ANALYSIS OF INCIDENT REPORTS IN AN ANESTHESIOLOGY UNIT OF A UNIVERSITY HOSPITAL

De la anestesia a la seguridad de la atención: experiencia de 6 años en el análisis de reportes de incidentes en un hospital universitario

Author
Marfán, Luis; Pontificia Universidad Católica de Chile

Pedemonte, Juan C; Pontificia Universidad Católica de Chile

Sandoval, Daniela; Pontificia Universidad Católica de Chile

Ferdinand, Constanza

Camus, Lorena; Pontificia Universidad Católica de Chile

Lacassie, Hector J; Pontificia Universidad Católica de Chile

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http://www.revistamedicadechile.cl/ojs/index.php/rmedica/article/view/5455
Abstract
Background: Incident reporting is an effective strategy used to enhance patient safety. An incident is an event that could eventually result in harm to a patient. Aim: To classify and analyze incidents reported by an Anesthesiology division at a University hospital in Chile. Material and methods: A retrospective analysis of the reported incidents registered in our institutional database from January 2008 to January 2014. They were classified according to three variables proposed by the World Health Organization system to determine the type of incident and patients’ potential harm. Results: There were 297 reports registered. Etiologic classification according to the WHO system showed that 29% (n=85) were related with management, 20% (59) with drugs, 20% (59) with medical devices, 16 % (48) with procedures and 15% (46) with human factors. Seventy two percent (58) of incidents caused low or moderate harm and 28% (22) resulted in a severe adverse event or death. Conclusions: Our analysis highlights that a high rate of incidents are associated with management, the leading cause of reports in our center. Due to the low incident report rate in our country, it is difficult to perform appropriate comparisons with other centers. In the future, local incident reporting systems should be improved.
 
Background: Incident reporting is an effective strategy used to enhance patient safety. An incident is an event that could eventually result in harm to a patient. Aim: To classify and analyze incidents reported by an Anesthesiology division at a University hospital in Chile. Material and methods: A retrospective analysis of the reported incidents registered in our institutional database from January 2008 to January 2014. They were classified according to three variables proposed by the World Health Organization system to determine the type of incident and patients’ potential harm. Results: There were 297 reports registered. Etiologic classification according to the WHO system showed that 29% (n=85) were related with management, 20% (59) with drugs, 20% (59) with medical devices, 16 % (48) with procedures and 15% (46) with human factors. Seventy two percent (58) of incidents caused low or moderate harm and 28% (22) resulted in a severe adverse event or death. Conclusions: Our analysis highlights that a high rate of incidents are associated with management, the leading cause of reports in our center. Due to the low incident report rate in our country, it is difficult to perform appropriate comparisons with other centers. In the future, local incident reporting systems should be improved.
 
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