RESUMO
INTRODUCTION: The acute care hospital, with its hospitalization departments, diagnostic centers, outpatient clinics, operation rooms and intensive care units, is a very complex industry with the goal of taking care of patients in every stage of their disease, starting with prevention and continuing with diagnosis and treatment. Diagnosis and treatment processes have many stages; most of them depend on high technology and advanced science. Studies in the USA demonstrated 98,000 to 241,000 cases of mortality due to medical errors and complications, third place after mortality due to cardiac diseases and cancer. The quality of treatment is obviously important. The more effective the drug, the higher the influence on disease activity and the better the recovery. Drug safety is not always appreciated and taken into account. The medical team is requested to notify on every mistake, adverse event and sentinel event on the one hand and "nearly missed" cases on the other hand. The reports are very important for system learning. We believe that by changing the system we can prevent many kinds of human errors. We believe that "to err is human", we are not looking for "blame or shame", but want to prevent the next potential mistake. According to the hospital vision, working plans and projects, an annual risk-management plan is needed. This plan has 3 parts: retrospective, prospective and continuing claims and complains assessment. A good annual, comprehensive risk-management plan will protect the patients and lead to a decrease in morbidity and mortality.