Preventing pediatric accidental decannulation events: A quality improvement initiative.

OBJECTIVE: To describe a quality improvement (QI) method to decrease pediatric accidental decannulation (AD) in the early postoperative period for children under age 3. METHODS: A retrospective chart review was conducted on children under age 3 who underwent tracheostomy at Duke University Health System from August 1, 2013 to May 1, 2023 (n = 104). A root cause analysis was used to assess factors associated with AD following pediatric tracheostomy. Based on the factors identified by the research team, retrospective data was collected before (8/1/13 - 1/31/22) and after (2/1/22 - 5/1/23) a single practice change was implemented: using twill neck ties, rather than foam neck ties, to secure newly-placed tracheostomy tubes. Twill ties were applied intraoperatively as a visual cue to signal a recent tracheostomy for the interdisciplinary care team. The primary outcome in the pre-intervention and post-intervention period was measured as 30-day incidence of AD per 10 tracheostomy cases. RESULTS: Prior to the intervention, a total of 11 ADs occurred in 9 patients across 93 pediatric tracheostomies (1.18 AD per 10 cases). Afterward, 0 ADs occurred across 11 pediatric tracheostomies (0 AD per 10 cases). CONCLUSION: This data suggests that the twill tie intervention may prevent AD and the associated morbidity. With the twill tie initiative, we describe 11 ADs and associated risk factors and present a QI intervention that may help prevent AD and improve patient safety in the early postoperative period.

A Comparative Study of Causality Detection Methods in Root Cause Diagnosis: From Industrial Processes to Brain Networks.

Abstracting causal knowledge from process measurements has become an appealing topic for decades, especially for fault root cause analysis (RCA) based on signals recorded by multiple sensors in a complex system. Although many causality detection methods have been developed and applied in different fields, some research communities may have an idiosyncratic implementation of their preferred methods, with limited accessibility to the wider community. Targeting interested experimental researchers and engineers, this paper provides a comprehensive comparison of data-based causality detection methods in root cause diagnosis across two distinct domains. We provide a possible taxonomy of those methods followed by descriptions of the main motivations of those concepts. Of the two cases we investigated, one is a root cause diagnosis of plant-wide oscillations in an industrial process, while the other is the localization of the epileptogenic focus in a human brain network where the connectivity pattern is transient and even more complex. Considering the differences in various causality detection methods, we designed several sets of experiments so that for each case, a total of 11 methods could be appropriately compared under a unified and reasonable evaluation framework. In each case, these methods were implemented separately and in a standard way to infer causal interactions among multiple variables to thus establish the causal network for RCA. From the cross-domain investigation, several findings are presented along with insights into them, including an interpretative pitfall that warrants caution.

Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report.

BACKGROUND: An intravesical gas explosion is a rare complication of transurethral resection of the prostate (TURP). It was first reported in English literature in 1926, and up to 2022 were only forty-one cases. Injury from an intravesical gas explosion, in the most severe cases appearing as extraperitoneal or intraperitoneal bladder rupture needed emergent repair surgery. CASE PRESENTATION: We present a case of a 75-year-old man who suffered an intravesical gas explosion during TURP. The patient underwent an emergent exploratory laparotomy for bladder repair and was transferred to the intensive care unit for further observation and treatment. Under the medical team's care for up to sixty days, the patient recovered smoothly without clinical sequelae. CONCLUSIONS: This case report presents an example of a rare complication of intravesical gas explosion during TURP, utilizing root cause analysis (RCA) to comprehend causal relationships and team strategies and tools to improve performance and patient safety (TeamSTEPPS) method delivers four teamwork skills that can be utilized during surgery and five recommendations to avoid gas explosions during TURP to prevent the recurrence of medical errors. In modern healthcare systems, promoting patient safety is crucial. Once complications appear, RCA and TeamSTEPPS are helpful means to support the healthcare team reflect and improve as a team.

Root cause analysis of safety incidents in antineoplastic use in children.

OBJECTIVES: to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients. METHODS: a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors. RESULTS: in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages. CONCLUSIONS: the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

Trial and error - Outcome of breech presentation depending on birth mode and root cause analysis of severe adverse events.

OBJECTIVES: The debate about the safest birth mode for breech presentation at term remains unresolved. The comparison of a vaginal breech birth (VBB) with an elective caesarean section (CS) regarding fetal outcomes favors the CS. However, the question of whether attempting a VBB is associated with poorer fetal outcomes is examined in this study. Additionally, the study evaluates factors contributing to a successful VBB and illustrates possible errors in VBB management. STUDY DESIGN: We performed a retrospective analysis of term breech births over 15 years in a Perinatal Center Level I regarding fetal, maternal, and obstetric outcomes by comparing successful with unsuccessful VBB attempt and all attempted VBB vs. CS including a multivariate analysis of predictors for a successful VBB. A root cause analysis of severe adverse events (SAE) was conducted to evaluate factors leading to poorer fetal outcomes in VBB. RESULTS: Of 863 breech cases, in 78 % a CS was performed and in 22 % a VBB was attempted, with 57 % succeeding. Comparing successful with unsuccessful VBB attempts, successful VBB showed significantly lower maternal blood loss (p < 0.001) but poorer umbilical arterial pH (UApH) (p < 0.001), while other fetal outcome parameters showed no significant differences. Predictive factors for a successful VBB attempt were a body mass index (BMI) below 30.0 kg/m2 (p = 0.010) and multiparity (p = 0.003). Comparing all attempted VBB to CS, maternal blood loss was significantly higher in CS (p < 0.001), while fetal outcomes were significantly worse in VBB attempts, included poorer Apgar scores (p < 0.001), poorer UApH values (p < 0.001), higher transfer rate to the Neonatal Intensive Care Unit (NICU) (p < 0.001) and higher rate of respiratory support in the first 24 h (p = 0.003). CONCLUSION: The failed attempt of VBB indicates significantly worse UApH without lower Apgar scores or higher transfer rate to the NICU. The likelihood of a successful VBB is 9% lower with obesity and 2.5 times higher in multiparous women. Attempting a VBB should include detailed pre-labor counseling, regarding predictive success factors, an experienced team, and consistent management during birth.

Patient Satisfaction with the Outpatient Department Services at a Tertiary Care Hospital in Northern India and Root Cause Analysis of the Lowest-Scoring Attribute using Fishbone Diagram.

BACKGROUND: Assessing patients' satisfaction is an easy and cost-effective method of evaluating the outpatient services provided by health-care institutions. OBJECTIVES: The objectives of this study were to determine patient satisfaction among patients attending various outpatient departments (OPDs) at a tertiary care hospital and the factors affecting their satisfaction. MATERIALS AND METHODS: A cross-sectional study was conducted among patients attending various OPDs at a tertiary care hospital in Faridabad. Exit face-to-face interviews were conducted for 334 patients above 18 years of age who availed OPD services followed by pharmacy services. Information regarding sociodemography, rating of satisfaction with various attributes of OPD services on a 5-point Likert scale, and reasons for dissatisfaction was collected. Data were analyzed using SPSS version 22. Root cause analysis for the lowest-scoring attribute was done using fishbone diagram. RESULTS: About 64% of the patients were satisfied with the OPD services. "Attitude and communication of doctors" was the prime contributor to patient satisfaction. "Promptness at medicine distribution counter" was the attribute that scored lowest followed by "waiting time at the registration counter." The mean waiting time for registration was 38.2 min, for consultation with doctor 41.3 min, for collection of samples 49.6 min, and for drug dispensing 61 min. CONCLUSION: The issues related to pharmacy services need to be promptly acknowledged and addressed.

A Systemwide Strategy to Embed Equity into Patient Safety Event Analysis.

BACKGROUND: There is a lack of framework to incorporate equity into event analysis. This quality improvement initiative involved the development of equity tools that were introduced in a two-hour interactive, case-based training across 11 acute care facilities at the largest municipal health care system in the United States. A pre and post survey (which included analysis of a clinical vignette) was also conducted to assess for knowledge and comfort embedding equity in patient safety event analysis, and to measure discomfort or distress during the training. A separate assessment was used to evaluate the tools. EQUITY TOOLS: A visual aid, the Patient Equity Wheel, was created to facilitate more comprehensive and robust health equity discussions by compiling a comprehensive list of equity categories, including internal, external, and organizational dimensions of equity. The Wheel was designed for use during each phase of event analysis. An Embedding Equity in Root Cause Analysis Worksheet was developed to aid in assessing considerations of equitable care in the investigation process and includes questions to ask staff to further assess bias or equitable care factors. INITIATIVE OUTCOME AND KEY INSIGHTS: Participant knowledge and level of comfort increased after training. The most commonly unrecognized categories of bias were Training/Competencies, Structural Workflow, and Culture/Norms. Most participants responded that they had no discomfort or distress during the training. Post-training feedback noted that the tools were being used across the system in various stages of event analysis and have been reported to improve health equity conversations.

Reducing urinary tract infection rates in post-operative surgical patients: A quality improvement intervention.

INTRODUCTION AND OBJECTIVES: The Scarborough Health Network joined the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) in fiscal year 2017-2018 with interest in tracking surgical outcomes in General and Vascular Surgery patients. Results of the ACS NSQIP program revealed poor outcomes in 30-day urinary tract infection (UTI) rates in this population group. Results were in the lowest quartile compared to peer hospitals. To improve patient care, SHN initiated a multi-pronged quality improvement plan (QIP). METHODS: The QIP focused on several improvements: (1) clarify the current state and conduct a root cause analysis, (2) determine a plan to encourage early removal of catheters in post-surgical patients, (3) enhance team communication in the pre-operative, operative and post-operative care environments, and (4) improve education around UTI prevention and treatment. RESULTS: This study demonstrates the success of the quality improvement plan to improve a peri-operative complication in surgical patients. By 2019, SHN saw a significant decrease in UTI rates, and became a top decile performer in ACS NSQIP. CONCLUSIONS: This study demonstrates the feasibility and success of implementing a quality improvement project, and its methods can be adapted at other hospital sites to improve patient care.

Root Cause Analysis of Delayed Emergency Department Computed Tomography Scans.

Introduction: A solution for emergency department (ED) congestion remains elusive. As reliance on imaging grows, computed tomography (CT) turnaround time has been identified as a major bottleneck. In this study we sought to identify factors associated with significantly delayed CT in the ED. Methods: We performed a retrospective analysis of all CT imaging completed at an urban, tertiary care ED from May 1-July 31, 2021. During that period, 5,685 CTs were performed on 4,344 patients, with a median time from CT order to completion of 108 minutes (Quartile 1 [Q1]: 57 minutes, Quartile 3 [Q3]: 182 minutes, interquartile range [IQR]: 125 minutes). Outliers were defined as studies that took longer than 369 minutes to complete (Q3 + 1.5 × IQR). We systematically reviewed outlier charts to determine factors associated with delay and identified five factors: behaviorally non-compliant or medically unstable patients; intravenous (IV) line issues; contrast allergies; glomerular filtration rate (GFR) concerns; and delays related to imaging protocol (eg, need for IV contrast, request for oral and/or rectal contrast). We calculated confidence intervals (CI) using the modified Wald method. Inter-rater reliability was assessed with a kappa analysis. Results: We identified a total of 182 outliers (4.2% of total patients). Fifteen (8.2%) cases were excluded for CT time-stamp inconsistencies. Of the 167 outliers analyzed, 38 delays (22.8%, 95% confidence interval [CI] 17.0-29.7) were due to behaviorally non-compliant or medically unstable patients; 30 (18.0%, 95% CI 12.8-24.5) were due to IV issues; 24 (14.4%, 95% CI 9.8-20.6) were due to contrast allergies; 21 (12.6%, 95% CI 8.3-18.5) were due to GFR concerns; and 20 (12.0%, 95% CI 7.8-17.9) were related to imaging study protocols. The cause of the delay was unknown in 55 cases (32.9%, 95% CI 26.3-40.4). Conclusion: Our review identified both modifiable and non-modifiable factors associated with significantly delayed CT in the ED. Patient factors such as behavior, allergies, and medical acuity cannot be controlled. However, institutional policies regarding difficult IV access, contrast administration in low GFR settings, and study protocols may be modified, capturing up to 42.6% of outliers.

Safety incident reporting and barriers (SIRaB) study: Strategies and approaches for investigating patient safety events in a hospital set-up.

BACKGROUND: Unsafe patient events not only entail a clinical impact but also lead to economic burden in terms of prolonged hospitalization or unintended harm and delay in care delivery. Monitoring and time-bound investigation of patient safety events (PSEs) is of paramount importance in a healthcare set-up. OBJECTIVES: To explore the safety incident reporting behaviour and the barriers in a hospital set-up. METHODS: The study had two sections: (a) Retrospective assessment of all safety incidents in the past 1 year, and (b) Understanding the barriers of safety reporting by interviewing the major stakeholders in patient safety reporting framework. Further root cause analysis and failure mode effect analysis were performed for the situation observed. Results were statistically analyzed. RESULTS: Of the total of 106 PSEs reported voluntarily to the system, the highest reporting functional group was that of nurses (40.57%), followed by physicians (18.87%) and pharmacists (17.92%). Among the various factors identified as barriers in safety incident reporting, fear of litigation was the most observed component. The most commonly observed event was those pertaining to medication management, followed by diagnostic delay. Glitches in healthcare delivery accounted for 8.73% of the total reported PSEs, followed by 5.72% of events occurring due to inter-stakeholder communication errors. 4.22% of the PSEs were attributed to organizational managerial dysfunctionalities. Majority of medication-related PSE has moderate risk prioritization gradation. CONCLUSION: Effective training and sensitization regarding the need to report the patient unsafe incidents or near misses to the healthcare system can help avert many untoward experiences. The notion of 'No Blame No Shame' should be well inculcated within the minds of each hospital unit such that even if an error occurs, its prompt reporting does not get harmed.

An observational study of root-cause analysis of medication errors in elderly with methotrexate toxicity.

INTRODUCTION: Medication errors are inherent in a healthcare system. This results in both time and cost burdens for both the patient and the health system. The aim of this study was to conduct a root-cause analysis of medication errors in elderly patients with methotrexate toxicity, analyze associated factors, and propose solutions. METHODS: This single-center prospective study was designed to identify medication errors in cases of methotrexate toxicity between November 2022 to May 2023. Categorical data and free-text data are used to describe incidents. Harm assessment, factors related to medication errors, and preventability were evaluated for each case. Possible strategies to prevent similar occurrences are discussed. RESULTS: Out of a total of 15 patients who presented during the study period, nine suffered from methotrexate toxicity due to medication errors. Most medication errors occurred during prescribing or dispensing (seven cases). Inadequate knowledge about medication and dosage, inadequate communication was identified as a contributing factor for all medication errors. Patients on long-term methotrexate treatment are at high risk of methotrexate toxicity. CONCLUSION: This study highlights the challenges of health literacy and lacking communication between healthcare providers and patients that can be met through community pharmacy programs for the elderly in lower-middle-income countries.

Root cause analysis of mortality after esophagectomy for cancer: a multicenter cohort study from the FREGAT database.

BACKGROUND: Esophagectomy is associated with significant mortality. A better understanding of the causes leading to death may help to reduce mortality. A root cause analysis of mortality after esophagectomy was performed. METHODS: Root cause analysis was retrospectively applied by an independent expert panel of 4 upper gastrointestinal surgeons and 1 anesthesiologist-intensivist to patients included in the French national multicenter prospective cohort FREGAT between August 2014 and September 2019 who underwent an esophagectomy for cancer and died within 90 days of surgery. A cause-and-effect diagram was used to determine the root causes related to death. Death was classified as potentially preventable or non-preventable. RESULTS: Among the 1,040 patients included in the FREGAT cohort, 70 (6.7%) patients (male: 81%, median age 68 [62-72] years) from 17 centers were included. Death was potentially preventable in 37 patients (53%). Root causes independently associated with preventable death were inappropriate indication (odds ratio 35.16 [2.50-494.39]; P = .008), patient characteristics (odds ratio 5.15 [1.19-22.35]; P = .029), unexpected intraoperative findings (odds ratio 18.99 [1.07-335.55]; P = .045), and delay in diagnosis of a complication (odds ratio 98.10 [6.24-1,541.04]; P = .001). Delay in treatment of a complication was found only in preventable deaths (28 [76%] vs 0; P < .001). National guidelines were less frequently followed (16 [43%] vs 22 [67%]; P = .050) in preventable deaths. The only independent risk factor of preventable death was center volume <26 esophagectomies per year (odds ratio 4.71 [1.55-14.33]; P = .006). CONCLUSIONS: More than one-half of deaths after esophagectomy were potentially preventable. Better patient selection, early diagnosis, and adequate management of complications through centralization could reduce mortality.

A 5-step root cause analysis model for test overutilization: A study on its application to plasma transferrin testing.

OBJECTIVES: This study aimed to develop a root cause analysis (RCA) model for test overutilization, applying it to transferrin overordering at our institution. METHODS: A comprehensive review was undertaken to establish a systematic RCA model. Upon implementation, the questionnaire identifying the root causes of transferrin overordering with infographic intervention was distributed to clinicians and nurses. RESULTS: The RCA model comprises 5 steps: (1) problem identification, (2) causal factor determination, (3) data collection, (4) significant factor identification, and (5) corrective action development and outcome measurement. The major causes of transferrin overutilization were confusion between transferrin and transferrin saturation, as well as unfamiliarity with the laboratory handbook. An infographic reduced postintervention transferrin ordering among clinicians (84.9%, P < .001) and nurses (46.8%, P < .001). CONCLUSIONS: This study presents a 5-step RCA model that offers a customized method to identify the causes of test overutilization. Applying this model to transferrin at our institution revealed 22 leading root causes. Laboratories are encouraged to adopt this RCA model as it can contribute to optimized patient care and more efficient resource allocation.

Learning from Non-Routine Events and Teamwork in Intensive Care Units: Challenges and Opportunities.

Patients admitted to intensive care units (ICUs) have profound and complex illnesses, often fraught with uncertainties in diagnoses, treatments, and care decisions. Clinicians often deviate from best practices to handle ICUs' myriad complexities and uncertainties. Non-routine events (NREs), defined as any aspect of care perceived by clinicians as deviations from optimal care, are latent and frequent safety threats that, if left unchecked, can be precursors to adverse events. Proper identification and analysis of NREs that represent latent safety threats have been proposed as a feasible and more effective approach for performance improvement than traditional root cause analysis for patient safety events. However, NRE studies to date have yet to show the holistic picture of NREs in the contexts of teamwork and time-dependent tasks that are frequently associated with NREs. NREs, an upstream interventional area to understand root causes, team performance, and human-computer interaction, still needs to be expanded. This article presents concepts of NREs, and the use of real-world data (RWD) and informatics methodology to investigate NREs in contexts and discusses the opportunities and challenges to enhance NREs research in teamwork and time-dependent tasks.

[Implementation and Effectiveness of Measures to Prevent Recurrence of Incidents Developed through Root Cause Analysis Using Work Flowchart].

PURPOSE: Incidents are recommended to be analyzed by root cause analysis (RCA). Our institution also conducts RCA for incidents and takes measures to prevent recurrence. The purpose of this study was to evaluate the effectiveness of countermeasures against the root causes analyzed by RCA in order to prevent recurrence of incidents. METHODS: Since the treatment planning CT scanner was replaced, incidents of failure to zero adjustment the coordinates of the bed position occurred four times during a three-month period. The RCA was used to investigate the root causes of these incidents and to formulate measures to prevent recurrence. To evaluate the effectiveness of the recurrence prevention measures, we collected the number of recurrence of incidents during the first year after the effectiveness of the recurrence prevention measures, and used the chi-square test to determine the significant difference in the probability of an incident occurring at a significance level of 5% or less. RESULTS: The measures to prevent the recurrence of incidents were to double-check that the coordinates of the bed position were adjusted to zero and to simulate operations based on a work flow that incorporated this double-check. During the first year period following the implementation of these recurrence prevention measures, the number of recurrence incidents was zero, and the probability of their occurrence decreased statistically significantly (p<0.05). CONCLUSION: Thorough double-checks and work simulation based on the work flow are effective methods for preventing the recurrence of incidents.

Priorities and root cause analysis of quality and safety problems in chilean hospitals / Prioridades y análisis de las causas de los problemas de calidad y seguridad en hospitales chilenos

BACKGROUND: Quality improvement is an important component of hospital operations. AIM: To prioritise clinical quality and safety problems in Chilean hospitals according to their severity, frequency, and detectability. MATERIAL AND METHODS: The study was conducted between December 2018 and June 2019. To identify quality and safety problems, an exploratory study was conducted using an online survey aimed to those responsible for clinical quality and safety in Chilean hospitals. The survey was sent to 94 hospitals and completed by quality management personnel at 34 hospitals, yielding a total of 25 valid surveys for analysis. Based on the information gathered, a risk priority score was computed to rank the problems surveyed. Focus groups were held to find the root causes of the quality and safety problem with the highest risk priority score. RESULTS: The three highest risk priorities were:1 ineffective interprofessional communication,2 lack of leadership for addressing frequently recurring safety issues, and3 antimicrobial resistance due to inappropriate use of antibiotics. For the communication problem, the focus group found two main root causes: those due to personnel and those relating to the hospitals themselves. CONCLUSIONS: Hospitals can systematically use the proposed approach to categorize their main clinical quality and safety problems, analyze their causes, and then design solutions.

ANTECEDENTES: La mejora continua de la calidad es un componente importante en las actividades hospitalarias. OBJETIVO: Priorizar los problemas de calidad y seguridad en hospitales chilenos de acuerdo a su severidad, frecuencia y detectabilidad. MATERIAL Y MÉTODOS: Se efectuó un estudio exploratorio con una encuesta en línea para detectar problemas de calidad y seguridad, dirigida a quienes están a cargo de los problemas de calidad y seguridad en los hospitales. La encuesta fue enviada a 94 hospitales y respondida por los encargados de calidad y seguridad en 34 de ellos, lográndose 25 encuestas válidas para análisis. El estudio se llevó a cabo entre diciembre de 2018 y junio de 2019. Se diseñó una escala de prioridades de riesgo para determinar la importancia relativa de los problemas detectados. Se llevaron a cabo grupos focales para determinar las causas del problema más importante. RESULTADOS: En Chile, los problemas de calidad y seguridad más importantes son la falta de comunicación interprofesional, falta de liderazgo para abordar los problemas de seguridad y calidad, y resistencia a antibióticos debido a su uso inapropiado. Problemas relacionados al personal y relacionados al hospital fueron las causas primarias de la falta de comunicación. CONCLUSIONES: Los hospitales podrían utilizar este enfoque de forma sistemática para categorizar sus principales problemas de calidad y seguridad, analizar las causas y diseñar soluciones.

Priorities and root cause analysis of quality and safety problems in chilean hospitals.

BACKGROUND: Quality improvement is an important component of hospital operations. AIM: To prioritise clinical quality and safety problems in Chilean hospitals according to their severity, frequency, and detectability. MATERIAL AND METHODS: The study was conducted between December 2018 and June 2019. To identify quality and safety problems, an exploratory study was conducted using an online survey aimed to those responsible for clinical quality and safety in Chilean hospitals. The survey was sent to 94 hospitals and completed by quality management personnel at 34 hospitals, yielding a total of 25 valid surveys for analysis. Based on the information gathered, a risk priority score was computed to rank the problems surveyed. Focus groups were held to find the root causes of the quality and safety problem with the highest risk priority score. RESULTS: The three highest risk priorities were:1 ineffective interprofessional communication,2 lack of leadership for addressing frequently recurring safety issues, and3 antimicrobial resistance due to inappropriate use of antibiotics. For the communication problem, the focus group found two main root causes: those due to personnel and those relating to the hospitals themselves. CONCLUSIONS: Hospitals can systematically use the proposed approach to categorize their main clinical quality and safety problems, analyze their causes, and then design solutions.

Metodologías validadas para el análisis causal de eventos adversos de trascendencia clínica en la biomedicina / Methodologies validated for the causal analysis of adverse events of clinical relevance in biomedicine

Introducción: El análisis causal de los eventos adversos amerita metodologías validadas para establecer la dinámica de cómo se originan los incidentes que afectan la seguridad del paciente en los ambientes de prestación de servicios de salud. Objetivo: Describir las bases conceptuales y metodológicas de los sistemas de análisis causal de eventos adversos de trascendencia clínica en la biomedicina. Métodos: Se realizó una revisión documental empleando la bibliografía nacional e internacional actualizada. Se utilizó el motor de búsqueda Google Académico, se consultaron artículos de libre acceso en las bases de datos Pubmed y SciELO, desde marzo 2019 hasta igual mes de 2020. Se emplearon como palabras clave: eventos adversos, análisis de causas raíz, seguridad del paciente, según los Descriptores en ciencias de la salud (DeCS). Fueron seleccionados 25 artículos (20 en idioma español, 5 en inglés), de ellos, 18 (72,0 por ciento) corresponden a los últimos 5 años. Análisis e integración de la información: Las metodologías del análisis causa-raíz, el método ANCLA, el análisis modal de fallos y efectos (AMFE) y el protocolo de Londres, comparten como propósito su función de usar el evento o error para revelar las brechas que vulneran la seguridad del paciente y los aspectos inadecuados en el proceso de atención de la salud. Conclusiones: Los sistemas de análisis causal de eventos adversos constituyen herramientas para incrementar la cultura de seguridad del paciente, pues detectan fallas y errores latentes en el sistema, cuya corrección es esencial para implementar estrategias de prevención(AU)

Introduction: Causal analysis of adverse events requires validated methodologies to determine the origin of incidents affecting patient safety in health care settings. Objective: Describe the conceptual and methodological bases of the systems for the causal analysis of adverse events of clinical relevance in biomedicine. Methods: A document review was conducted of updated national and international bibliography. The search was carried out in the search engine Google Scholar, and open access papers were consulted in the databases PubMed and SciELO from March 2019 to March 2020. The key words used were adverse events, root cause analysis and patient safety, obtained from Health Sciences Descriptors (DeCS). A total 25 papers were selected (20 in Spanish and 5 in English), of which 18 (72.0 percent had been published in the last five years. Data analysis and integration: Root-cause analysis methodologies, the ANCLA score, the failure modes and effects analysis (FMEA) and the London Protocol share the common purpose of using events or errors to reveal gaps that weaken patient safety and inappropriate aspects of the health care process. Conclusions: Systems for the causal analysis of adverse events are tools to enhance patient safety culture, for they detect failures and errors latent in the system whose correction is essential to implement prevention strategies(AU).

Costs and root causes of medication errors and falls in a Teaching Hospital: cross-sectional study / Costos y causas principales de los errores y caídas de medicación y caídas en un Hospital Docente: un estudio transversal / Custos e causas-raízes de erros de medicação e quedas em Hospital de Ensino: estudo transversal

ABSTRACT Objectives to characterize accidents/falls and medication errors in the care process in a teaching hospital and to determine their root causes and variable direct costs. Method cross-sectional study implemented in two stages: the first, was based on the analysis of secondary sources (notifications, medical records and cost reports) and the second, on the application of root-cause analysis for incidents with moderate/severe harm. The study was carried out in a teaching hospital in Paraná, which exclusively serves the Brazilian Unified Health System and composes the Network of Sentinel Hospitals. Thirty reports of accidents/falls and 37 reports of medication errors were investigated. Descriptive statistical analysis and the methodology proposed by The Joint Commission International were applied. Results among the accidents/falls, 33.3% occurred in the emergency room; 40.0% were related to the bed, in similar proportions in the morning and night periods; 51.4% of medication errors occurred in the hospitalization unit, the majority in the night time (32.4%), with an emphasis on dose omissions (27.0%) and dispensing errors (21.6%). Most incidents did not cause additional harm or cost. The average cost was R$ 158.55 for the management of falls. Additional costs for medication errors ranged from R$ 31.16 to R$ 21,534.61. The contributing factors and root causes of the incidents were mainly related to the team, the professional and the execution of care. Conclusion accidents/falls and medication errors presented a low frequency of harm to the patient, but impacted costs to the hospital. Regarding root causes, aspects of the health work process related to direct patient care were highlighted.

RESUMEN Objetivos caracterizar accidentes/caídas y errores de medicación en el proceso asistencial en un hospital universitario y; determinar sus causas fundamentales y los costos directos variables. Método estudio transversal implementado en dos etapas: la primera, basada en el análisis de fuentes secundarias (notificaciones, historias clínicas e informes de costos) y; el segundo, en la aplicación del análisis raíz-raíz para incidentes con daños moderados / severos. Realizado en un hospital docente de Paraná, que atiende exclusivamente al Sistema Único de Salud y forma parte de la Red de Hospitales Centinelas. Se investigaron 30 notificaciones de accidentes / caídas y 37 de errores de medicación. Se aplicó el análisis estadístico descriptivo y la metodología propuesta por The Joint Commission International. Resultados entre los accidentes / caídas, el 33,3% ocurrió en urgencias; 40,0% estaban relacionados con la cama, en proporciones similares en los periodos de mañana y noche; El 51,4% de los errores de medicación ocurrieron en la unidad de internación, la mayoría durante la noche (32,4%), con énfasis en omisiones de dosis (27,0%) y errores de dispensación (21,6%). La mayoría de los incidentes no resultaron en daños o costos adicionales. El costo promedio fue de R$ 158,55 para el manejo de caídas. Los costos adicionales por errores de medicación oscilaron entre R$ 31,16 y R$ 21.534,61. Los factores contribuyentes y las causas fundamentales de los incidentes se relacionaron principalmente con el equipo, el profesional y la ejecución de la atención. Conclusión los accidentes / caídas y los errores de medicación tuvieron una baja frecuencia de daño al paciente, pero impactaron los costos hospitalarios. En relación a las causas raíz, se destacaron aspectos del proceso de trabajo en salud, relacionados con la atención directa al paciente.

RESUMO Objetivos caracterizar os acidentes/quedas e erros de medicação no processo de cuidado em um hospital de ensino e; determinar suas causas-raízes e os custos diretos variáveis. Método estudo transversal implementado em duas etapas: a primeira se pautou na análise de fontes secundárias (notificações, prontuários e relatórios de custos) e; a segunda, na aplicação de análise de cauza-raíz para incidentes com danos moderados/graves de julho a dezembro de 2019. Realizado em hospital de ensino do Paraná, que atende exclusivamente o Sistema Único de Saúde e compõe a Rede de Hospitais Sentinelas. Foram investigadas 30 notificações de acidentes/quedas e 37 de erros de medicação. Aplicaram-se a análise estatística descritiva e a metodologia proposta pela The Joint Comission International. Resultados dentre os acidentes/quedas, 33,3% ocorreram no pronto socorro; 40,0% tiveram relação com o leito, em proporções semelhantes nos períodos matutino e noturno; 51,4% dos erros de medicação ocorreram em unidade de internação, a maioria no período noturno (32,4%), com destaque para omissões de dose (27,0%) e erros de dispensação (21,6%). A maioria dos incidentes não ocasionou danos ou custo adicional. O custo médio foi R$ 158,55 para manejo das quedas. Os custos adicionais para erros de medicação variaram entre R$ 31,16 e R$ 21.534,61. Os fatores contribuintes e causas-raízes dos incidentes se relacionaram, principalmente, à equipe, ao profissional e à execução do cuidado. Conclusão os acidentes/quedas e erros de medicação apresentaram baixa frequência de danos ao paciente, porém impactaram no custo hospitalar. Em relação às causas-raízes, destacaram- se os aspectos do processo de trabalho em saúde, relacionados ao cuidado direto ao paciente.

Covid-19, causas fundamentais,classe social e território / COVID-19, fundamental causes, social class and territory / Covid-19, causas fundamentales, clase social y territorio

Resumo A teoria que considera as condições sociais como causas fundamentais da saúde, em articulação com as noções de classe social e território, é usada em reflexões acerca da trajetória e da distribuição dos efeitos da pandemia da Covid-19 no país. Parte-se de sínteses teóricas, abordagens e evidências de trabalhos do autor sobre desigualdade de saúde no Brasil. Entende-se que o 'meio social', de natureza relacional e estruturada, afeta a propagação e a distribuição da doença entre os grupos. As diferenças de classe em circunstâncias de trabalho, localização e moradia são referidas. No tocante às diferenças sociais no risco de desenlace fatal da doença, são consideradas a distribuição prévia de condições adversas e as diferenças no modo como as instituições de saúde processam as pessoas. Como proposto pela teoria, as desigualdades de recursos, informações, disposições e capacidade estariam afetando a distribuição social dos efeitos da pandemia no Brasil.

Abstract The theory of social conditions as fundamental causes of health, in conjunction with the notions of social class and territory, is used in reflections about the trajectory and distribution of the effects of the Covid-19 pandemic in the country. It starts with theoretical syntheses, approaches and evidences from the author's works on health inequality in Brazil. It is understood that the 'social environment', of a relational and structured nature, affects the spread and distribution of the disease among the groups. Class differences in circumstances of work, location and housing are mentioned. Regarding social differences in the risk of fatal outcome of the disease, the previous distribution of adverse conditions and differences in the way health institutions process people are considered. As proposed by the theory, inequalities in resources, information, dispositions and capacity would be affecting the social distribution of the effects of the pandemic in Brazil.

Resumen La teoría de las condiciones sociales como causas fundamentales de la salud, junto con las nociones de clase social y territorio, es utilizada en reflexiones sobre la trayectoria y distribución de los efectos de la pandemia de Covid-19 en el país. El punto de partida son síntesis teóricas, enfoques y evidencias de los trabajos del autor sobre la desigualdad en salud en Brasil. Se entiende que el "entorno social", de naturaleza relacional y estructurada, afecta la propagación y distribución de la enfermedad entre los grupos. Se mencionan las diferencias de clase en circunstancias de trabajo, ubicación y vivienda. Con respecto a las diferencias sociales en el riesgo de desenlace fatal de la enfermedad, se considera la distribución previa de condiciones adversas y las diferencias en la forma en que las instituciones de salud procesan a las personas. Según lo propuesto por la teoría, las desigualdades en recursos, información, disposiciones y capacidad estarían afectando la distribución social de los efectos de la pandemia en Brasil.