Adverse event reporting in an intensive care unit at Tunja, Colombia
DOI:
https://doi.org/10.31053/1853.0605.v70.n2.20234Keywords:
adverse event, critical care, patient safetyAbstract
Introduction: Patient safety in critical areas has been subject of several studies. In Colombia, there is a growing conscience about adverse events management. This study explores the first phase of this management: report in a typical private intensive care unit.
Objective: To assess adverse event report at a Colombian tertiary level institution, through frequency and report category assessment.
Methods: A descriptive study regarding adverse event report rates during 2011 period in Clinica de los Andes de Tunja, was carried out, through frequency and report category assessment. Adverse event report rate was defined as the number of reports per 1000 patient bed. We reported major and minor categories of events.
Results: A total of 383 admissions (2374 patient days) were recorded. 54 adverse events were reported (rate of 22,74 per 1000 patient days). The most frequent events were related to intravenous route (55%) (CI 95% 50,1-58,3) followed by process deviation (22%)(CI 95% 18,2-26,1).
Conclusions: An adverse event report rate closeto the upper limit of literature reports numbers was found. Probably, there is still non quantified under-report of adverse events, likely due to cultural factors.
Downloads
References
1. Riveros E, Cendales S. Modelos de calidad y mejoramiento continuo en cuidado intensivo: una mirada a Norteamérica y Europa. Aplicación en Colombia. Acta Colombiana de Cuidado Intensivo.2011;11:199-206.
2. Valentin A, Capuzzo M, Guidet B, Moreno R, Metnitz B, Bauer P, Metnitz P: Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009, 338:b814.
3. Beckmann U, Baldwin I, Hart GK. The Australian Incident Monitoring Study in Intensive Care: AIMSICU. An analysis of the first year of reporting. Anaesth Intensive Care. 1996;24:320-329.
4. Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care. 2002;17:86-94.
5. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Charles A, Bates DW: The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005, 33:1694-1700.
6. Nuckols TK, Bell DS, Liu H. Rates and types of events reported to established incidents reporting systems in two US hospitals. QualSaf Health Care. 2007; 16:164-168.
7. Tighe CM, Woloshynowych M, Brown R. Incident reporting in one UK accident and emergency department. AccidEmergNurs. 2006;14:27-37.
8. Travaglia JF, Westbrook MT, Braithwaite J. Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals. Health (London). 2009;13:277-296.
9. Freestone L, Bolsin SN, Colson M. Voluntary incident reporting by anesthetic trainees in an australian hospital. Int J Qual Health Care. 2006;18:452-457.
10. Maass G, Cortezzo M. Computerizing incident reporting at a community hospital. JtComm J QualImprov. 2000;26:361-373.
11. Decreto 1011 de 2006. Presidencia de la República. Bogotá. 2006.
12. Ziegenfuss JT Jr, McKenna CK. Ten tools of continuous quality improvement: a review and case example of hospital discharge. Am J Med Qual. 1995 Winter;10(4):213-20.
13. Milch CE, Salem DN, Pauker SG, et al. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. J Gen Intern Med. 2006;21:165-170.
14. Fukuda H, Imanaka Y, Hirose M, et al. Impact of system-level activities and reporting design on the number of incident reports for patient safety. QualSaf Health Care. 2010;19:122-127.
15. Evans SM, Smith BJ, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. QualSaf Health Care. 2007;16:169-175.
16. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust. 2004;181:36-39.
17. Ashcroft DM, Morecroft C, Parker D, et al. Likelihood of reporting adverse events in community pharmacy: an experimental study. QualSaf Health Care. 2006;15:48-52.
18. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. QualSaf Health Care. 2002;11:15-18.
19. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320:759-763.
20. Tamuz M, Thomas EJ, Franchois KE. Defining and classifying medical error: lessons for patient safety reporting systems. QualSaf Health Care. 2004;13:13-20.
21. Nakajima K, Kurata Y, Takeda H. AWeb-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese hospital. QualSaf Health Care. 2005;14:123-129.
22. Levtzion-Korach O, Alcafai H, Orav EJ. Evaluation of the contributions of an electronic web-based reporting system: enabling action. J Patient Saf. 2009;5:9-15.
23. Beckmann U, Bohringer C, Carless R. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003;31:1006-1011.
24. Lorente L, Huidobro MS, Martin MM, Jimenez A, Mora ML. Accidental catheter removal in critically-ill patients: a prospective and observational study. Critical Care. 2004;8:R229-R233.
25. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21:305-315.
Downloads
Published
Issue
Section
License
Copyright (c) 2013 Universidad Nacional de Córdoba
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The generation of derivative works is allowed as long as it is not done for commercial purposes. The original work may not be used for commercial purposes.
How to Cite
