Reporting of Adverse Events in the Internal Medicine Department of Hospital Nacional de Clínicas, Universidad Nacional de Córdoba.

Abstract

The global effort to reduce medical errors is a priority among leading international health organizations. Given the limited research in the field of patient safety, the World Alliance for Patient Safety has emphasized the importance of adverse event (AE) reporting as a critical starting point for understanding the underlying causes and implementing preventive measures. Objective To identify and characterize adverse events in the Internal Medicine Department.

This observational, descriptive, prospective, and cross-sectional study was conducted using an anonymous Google form for AE reporting. Data collection occurred from May 13, 2024, to July 30, 2024. Collected data included patient demographics, location and timing of the event, a detailed description of the event, documentation in the medical record, any immediate actions taken, and the consequences categorized as no injury, reversible injury, or irreversible injury.

A total of 22 adverse events were reported. The distribution across shifts was as follows: morning (45.5%), afternoon (22.7%), and night (31.8%). The events occurred in the Ramón Carrillo Norte unit (50%), Central Emergency Department (13.6%), and Ramón Carrillo Sur unit (36.4%). The primary causes identified were communication errors (31.8%), workplace mistreatment among healthcare personnel (18.3%), and non-compliance with biosafety standards (13.6%). Additional causes included: criteria for admission to higher complexity care (9.1%), lack of patient identification (4.5%), equipment failure (9.1%), falls (4.5%), and insufficient skills (9.1%). Notably, 40.9% of the events were not documented in the patient’s medical record. Immediate corrective actions were taken in 59.1% of the cases. The outcomes were distributed as follows: no injury (59.1%), reversible injuries (31.8%), and irreversible injuries (9.1%).

Voluntary, anonymous, and non-punitive reporting of adverse events is an essential tool for driving systemic change and improving patient safety. This study highlights the frequent occurrence of communication errors, non-compliance with biosafety protocols, and workplace mistreatment within the healthcare team. The absence of documentation in a significant portion of cases and the presence of irreversible injuries underscore the urgent need for a systematic and comprehensive AE reporting system within the Internal Medicine Department to mitigate these events and enhance overall patient care.