M C Martín Delgado1, P Merino de Cos2, G Sirgo Rodríguez3, J Álvarez Rodríguez4, I Gutiérrez Cía5, B Obón Azuara6, Á Alonso Ovies4. 1. Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, España. Electronic address: mmartin@torrejonsalud.com. 2. Servicio de Medicina Intensiva, Hospital Can Misses, Ibiza, España. 3. Unidad de Cuidados Intensivos, Hospital Universitario Joan XXIII, Instituto de Investigación Sanitaria Pere Virgili, Universidad Rovira i Virgili, Tarragona, España. 4. Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España. 5. Servicio de Medicina Intensiva, Hospital Clínico Universitario, Zaragoza, España. 6. Servicio de Medicina Preventiva y Salud Pública, Hospital Clínico Universitario, Zaragoza, España.
Abstract
OBJECTIVE: To explore contributing factors (CF) associated to related critical patients safety incidents. DESIGN: SYREC study pos hoc analysis. SETTING: A total of 79 Intensive Care Departments were involved. PATIENTS: The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. MAIN VARIABLES: The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. RESULTS: A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. CONCLUSIONS: The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.
OBJECTIVE: To explore contributing factors (CF) associated to related critical patients safety incidents. DESIGN: SYREC study pos hoc analysis. SETTING: A total of 79 Intensive Care Departments were involved. PATIENTS: The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. MAIN VARIABLES: The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. RESULTS: A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. CONCLUSIONS: The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.
Authors: Júlian Katrin Albuquerque de Oliveira; Eliana Ofélia Llapa-Rodriguez; Iza Maria Fraga Lobo; Luciana de Santana Lôbo Silva; Simone de Godoy; Gilvan Gomes da Silva Journal: Rev Lat Am Enfermagem Date: 2018-08-09