Underutilization of the reports of adverse events in an Argentine hospital

Abstract

BACKGROUND:

An adverse event is defined as any unintentional harm that results in temporary or permanent disability and/or prolongation of hospitalization time, or death of a patient; as a consequence of health care provided by any staff member of the health institution.

OBJECTIVES:

The aim was to describe the adverse events that affect patient safety, reported in 2015 in a private hospital in the city of Córdoba, Argentina.

METHODS:

We analyzed 678 events reported through the computer system on the hospital’s intranet.

RESULTS:

The highest frequency of events reported corresponded to the nursing professionals (40.7% ). Problems related to drug therapy process showed the highest frequency of reports (17.7% ), followed by communication failures (11.1% ) and patient’s fall (10.3% ). In the notification of the causes of the incident, 51.9% of “No answer” was observed.

CONCLUSION:

In the case of this hospital, this valuable tool is being underutilized. The reports should allow identifying the entire chain of events that lead to the incidents to address effective interventions in patient safety that involve all hospital staff, with greater emphasis on senior staff.