidos quirúrgicamente con hospitalización. Con una periodicidad mensual, se realizaron 12 auditorias de las historias clínicas correspondientes a los pacientes dados de alta en la semana anterior al día de la evaluación. El equipo evaluador estaba compuesto por: un cirujano pediátrico experto, dos enfermeras de planta más un médico y una enfermera del Servicio de Calidad. RESULTADOS: Se revisaron 95 historias y 406 días de estancia. 31 pacientes (32,6%) sufrieron uno o más eventos adversos. Total EAs: 43. Número EAs/1.000 pacientes/día: 105,9. Los 3 EA más frecuentes fueron: vómitos, prurito y dolor. 28 EAs fueron de gravedad leve y 3 moderada, según la clasificación del National Coordinating Council for Medication Error Reporting and Prevention. Ningún EA fue grave o crítico. CONCLUSIONES: La determinación de la prevalencia mediante evaluaciones regulares de historias clínicas es un método que permite obtener información de forma fácil sobre la frecuencia de aparición, el conocimiento exacto de los tipos de EAs y la aplicación de medidas correctoras. Este método tiene como limitación principal la posible falta de recogida EAs graves así como registro y análisis de eventos centinelas que pueden ocurrir en el periodo entre evaluaciones.
ABSTRACT
INTRODUCTION: Patient safety is a key priority in quality management for healthcare services providers. Every patient is entitled to receive safe and effective healthcare. AIMS: The aim of this study was to design a patient safety plan for a Paediatric Surgery Department. METHODS: We carried out a literature review and we established a work group that included healthcare professionals from the Paediatric Surgery Department and the Quality and Medical Records Department. The group identified potential adverse events, failures and causes and established a rating using Failure Mode Effects Analysis. Potential risks were mapped out and a plan was designed establishing actions to reduce risks. We designated leaders to ensure the effective implementation of the plan. RESULTS: A total of 58 adverse events were identified in the Paediatric Surgery Department. We detected 128 failures that were produced by 211 different causes. The group developed a proposal with 424 specific measures to carry out preventive and/or remedial actions that were then narrowed down to 322. The group designed a plan to apply the programme, which is currently being implemented. CONCLUSIONS: The methodology used enabled obtaining key information for improvement of patient safety and developing preventive and/or remedial actions. These measures are applicable in practice, as they were designed using proposals and agreements with professionals that take active part in the care of children with surgical conditions.
