Portal de Periódicos da CAPES

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine

2015; Elsevier BV; Volume: 39; Issue: 5 Linguagem: Espanhol

10.1016/j.medine.2015.05.001

2173-5727

M.C. Martín Delgado, P. Merino de Cós, G. Sirgo Rodríguez, J. Alvarez, I. Gutiérrez Cía, B. Obón Azuara, Á. Alonso Ovies,

Clinical Reasoning and Diagnostic Skills

To explore contributing factors (CFs) associated to related critical patients safety incidents. SYREC study post hoc analysis. A total of 79 Intensive Care Departments were involved. The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. The CFs 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 were analyzed. A total 2965 CFs were reported (1729 were associated to near miss and 1236 to adverse events). The CFs group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CFs in adverse events. CFs were reported in all classes of incidents. The majority of CFs were reported in the incidents classified such as less serious, even though CFs patients factors were associated to serious incidents. Individual factors were considered as avoidable and patients factors as unavoidable. The CFs group more frequently reported were patient factors and were associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CFs most frequently reported were associated to near miss. Analizar los factores contribuyentes (FC) que intervienen en la aparición de incidentes relacionados con la seguridad del paciente crítico. Análisis post hoc del estudio SYREC. Un total de 79 servicios de Medicina Intensiva. Un total de 1.017 pacientes, de los que se incluyeron 591 en los que se notificó al menos un incidente. FC categorizados según una adaptación del modelo propuesto por la National Patient Safety Agency del Reino Unido. Tipo, clase y gravedad de los incidentes relacionados con la seguridad del paciente. Se notificaron 2.965 FC (1.729 se comunicaron en incidentes sin daño y 1.236 en eventos adversos). El grupo de FC más frecuente fue el relacionado con el paciente. Los FC relacionados con el profesional se notificaron más en los incidentes sin daño. En cambio, los relacionados con la tarea se comunicaron más en los eventos adversos. Se declararon FC en todas las clases de incidentes. La mayoría de FC se notificaron en los incidentes menos graves aunque los FC relacionados con el paciente se asociaron a incidentes de mayor gravedad. Los incidentes que se asociaron a los FC relacionados con el profesional se consideraron evitables y los FC relacionados con el paciente, inevitables. Los FC relacionados con el paciente fueron los más frecuentes y se relacionaron con los incidentes más graves y considerados inevitables. Los relacionados con el profesional se notificaron en las categorías menos graves y se consideraron evitables. La identificación de FC fue más frecuente en los incidentes sin daño.